NTI2010 Increasing Quality And Safety

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  • Reference PHVS’s GPS model – MVV, Strategic Objectives, Planning and aligning, Executing Plan, Development
  • Establishing system-level performance helps answer two questions. What are we trying to achieve How are we doing at it? These two main questions really summarize How Good We Are .
  • Reference Performance Improvement Committee’s based on Malcolm Baldrige – 7 Teams: Leadership Team Strategy Team Customer Service Steering Committee Knowledge Management Team Workforce Team Process Improvement Team Key Measures Team
  • This type of system ensures that leaders take timely action to resolve issues that may be prohibiting execution (e.g., break down barriers, provide resources for project leaders, or replace project leadership). If the project is well executed, and little progress on system-level is seen, the senior team must take action to revise the strategic project portfolio. This can be accomplished through multidisciplinary teams, PDCA team or Quality Improvement processes utilized in your institutions.
  • The most commonly cited reason for failure of organizations to reach breakthrough aims is the failure of the senior leadership group to function as an effective team, with the appropriate balance of skills, health relationships, and deep personal commitments to achievement of the goals. Most important is that these principles must be translated into specific structural and process changes if they are to have an effect on the organization’s culture: The most powerful of these structures and process is putting the patient in the room Self-Serving Conversations cease – Many complaints (e.g., “We can’t do it that way because that would require us to cooperate with that other cardiology group which we compete with”) sound unseemly when patients and families are in the room. The whole system of Care Comes into Play: Patients experience care across mulitple departments, medical groups, and organizations. They want solutions that work for them, not just for one part of the system. Better, more Innovative Ideas come forward: Patients and families are a tremendous wellspring of ideas for improvement and redesign. Physicians and Nurses feel supported and inspired: When patients are on committees and task forces, they become a source of energy and positive reinforcement for care professionals.
  • Organizations are now beginning to understand the financial impact of harm events such as falls, medication errors, and delayed care are having. Utilization of Evidence Based care protocols are demonstrating a significant cost reduction when utilized. Eliminating errors and clinical waste also have a significant impact in cost savings. Cost reduction efforts commonly have been a reaction to external changes in the market or payment systems and are generally one-time events focused on: Reducing the cost of labor Reducing the cost of supplies Changing vendor contracts Compared to other CFO’s in other industries, health care CFO’s typically do not focus on improving the processes themselves – Taking out wasted time and effort Eliminating defects that require rework. The core process of health care – diagnosing, treating and communication with patient has been a “Black Box” and off limits to CFO’s
  • Strongest Examples of Leverage Point Five: Virginia Mason Medical Center, Washington Park Nicollet Health Services, Minnesota Using Lean techniques – Process 64 patients daily through their same day endoscopy facility that once struggled to care for 30 – 32 patients daily. $3 million in capital expenditures were avoided by utilizing Lean methodology ThedaCare, Wisconsin Extensive reduction in waste in their first couple years of operation by utilizing Lean methodology – CFO built a long-range financial plan that does not require any price increases. McLeod Regional Medical Center, South Carolina Eliminate 112 minutes of wasted nursing documentation time per cardiac patient, thus freeing up nursing to provide higher levels of quality and safety. All have adopted lean management principles (Toyota Production System)
  • Physician Engagement: At PVHS – 2009 Gallup poll taken by physicians – placed their level of engagement in the 96 th Percentile. Equally, physician-nurse communication/collaboration was ranked in the 96 th percentile as well.
  • 1.1 The key idea is to learn what the physicians’ quality agenda is and harness the organization’s quality efforts to their agenda. Physicians are less excited about improving the hospital’s publically reported data, reducing length of stay or removing waste in the supply chain – “Not my problem, it’s the hospitals” 1.2 Physicians care about mortality and harm – quality and safety outcomes. One way to engage them is make sure that organization’s aims focus on outcomes meaningful to physicians. Example: Instead of being in the top 10 th percentile of CMS Core Measures – Aim for “reducing the risk of needles deaths in the hospital.” One strategy might be to improve the reliability of CMS Core Measures for acute myocardial infarction and pneumonia. Another might be to increase the amount of smoking cessation education provided to patients or the development of Centers of Excellence
  • Reframe Values and Beliefs Organizations need to reexamine and reframe some of their core values and beliefs if true engagement in quality and safety is to occur. Doctors must begin to see their responsibility for the system’s quality results, and not just for their own personal quality performance. One example of redesign is the traditional “Morbidity and Mortality Conference”. In general this conference asks “Did someone make an error of judgment or of technique in this case?”. The new redesigned process requires physicians and administrators to ask the following question: “ What were the systems factors – culture, structure, processes that contributed to this death and what can we do together to change these factors?” Ask Physicians what they need.
  • Team – Should be about 10 members including those who work closely with physicians (major nursing units, medical office staff, high volume outpatient departments and admitting) Data – Information from physician satisfaction surveys – (Thomson Reuters, AVATAR, Gallop) is utilized as a springboard for brainstorming for optimal environments for physicians. Goals – Set 90 day action plan is shared with leaders. Monthly targets are set along with outcomes for the year.
  • Reframe Values and Beliefs Organizations need to reexamine and reframe some of their core values and beliefs if true engagement in quality and safety is to occur. Doctors must begin to see their responsibility for the system’s quality results, and not just for their own personal quality performance. One example of redesign is the traditional “Morbidity and Mortality Conference”. In general this conference asks “Did someone make an error of judgment or of technique in this case?”. The new redesigned process requires physicians and administrators to ask the following question: “ What were the systems factors – culture, structure, processes that contributed to this death and what can we do together to change these factors?” Ask Physicians what they need.
  • 3.1. Not all physicians need to be engaged in any particular quality initiative. Those who are engaged do not need to be engaged in exactly the same way. 3.2. Plan segmentation through physician champions, physician members of the actual improvement team, structural leaders of the medical staff who might need to adopt a new policy. 3.3. Engage those physicians who are more likely to “block” recommendations that emerge from the project team or policies recommended by the structural leaders.
  • 4.1. Physicians are often cynical about quality improvement based on methods utilized in the past that really disengaged them previously. (Example: Don’t ask physicians to join improvement teams that meet twice a month during times when physicians are making rounds; utilizing the time for activities that do not require physician input; gathering data without testing any changes, then sending out flawed performance data on quality measures asking them to improve on it). See fig’s. Next slides on what this process looks like and what it should look like.
  • As a guideline, use small tests to refine the design for the local setting. Do not spend more than one meeting on the WHAT of a guideline. There are relatively good “Starter Kits” for a clinical guideline or protocol available from a national, reputable source. Do not spend time reinventing the wheel or the science behind the project. Focus on how to make the exiting protocol work within the local context. The TEAM tests various methods for the how, who, when, where , initially on a very small scale, making frequent changes to improve implementation. Tests of change increase in scale, until most physicians find themselves able to use the protocol in their patient care, at which point the protocol is adopted with the expectation that physicians opt out if they do not wish to use it.
  • 5.1. Change is required to make improvements in quality and safety, yet it is often met with set back through what is called Monovoxoplegia or “paralysis by one loud voice.” Physicians are among the most powerful voice in healthcare organizations and their collegial nature makes them reluctant to challenge other physicians. This paralysis is common place in physician meetings, improvement teams, executive teams and even board rooms, where lay members sit silent when one physician speaks up against a proposed change. There is no simple solution to Monovoxoplegia , however, the basis of an effective approach relies on building an organizational culture of courage – The Courage to ask questions The Courage to challenge the status quo The Courage to support the physicians and nurses WHO do wish to make improvements. Courage could be illustrated best by Donna Isgett from McLeod Regional Medical Center and the question she asks physicians when they balk at Evidence Based Practice. “Are you saying that you value your individual autonomy more than you value your patient’s outcomes?” Knowing they will be supported all the way to the board enables all clinicians, including physicians to ask tough questions… Courage is infectious
  • 6.1. When involving physicians – don’t hand them a final or near-final version of proposed changes and expect acceptance. 6.2. Work with real leaders – Usually there are one or two opinion leaders. Although they might not be leaders within the organization per se’ they have earned the respect of their peers and have the ability to influence others. These leaders MUST be involved in the improvement changes. 6.3. Choose messengers and messages Carefully: Credibility is generally view as credible by the whom delivers the message, so it is important on who delivers the message (specialist, general practitioner, or someone with specific specialty certifications. Communication should be designed to be engaging rather than inflammatory. 6.4. Be Transparent, especially with data – Physicians usually do not trust interpreted data. Give them access to raw data. Even if they do not look at the data, they will value knowing that you trust them to do so. 6.5 Value Their time with you Time:
  • The self assessment should be completed by senior leadership – initially as individuals, then as a team in order to review results and action plans
  • Continue completing all 7 Leverage points with action plans.
  • Customer Services & Patient/Family Center Care – PVHS Team committee:
  • PVHS – Customer Service Steering Committee
  • Organizations that are to consistently improve system-level performance will have capabilities in three areas: System-Level Aims, Local management and supervision, and development of sufficient number of employee’s:
  • This slide represents the differences between the Institute of Medicine and TPS based on Cost per capita for severely ill persons with multiple chronic diseases.
  • Pitfalls – Often encounter resistance to the ambition of the goal. Response: Reduce the ambition of the goal by moving to a lower level in the system that requires less integration (Cost per case in a hospital, rather than total costs With many opportunities for improvement, setting too many goals will underscore the ambitions. Typically leading to under-resourcing. The goal for organizations now is to look at the future of healthcare. Suggestions: Keep discussions centered on the patient’s experience over time Use the Toyota specifications as a comparison for the level of ambition Concede that one project may not be sufficient to accomplish the goal
  • HSMR – is the calculation used to compare a hospital’s actual mortality rate to the risk-adjusted expected mortality rate
  • HSMR – is the calculation used to compare a hospital’s actual mortality rate to the risk-adjusted expected mortality rate Discuss Fall Program/protocol and video monitoring – Graph? Patient-Family Center Care @ PVHS
  • IHI’s 100,000 Lives Campaign as well as 5 Million Lives campaign are two strategic goals adopted by 3,700 hospitals and health systems. Stories of PVHS – Malcolm Baldrige Teams-
  • Utilization of the Rapid Cycle PDCA’s (PDSA) can implement change in a shorter period of time. These are not meant to be dragged out 6-10 months, but 3-6.
  • HSMR – is the calculation used to compare a hospital’s actual mortality rate to the risk-adjusted expected mortality rate Discuss Fall Program/protocol and video monitoring – Graph? Patient-Family Center Care @ PVHS
  • NTI2010 Increasing Quality And Safety

    1. 2. Increasing Quality & Safety in Your Organization: Utilizing IHI’s Seven Leadership Leverage Points Todd M. Grivetti, MSN, RN, CCRN, CNML Clinical Nurse Manager Regional Neurosciences Center Poudre Valley Hospital Ft. Collins, CO.
    2. 3. Housekeeping <ul><li>Cell Phones to Vibrate </li></ul><ul><li>Pager to Vibrate </li></ul>
    3. 4. Session Information <ul><li>Class Code: 500 </li></ul><ul><li>CE / Cat: 3 hrs / C </li></ul><ul><li>Times: 2:15 pm 5:15 pm </li></ul>
    4. 5. About Me
    5. 6. About the Organization
    6. 7. Learning Objectives <ul><li>Discuss and define IHI’s Seven Leadership Leverage points </li></ul><ul><li>Describe how to incorporate IHI’s model into your organization for successful and sustained quality and safety improvement. </li></ul><ul><li>Implement strategic plan to take back to your organization. </li></ul><ul><li>Describe Toyota Process System </li></ul>
    7. 8. Overview – Seven Leadership Leverage Points <ul><li>Framework </li></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Infrastructure </li></ul></ul><ul><li>Achieve Strategic Goals </li></ul><ul><li>Build Capacity </li></ul><ul><li>Manage Local Improvement </li></ul>
    8. 9. Leverage Points Explained <ul><li>1. Establish and oversee Specific System-level Aims at the Highest Governance level. </li></ul><ul><li>2. Develop an Executable strategy to achieve the system-level Aims and Oversee their execution at the highest Governance Level. </li></ul><ul><li>3. Channel Leadership Attention to System Level Improvement: Personal Leadership, Leadership systems and Transparency </li></ul><ul><li>4. Put Patients and Families on the Improvement Team </li></ul><ul><li>5. Make the Chief Financial Officer a Quality Champion </li></ul><ul><li>6. Engage Physicians </li></ul><ul><li>7. Build Improvement Capability </li></ul>
    9. 10. Leverage Point One: <ul><li>Establish and Oversee Specific System-Level Aims at the Highest Governance Level </li></ul><ul><ul><li>Establish solid measures of system-level performance </li></ul></ul><ul><ul><ul><li>Hospital mortality rates </li></ul></ul></ul><ul><ul><ul><li>Cost per adjusted admission </li></ul></ul></ul><ul><ul><ul><li>Adverse drug events per 1,000 doses </li></ul></ul></ul><ul><ul><ul><ul><li>Ability to track monthly </li></ul></ul></ul></ul><ul><ul><ul><li>Adopt specific aims for breakthrough improvement of those measures </li></ul></ul></ul><ul><ul><ul><li>Establish effective oversight of those aims at the highest levels of governance and leadership </li></ul></ul></ul><ul><ul><ul><li>Commit personally to these aims and communicate them to all stakeholders in way that engenders heartfelt commitment to achieving them. </li></ul></ul></ul>
    10. 11. Leverage Point One <ul><li>Whole Systems-Measure </li></ul><ul><ul><li>Measures provide an excellent example of a balanced set of World-Class, system level (“Big Dot”) quality performance measures </li></ul></ul><ul><ul><ul><li>Measures are intended to complement an organization’s existing </li></ul></ul></ul><ul><ul><ul><ul><li>Balanced Scorecards </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Measurement dashboards </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Performance measurement systems </li></ul></ul></ul></ul><ul><ul><li>Toyota Specifications </li></ul></ul><ul><ul><ul><li>Breakthrough performance </li></ul></ul></ul><ul><ul><ul><li>Performance that exceeds previous believed “limits” </li></ul></ul></ul>
    11. 12. Leverage Point One Summary <ul><li>Responsibility of adopting aims and overseeing measures cannot be the sole responsibility of the board </li></ul><ul><li>Aims must be focused and realistic </li></ul><ul><li>Data feedback is important for boards to track whether there is improvement or not. </li></ul><ul><ul><li>Use consistent operation definitions </li></ul></ul><ul><ul><li>Be timely </li></ul></ul><ul><ul><li>Benchmark against other organizations </li></ul></ul>
    12. 13. Leverage Point Two: Develop an Executable Strategy to Achieve the System-Level Aims <ul><li>IHI’s Execution of Strategic Improvement Initiatives </li></ul><ul><ul><li>Four Critical Steps for Leaders </li></ul></ul><ul><ul><ul><li>Senior Team and Board must adopt a few focused breakthrough quality and safety aims. </li></ul></ul></ul><ul><ul><ul><li>Senior Team must develop plan “rational portfolio of projects” with scale and paced needed to achieve </li></ul></ul></ul><ul><ul><ul><li>Key projects must be resourced with capable leaders both large projects and at day-to-day microsystem level </li></ul></ul></ul><ul><ul><ul><li>Management team must monitor and respond to data from the field at multiple levels in order to steer the execution of the strategy. </li></ul></ul></ul>
    13. 14. Leverage Point Two Summary <ul><li>Framework for execution </li></ul><ul><ul><li>System-Level aims have a powerful influence on choices of projects. </li></ul></ul><ul><ul><li>Ask the following questions: </li></ul></ul><ul><li>How does what you’re already working on in your department support the system-level aim? </li></ul><ul><ul><ul><li>What do we need to do in order to accomplish the aim? </li></ul></ul></ul><ul><ul><li>Large complex projects must be led by capable leaders who are given the time to do the projects or they will be unsuccessful. </li></ul></ul>
    14. 15. Leverage Point Two Summary <ul><li>Successful leadership system for execution has two critical components: </li></ul><ul><ul><li>Obtain data and feedback regularly on how: </li></ul></ul><ul><ul><ul><li>The strategic project portfolio is being executed </li></ul></ul></ul><ul><ul><ul><li>The strategy is working </li></ul></ul></ul><ul><ul><li>Have senior executives regularly review and respond to timely, useful data on these two questions. </li></ul></ul>
    15. 16. Leverage Point Three: Channel Leadership Attention to System-Level Improvement <ul><li>Personal Leadership </li></ul><ul><li>Leadership Systems </li></ul><ul><li>Transparency </li></ul>
    16. 17. Leverage Point Three: Channel Leadership Attention to System-Level Improvement <ul><li>Common practice: </li></ul><ul><ul><li>Executives constantly send signals about what they believe to be important – Some are NEGATIVE: </li></ul></ul><ul><ul><ul><li>Arriving late to meetings </li></ul></ul></ul><ul><ul><ul><li>Starting meetings late </li></ul></ul></ul><ul><ul><ul><li>Not asking questions </li></ul></ul></ul><ul><ul><ul><li>Taking phone calls/check e-mail during the meeting </li></ul></ul></ul><ul><ul><ul><li>Leaving early </li></ul></ul></ul>
    17. 18. Leverage Point Three: Channel Leadership Attention to System-Level Improvement <ul><li>Personal Leadership </li></ul><ul><ul><li>Prioritize calendars </li></ul></ul><ul><ul><ul><li>Change personal schedules to make time for data review, meetings with project leaders, and other activities that support the work. </li></ul></ul></ul><ul><ul><li>Conduct Project Reviews </li></ul></ul><ul><ul><ul><li>Senior executives send powerful signals by personally performing reviews with project teams; asking about aims, connecting the work of the team to the overall organization aims, focusing on results, helping the team overcome barriers, and providing encouragement. </li></ul></ul></ul><ul><ul><li>Tell Stories </li></ul></ul><ul><ul><ul><li>Positive organizational “buzz” can be created – both informal and formal communications. Stories reinforce the culture changes and practices needed. Stories encourage more rapid adoption of needed patterns and practices. </li></ul></ul></ul>
    18. 19. Leverage Point Three: Channel Leadership Attention to System-Level Improvement <ul><li>Leadership Systems </li></ul><ul><ul><li>Personal leadership must be supported by good leadership systems </li></ul></ul><ul><ul><ul><li>The interrelated set of structures and processes by which leaders work. </li></ul></ul></ul><ul><ul><ul><ul><li>Senior Executives could remake their calendars to include project meetings, conduct team reviews, and tell great stories that reinforce the desired culture changes and behaviors. </li></ul></ul></ul></ul><ul><ul><li>What performance data is “top of mind” </li></ul></ul>
    19. 20. Leverage Point Three: Channel Leadership Attention to System-Level Improvement <ul><li>Finance </li></ul><ul><ul><li>Last Month’s Operating Margin </li></ul></ul><ul><ul><li>Customer Satisfaction Scores </li></ul></ul><ul><li>Nursing </li></ul><ul><ul><li>Mortality Rate </li></ul></ul><ul><ul><li>Number of Hospital Acquired infections </li></ul></ul><ul><ul><li>Number of Decubitus ulcers </li></ul></ul><ul><li>Quality/Safety </li></ul><ul><ul><li>Joint commission National Patient Safety goals </li></ul></ul><ul><ul><li>Number of Surgical Site Infections </li></ul></ul><ul><ul><li>Number of Core Measures met. </li></ul></ul>
    20. 21. Leverage Point Three: Channel Leadership Attention to System-Level Improvement <ul><li>Transparency </li></ul><ul><ul><li>The fundamental force behind this method is simple and demonstrated in the following slides. </li></ul></ul><ul><ul><ul><li>Public (Regulators, media, community, patients) are paying attention to all of your quality and safety performance data. </li></ul></ul></ul><ul><ul><ul><ul><li>People inside the organization will tend to work with greater urgency to improve performance. </li></ul></ul></ul></ul>
    21. 22. Leverage Point Three: Channel Leadership Attention to System-Level Improvement <ul><li>All publically Reported data now – </li></ul><ul><ul><li>Joint Commission – www.jointcommission.org </li></ul></ul><ul><ul><li>Leap Frog – www.leapfroggroup.org </li></ul></ul><ul><ul><li>HCAHPS – www.cms.gov </li></ul></ul><ul><ul><li>Health grades – www.healthgrades.com </li></ul></ul>
    22. 28. Leverage Point Three Summary <ul><li>Health system leaders frequently express reservations about transparency because they fear loosing patients to other competitors. </li></ul><ul><li>Recent studies of transparency do not support the fears of hospital marketing departments of shifts in market share and volumes, even when reports show the hospital in a bad light. </li></ul><ul><li>There are no substantial findings to increased malpractice claims or loss of philanthropic monies when performance is poor. </li></ul>
    23. 29. Leverage Point Four: Put Patients and Families on the Improvement Team <ul><li>Get the right team on the bus “patients” </li></ul><ul><ul><li>Real power and influence </li></ul></ul><ul><ul><li>Use wisdom and experience to redesign and improve care systems </li></ul></ul><ul><li>This principle aligns with the American Hospital Association (AHA) approach to Patient-and-Family Centered care: </li></ul><ul><ul><li>All people (patients, families, and staff) will be treated with dignity and respect </li></ul></ul><ul><ul><li>Health care providers will communicate and share complete and unbiased information with patients and families in ways that are affirming and useful </li></ul></ul><ul><ul><li>Patients and families participate in experiences that enhance control and independence </li></ul></ul><ul><ul><li>Collaboration among patients, family members, and providers occur in policy and program development and professional education, as well as in the delivery of care. </li></ul></ul>
    24. 30. Leverage Point Four Summary <ul><li>Leverage four is an important force for driving the achievements and measuring results. </li></ul><ul><li>It has the greatest potential to drive the long-term transformation of the entire organization. </li></ul>
    25. 31. Leverage Five: Make the Chief Financial Officer a Quality Champion <ul><li>Why? </li></ul><ul><ul><li>Connection between quality and business performance is still weak. </li></ul></ul><ul><ul><li>Combination of pay-for-performance </li></ul></ul><ul><ul><li>Major changes to Medicare reimbursement </li></ul></ul><ul><ul><li>Elimination of increase payments for “never events” </li></ul></ul><ul><li>These have placed quality and payment on the radar of many CFO’s </li></ul>
    26. 32. CFO Cost Reduction Efforts: Health Care vs. Other Industries Where Health Care CFO’s go to reduce Costs <ul><li>Inputs to Core </li></ul><ul><li>Processes </li></ul><ul><li>Supplies </li></ul><ul><li>Staff </li></ul><ul><li>Equipment </li></ul><ul><li>…… . </li></ul><ul><li>Core Processes </li></ul><ul><li>Evaluating </li></ul><ul><li>Diagnosing </li></ul><ul><li>Treating </li></ul><ul><li>Communicating </li></ul><ul><li>…… </li></ul><ul><li>Outputs </li></ul><ul><li>Quality results </li></ul><ul><li>Safety Results </li></ul><ul><li>Costs </li></ul><ul><li>……… </li></ul>Where other Industries’ CFO’s Go to Reduce Costs
    27. 33. Level Five Summary <ul><li>Health Care Organizations would be far more likely to achieve dramatic improvement in system-level measures of financial and quality performance if CFO’s were to become strong drivers of quality based elimination of waste, and if their commitment were translated deeply into the budgeting, capital investment, and innovation and learning systems of an organization. </li></ul>Institute for Healthcare Improvement, 2008
    28. 34. Level Point Six: Engage Physicians <ul><li>Physicians themselves cannot bring about system-level performance improvement </li></ul><ul><ul><li>They are powerful in stopping it from moving forward </li></ul></ul><ul><li>System level improvement must be done with: </li></ul><ul><ul><li>Enthusiasm </li></ul></ul><ul><ul><li>Knowledge </li></ul></ul><ul><ul><li>Cultural clout </li></ul></ul><ul><ul><li>Personal leadership of physicians </li></ul></ul>
    29. 35. Level Point Six: Engage Physicians IHI Framework for Engaging Physicians <ul><li>1. Discover Common Purpose </li></ul><ul><li>2. Reframe Values and Beliefs </li></ul><ul><li>3. Segment the Engagement Plan </li></ul><ul><li>4. Use “Engaging” Improvement methods </li></ul><ul><li>5. Show Courage </li></ul><ul><li>6. Adopt an Engaging Style </li></ul>
    30. 36. Level Point Six: Engage Physicians IHI Framework for Engaging Physicians <ul><li>Discover a Common Purpose </li></ul><ul><ul><li>Improve patient outcomes </li></ul></ul><ul><ul><li>Reduce hassles and wasted time </li></ul></ul><ul><ul><li>Understand the organization’s culture </li></ul></ul><ul><ul><li>Understand the legal opportunities and barriers </li></ul></ul>
    31. 37. Level Point Six: Engage Physicians IHI Framework for Engaging Physicians <ul><li>Reframe Values and Beliefs </li></ul><ul><ul><li>Make physicians partners, not customers </li></ul></ul><ul><ul><li>Promote both system and individual responsibility for quality </li></ul></ul>
    32. 38. Level Point Six: Engage Physicians IHI Framework for Engaging Physicians <ul><li>Ask physicians what they need – Physician Satisfaction Team </li></ul><ul><ul><li>Getting started </li></ul></ul><ul><ul><ul><li>Gather the team </li></ul></ul></ul><ul><ul><ul><li>Gather data </li></ul></ul></ul><ul><ul><ul><li>Set goals </li></ul></ul></ul><ul><ul><ul><li>Take action </li></ul></ul></ul><ul><ul><ul><li>Evaluate and communicate results </li></ul></ul></ul>
    33. 39. Level Point Six: Engage Physicians IHI Framework for Engaging Physicians <ul><li>Tips for Quick wins with Physicians </li></ul><ul><ul><li>Send thank you notes </li></ul></ul><ul><ul><li>Pass along compliments </li></ul></ul><ul><ul><li>Spotlight physicians </li></ul></ul>
    34. 40. Level Point Six: Engage Physicians IHI Framework for Engaging Physicians <ul><li>Segment the Engagement Plan </li></ul><ul><ul><li>Use the 20/80 rule </li></ul></ul><ul><ul><li>Identify and active champions </li></ul></ul><ul><ul><li>Educate and inform structural leaders </li></ul></ul><ul><ul><li>Develop project management skills </li></ul></ul><ul><ul><li>Identify and work with “laggards” </li></ul></ul>
    35. 41. Level Point Six: Engage Physicians IHI Framework for Engaging Physicians <ul><li>Use “Engaging” Improvement methods </li></ul><ul><ul><li>Standardize what is standardizable, no more. </li></ul></ul><ul><ul><li>Generate light, not heat with data (use data sensibly) </li></ul></ul><ul><ul><li>Make the right thing easy to try </li></ul></ul><ul><ul><li>Make the right thing easy to do </li></ul></ul>
    36. 42. Standardizing Clinical Processes: Typical Approach Design Design Design Design Approve Conference Rooms REAL WORLD Implement
    37. 43. Standardized Clinical Processes: Refine the Design using Small Tests of Change Design Conference Rooms Approve (if necessary) Real World Test and Modify Test and Modify Test and Modify Implement
    38. 44. Level Point Six: Engage Physicians IHI Framework for Engaging Physicians <ul><li>Show Courage </li></ul><ul><ul><li>Provide backup all the way to the board. </li></ul></ul><ul><ul><li>Never easy – especially when powerful voices speak out against it </li></ul></ul><ul><ul><li>Source: Reinersten, J. (2008). Engaging Physicians: How the team can incorporate quality and safety. Healthcare Executive. May/June. 2008. p.78-81. </li></ul></ul>
    39. 45. Level Point Six: Engage Physicians IHI Framework for Engaging Physicians <ul><li>Adopt and Engaging Style – Suggested ideas </li></ul><ul><ul><li>Involve physicians from the Beginning </li></ul></ul><ul><ul><li>Work with real leaders </li></ul></ul><ul><ul><li>Choose Messages and Messengers Carefully </li></ul></ul><ul><ul><li>Be Transparent, especially with data </li></ul></ul><ul><ul><li>Value their time with your time </li></ul></ul>
    40. 46. Sample Implementation Process Source: StuderGroup.com (2005)
    41. 47. Leverage Point Seven: Build Improvement Capability <ul><li>Leaders must devote resources to establish capable leaders of improvement in every microsystem. </li></ul><ul><ul><li>“ Quality is everyone’s responsibility” </li></ul></ul><ul><ul><ul><ul><li>W. Edwards Deming </li></ul></ul></ul></ul><ul><li>More that 90 percent of leaders believe their performance problems can be traced to failed executions strategies. </li></ul>
    42. 48. Leverage Point Seven: Build Improvement Capability <ul><li>Cited Leadership problems: </li></ul><ul><ul><li>Short attention span </li></ul></ul><ul><ul><li>Inadequate resourcing </li></ul></ul><ul><ul><li>Too little executive oversight and monitoring </li></ul></ul><ul><ul><li>Failure to address “political” problems among professional groups. </li></ul></ul>
    43. 49. Leverage Point Seven: Build Improvement Capability <ul><li>Capabilities required of senior leaders to drive system-level improvement – requires both the ability to know, use, and teach: </li></ul><ul><ul><li>The model of improvement and small-scale rapid tests of change. </li></ul></ul><ul><ul><li>A coherent improvement strategy such as the Toyota Production System. </li></ul></ul><ul><ul><li>Concepts and practices in flow management. </li></ul></ul><ul><ul><li>Sophisticated practices in flow management. </li></ul></ul><ul><ul><li>Concepts and practices of scale-up spread of improvements </li></ul></ul><ul><ul><li>Concepts and practices of safety systems. </li></ul></ul>
    44. 50. Self Assessment Tool for System-Level Results <ul><li>Discussion and action tool designed to help </li></ul><ul><ul><li>Administration </li></ul></ul><ul><ul><li>Physicians </li></ul></ul><ul><ul><li>Nursing leaders </li></ul></ul><ul><li>Used to: </li></ul><ul><ul><li>Design and plan work leading to significant reduction in one or two system level measures </li></ul></ul><ul><ul><ul><li>Mortality rates </li></ul></ul></ul><ul><ul><ul><li>Harm rates </li></ul></ul></ul><ul><ul><ul><li>Nosocomial infection rates </li></ul></ul></ul>
    45. 51. 15 minute Break Yampa Valley near Steamboat Springs, CO. 2009 Photograph by Todd Grivetti ©
    46. 52. Leadership Leverage Points Self-Assessment Tool for System-Level Results Board has adopted the aims and is overseeing their achievement using system-level measures of progress against the aim. Senior Leadership team has developed specific “how much, by when” aims for system-level measures of quality and safety. 1. Establish and Oversee Specific System-Level Aims for Improvement at the Highest Governance Level By When By Whom Action Needed / Action Planned Leadership Leverage Points
    47. 53. Leadership Leverage Points Self-Assessment Tool for System-Level Results Senior Leadership team has resourced the projects that are necessary to achieve the aim with effective leaders. Senior Leadership team has developed a plan to achieve the aims that is focused on the right drivers, and had the necessary scale and pace. 2. Develop an Executable Strategy to Achieve the System-Level Aims and Oversee their Execution at the Highest Governance Level By When By Whom Action Needed / Action Planned Leadership Leverage Points
    48. 54. Summary of Seven Leadership Leverage Points for 2008 Changes <ul><li>Original leverage point focused on establishing the most effective senior leadership team. </li></ul><ul><li>Revised leverage point focuses exclusively on the transformational role of patients and families on leadership and improvement teams. </li></ul>Four : Put Patients and Families on the Improvement Team <ul><li>Confirmation and examples of the power of leadership attention to improvement aims. </li></ul><ul><li>A major new emphasis on the power of transparency to drive improvement and change. </li></ul>Three : Channel Leadership Attention to System-Level Improvement: Personal Leadership, Leadership systems, and Transparency <ul><li>Learning what it takes to execute change on large scale. </li></ul><ul><li>Focus on one or two major aims </li></ul><ul><li>Rigorous steering of the execution plan using good data from the field </li></ul><ul><li>Resourcing strategic improvements with capable improvers and change leaders as their primary job responsibility. </li></ul>Two: Develop and Executable Strategy to Achieve the system-level Aims and Oversee the execution at the highest governance level <ul><li>Emphasis on the critical role of the board in quality. </li></ul><ul><li>Learning about the power of stories and data at the board level. </li></ul>One : Establish and Oversee specific system-level Aims at the Highest Governance Level Key Changes in 2008 Leverage Points
    49. 55. Summary of Seven Leadership Leverage Points for 2008 Changes <ul><li>Continued reinforcement of the critical need to build capable improvers at every level as an important underpinning for the other six leverage points. </li></ul>Seven : Build Improvement Capability <ul><li>Developed an entirely new framework for engaging physicians in a shared quality agenda, with extensive examples. </li></ul>Six : Engage Physicians <ul><li>Learning about the potentially powerful role of the CFO can play in improvement once they see “reduce waste in core processes” as the primary driver of cost reductions, rather than the traditional approach of “reduce inputs to (defective) core processes” </li></ul>Five : Make the Chief Financial Officer a Quality Champion Key Changes in 2008 Leverage Points
    50. 56. Improving & Executing System Level Change Utilizing Leadership Frameworks & Toyota Production Specifications
    51. 57. Framework for Leadership Improvement 1. Set Direction: Mission, Vision, Strategy Make Status Quo Uncomfortable Make Future Attractive Push Pull <ul><li>3. Build Will </li></ul><ul><li>Plan for Improvement </li></ul><ul><li>Set Aims/Allocate Resources </li></ul><ul><li>Measure System Performance </li></ul><ul><li>Provide Encouragement </li></ul><ul><li>Make Financial Linkages </li></ul><ul><li>Learn Subject Matter </li></ul><ul><li>Work on Larger System </li></ul><ul><li>4. Generate Ideas </li></ul><ul><li>Read and Scan widely, Learn from other industries and disciplines </li></ul><ul><li>Benchmark to find Ideas </li></ul><ul><li>Listen to Customers </li></ul><ul><li>Invest in Research and Development </li></ul><ul><li>Manage Knowledge </li></ul><ul><li>Understand Organization as a System </li></ul><ul><li>5. Execute Change </li></ul><ul><li>Use Model for Improvement, Design and Redesign. </li></ul><ul><li>Review and Guide Key initiatives </li></ul><ul><li>Spread ideas </li></ul><ul><li>Communicate results </li></ul><ul><li>Sustain Improved Levels of Performance . </li></ul><ul><li>2. Establish the Foundation </li></ul><ul><li>Reframe Operating Values *Prepare Personally *Build Relationships </li></ul><ul><li>Build Improvement Capability *Choose and Align the Senior Team *Develop Future Leadership </li></ul>Source: IHI 2005.
    52. 58. Improving System Level Performance: Setting Goals and Ensuring Results <ul><li>Four Components </li></ul><ul><ul><li>Setting Breakthrough Performance Goals </li></ul></ul><ul><ul><li>Developing a portfolio of projects to support goals </li></ul></ul><ul><ul><li>Deploying resources to projects that are appropriate for the aim </li></ul></ul><ul><ul><li>Establish an Oversight and Learning System to Increase Chance of Producing Intended Results. </li></ul></ul>
    53. 59. Improving System Level Performance: Setting Goals and Ensuring Results <ul><li>Setting Breakthrough Performance Goals </li></ul><ul><ul><li>Generally set through strategic and business planning for the organization. </li></ul></ul><ul><ul><ul><li>Efficiency – Consists of: </li></ul></ul></ul><ul><ul><ul><ul><li>Assuming responsibility for total cost of care </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cost per capita </li></ul></ul></ul></ul><ul><ul><ul><ul><li>VS – </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hospital costs </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Length of Stay (LOS) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cost per case </li></ul></ul></ul></ul></ul>
    54. 60. Setting Goals and Ensuring Results <ul><li>Set Milestones and Acknowledge Progress </li></ul><ul><ul><li>Milestones allow you to monitor progress and help ensure you are on track </li></ul></ul><ul><ul><li>Identify and address issues that cause delays </li></ul></ul><ul><ul><li>Acknowledge and celebrate success/progress </li></ul></ul><ul><ul><li>Thank Stakeholders for their support. </li></ul></ul>
    55. 61. Four Sources of Leverage <ul><li>Complex Systems Theory </li></ul><ul><li>Observed Performance of Leaders in Health Systems </li></ul><ul><li>Hunches, Intuition, and Collective Experience </li></ul><ul><li>Ongoing Research and Development of Management Theories and Methods </li></ul>
    56. 62. Complex Systems Theory <ul><li>Complex adaptive systems cannot be specified and managed in detail (healthcare systems) </li></ul><ul><li>Highly likely that small changes in certain critical aspects of these systems might bring about surprising and unpredictable amounts of improvement or deterioration in overall system performance. </li></ul><ul><li>If leaders could choose the right system attributes (“leverage points”) and make small, but important changes; very large performance change might result. </li></ul>
    57. 63. Observed Performance of Leaders in Health Systems <ul><li>IHI’s Pursuing Perfection </li></ul><ul><li>IMPACT </li></ul><ul><li>100,000 Lives Campaign </li></ul><ul><li>5 Million Lives Campaign </li></ul><ul><li>Where has system level changes occurred? </li></ul><ul><ul><li>Does not occur without declared aim to achieve it. </li></ul></ul><ul><li>Leverage points based largely on qualitative data and stories of leaders versus solid base research. </li></ul>
    58. 64. Hunches, Intuition and Collective Experience <ul><li>Particularly those that surface as recurrent “difficult moments” for leaders. </li></ul><ul><li>Sense that the business case for quality is still fragile in many healthcare organizations and if the Chief Financial Officer (CFO) were to somehow become a champion for system level improvement quality, dramatic improvement would be much more likely. </li></ul>
    59. 65. Ongoing Research and Development of Management Theories and Methods <ul><li>IHI has continued to provide research and gained valuable knowledge such as: </li></ul><ul><ul><li>Execution </li></ul></ul><ul><ul><li>Governing Boards </li></ul></ul><ul><ul><li>Transparency </li></ul></ul><ul><ul><li>Physician engagement </li></ul></ul>
    60. 66. Achieve Strategic Goals Manage Local Improvement Build Capability ENVIRONMENT INFRASTRUCTURE Spread and Change Provide Leaders for Large System Change Spread and Change Provide Leaders for Large System Projects Provide Day to Day Leaders for Microsystems Core Elements for Process Improvement
    61. 67. Achieve Strategic Goals <ul><li>Strategic Goals Must: </li></ul><ul><ul><li>Be aligned with organizational priorities </li></ul></ul><ul><ul><li>Be associated with human and capital costs </li></ul></ul><ul><li>Boards, executives and clinical leaders proactively set goals for system level transformation. </li></ul><ul><ul><li>Identify new opportunities for improvement </li></ul></ul><ul><ul><li>Remove barriers </li></ul></ul><ul><ul><li>Celebrate Success </li></ul></ul>
    62. 68. Manage Local Improvement <ul><li>Plan for daily management of local improvement projects </li></ul><ul><ul><li>Support or sustain breakthrough aims to manage daily operations. </li></ul></ul><ul><li>Regularly and transparently review performance data </li></ul><ul><ul><li>Frequent and open assessment of data </li></ul></ul><ul><ul><ul><li>Includes everyone involved </li></ul></ul></ul><ul><ul><ul><li>Builds joint accountability for progress. </li></ul></ul></ul>
    63. 69. Develop Human Capital <ul><li>Medical staff takes responsibility for clinical improvement </li></ul><ul><ul><li>Physicians actively engaged in data review </li></ul></ul><ul><ul><li>Chief Medical Officer responsible for quality </li></ul></ul><ul><ul><ul><li>Creating a sense of ownership among medical staff </li></ul></ul></ul><ul><li>Organization invests in human capital and continuous learning, building capacity at all levels. </li></ul><ul><li>Successful organizations </li></ul><ul><ul><li>Invest significant resources to develop staff </li></ul></ul><ul><ul><li>Develop middle managers </li></ul></ul><ul><ul><li>Provide training with safety officers and improvement advisors </li></ul></ul>
    64. 70. “ It is Leadership’s job to build the will for change among busy professionals, implement systems to capture new ideas and spread them to the right people within the organization, and design and implement an effective strategy” Bisognano, Schummers, McCannon
    65. 71. Whole System-Measures and Toyota Specifications – System Level Whole System Measures and Toyota Specifications: System Level. IHI, 2008 $3,000 per capita Per capita health care expenditures Efficient 5% of Adults self-rate their health status as fair or poor. (Response rate will not differ by income) Self-Reported health status Effective and Equitable 72% of Patients report, “They give me exactly the help I want (and need) when I want (and need) it.” Patient Experience Score ( Response to the question in the How’s Your Health Database, “They give me exactly the help I want (and need) exactly when I want (and need) it.” Patient Centered Toyota Specifications Whole System Measure IOM Dimension of Quality
    66. 72. Improving System Level Performance: Setting Goals and Ensuring Results <ul><li>Component Level </li></ul><ul><ul><li>Looking at new ways of integrating several aspects of healthcare along the continuum </li></ul></ul><ul><ul><ul><li>Hospital </li></ul></ul></ul><ul><ul><ul><li>Home Care </li></ul></ul></ul><ul><ul><ul><li>Primary care offices </li></ul></ul></ul><ul><ul><ul><li>Family </li></ul></ul></ul><ul><ul><ul><ul><li>All center on the unique needs of the individual patient </li></ul></ul></ul></ul>
    67. 73. Whole System-Measures and Toyota Specifications: Component Level HSMR = 57 Hospital Standardized Mortality ratio (HSMR) Effective Care Primary Care: Same Day Access Specialty Care: Within 7 Days Days to third next available appointment Timely Access to Care 5 Adverse events per 1000 pt. days Adverse Events per 1000 pt. days Safe Care Reliability Levels 10 2 Pervasive Reliability Evidence Based Care Performance Specifications Measure Dimension
    68. 74. Mayo Clinic Comparisons
    69. 75. Whole System-Measures and Toyota Specifications: Component Level 81% of Patients are Satisfied Patient Satisfaction Patient – Centered Care $5,026 per enrollee Medicare Reimbursement Efficient Care 7.24 Hospital Days per Decedent during last six months of life Hospital Days per Decedent during the last six months of life Efficient Utilization and Resource Use 0.2 Cases with lost work days/100 FTE’s/Year Occupational Injuries and Illnesses Safe Work Place 30-Day Hospital Readmission = 4.69% Hospital Readmission Percentage Effective Care that Crosses Barriers HSMR = 57 Hospital Standardized Mortality ratio (HSMR) Effective Care Primary Care: Same Day Access Specialty Care: Within 7 Days Days to third next available appointment Timely Access to Care 5 Adverse events per 1000 pt. days Adverse Events per 1000 pt. days Safe Care Reliability Levels 10 2 Pervasive Reliability Evidence Based Care Performance Specifications Measure Dimension
    70. 76. Leadership’s Role in the Execution <ul><li>Successful execution of strategic goals depends on a genuine sense of share responsibility. </li></ul><ul><li>Execution remains the weak link in the framework for improvement </li></ul><ul><li>Make the case for Change </li></ul><ul><ul><li>Consider the reasons for the change </li></ul></ul><ul><ul><li>Describe current and desired states </li></ul></ul><ul><ul><li>Address the 5 W’s (Who, What, When Where, Why) </li></ul></ul>
    71. 77. Leadership’s Role in the Execution <ul><li>Enlist Stake Holders </li></ul><ul><ul><li>Look across the organization </li></ul></ul><ul><ul><ul><li>Departments/individuals interested in working on change </li></ul></ul></ul><ul><ul><ul><li>Determine supporters and potential naysayers </li></ul></ul></ul><ul><ul><ul><li>Invite Stakeholders to “come on board” </li></ul></ul></ul><ul><ul><ul><li>Make sure you have appropriate sponsorship/approval </li></ul></ul></ul><ul><ul><ul><li>Put together the team who will plan, implement and define roles and responsibilities. </li></ul></ul></ul>
    72. 78. Leadership’s Role in Execution <ul><li>Communicate The Vision </li></ul><ul><ul><li>Identify who are the best people to communicate the change </li></ul></ul><ul><ul><li>Who do you need to communicate to? </li></ul></ul><ul><ul><li>What do you need to communicate and what action need to be take </li></ul></ul><ul><ul><li>Communicate, Communicate, Communicate </li></ul></ul><ul><ul><ul><li>Transparency is Key </li></ul></ul></ul><ul><ul><ul><li>Face-to-Face is best </li></ul></ul></ul>
    73. 79. Leadership’s Role in Execution <ul><li>Expect Barriers to come up </li></ul><ul><ul><li>Unexpected resistance </li></ul></ul><ul><ul><li>Lack of knowledge or Ability </li></ul></ul><ul><ul><li>Process issues </li></ul></ul><ul><ul><li>Technology issues </li></ul></ul><ul><li>Develop plan to remove/address </li></ul><ul><li>Utilize Change/Transition Blueprint to help identify. </li></ul>
    74. 80. Leadership’s Role in Execution <ul><li>Why people resist change </li></ul><ul><ul><li>Fear of the unknown </li></ul></ul><ul><ul><ul><li>Safety is challenged </li></ul></ul></ul><ul><ul><li>Loss of Confidence </li></ul></ul><ul><ul><ul><li>Feeling of “significance” is challenged </li></ul></ul></ul><ul><ul><li>Lack of buy-in </li></ul></ul><ul><ul><li>Feeling overwhelmed </li></ul></ul>
    75. 81. Leadership’s Role in Execution <ul><li>Managing Resistance </li></ul><ul><ul><li>Change management right the first time </li></ul></ul><ul><ul><ul><li>Effective change management can eliminate many causes of resistance before they occur. </li></ul></ul></ul><ul><ul><li>Expect it </li></ul></ul><ul><ul><ul><li>Do not be surprised by resistance, expect it and plan for it. </li></ul></ul></ul><ul><ul><li>Identify root cause </li></ul></ul><ul><ul><ul><li>Make sure you aren’t simply responding to the symptom </li></ul></ul></ul><ul><ul><li>Engage Support </li></ul></ul><ul><ul><ul><li>Managers, Directors, and Executive support </li></ul></ul></ul><ul><ul><li>Consider the Culture </li></ul></ul><ul><ul><ul><li>Leader support </li></ul></ul></ul><ul><ul><ul><li>Informal Leaders </li></ul></ul></ul><ul><ul><ul><li>Generational issues </li></ul></ul></ul>
    76. 82. Step 3: Key Stakeholders/Customers Who may be affected by changing of the current state? Example: Specific departments, people, customers Step 4: Context (External, Internal Factors Driving the Need for Change) Example: Why would changing from the current state matter? Step 5: Approaches/Actions What possible ways could this issue be resolved? Example: Education program, change in policy, PDCA team, brainstorming Strategic Conversations Step 1: Current State What is the current situation that is driving the change? Example: What is not occurring? Step 2: Future State What would be the ideal situation after the change? Example: That particular “something” would be occurring.
    77. 84. Whole System-Measures and Toyota Specifications: Component Level 81% of Patients are Satisfied Patient Satisfaction Patient – Centered Care $5,026 per enrollee Medicare Reimbursement Efficient Care 7.24 Hospital Days per Decedent during last six months of life Hospital Days per Decedent during the last six months of life Efficient Utilization and Resource Use 0.2 Cases with lost work days/100 FTE’s/Year Occupational Injuries and Illnesses Safe Work Place 30-Day Hospital Readmission = 4.69% Hospital Readmission Percentage Effective Care that Crosses Barriers HSMR = 57 Hospital Standardized Mortality ratio (HSMR) Effective Care Primary Care: Same Day Access Specialty Care: Within 7 Days Days to third next available appointment Timely Access to Care 5 Adverse events per 1000 pt. days Adverse Events per 1000 pt. days Safe Care Reliability Levels 10 2 Pervasive Reliability Evidence Based Care Performance Specifications Measure Dimension
    78. 85. IHI’s Triple Aim <ul><li>Improve the Health of the defined population </li></ul><ul><li>Enhance the patient care Experience </li></ul><ul><ul><li>Quality </li></ul></ul><ul><ul><li>Access </li></ul></ul><ul><ul><li>Reliability </li></ul></ul><ul><li>Reduce, control cost per capita cost of care </li></ul>
    79. 86. Triple Aim <ul><li>Components: </li></ul><ul><ul><li>Focus on individuals and families </li></ul></ul><ul><ul><li>Redesign of primary care services and structures </li></ul></ul><ul><ul><li>Population health management </li></ul></ul><ul><ul><li>A cost-control platform </li></ul></ul><ul><ul><li>System integration and execution </li></ul></ul><ul><li>Macro & Micro level integrators </li></ul>
    80. 87. Triple Aim Design and Coordination of Care Per Capita Cost Population Health Individual Experience <ul><li>Act with the Individual and Family </li></ul><ul><li>Learn for the Population </li></ul>Beasley, 2009. Triple Aim
    81. 88. References/Bibliography/Webliography <ul><li>Beasley C. The Triple Aim: Optimizing health, care, and cost. Healthcare Executive. 2009 Jan/Feb;24 (1):64-65. </li></ul><ul><li>Bisognano M., Schummers, D., McCannon, J. Leadership’s role in execution. Healthcare Executive. 2008 Mar/Apr;23(2):66-70. </li></ul><ul><li>Conway, J. 2000. Strategies for Leadership: Hospital Executive and their role in patient safety. Dana-Farber Cancer Institute. </li></ul><ul><li>Conway J. Could it happen here? Learning from other organizations' safety efforts. Healthcare Executive. 2008 Nov/Dec;23(6):64-67. </li></ul><ul><li>Improving Quality and Achieving Equity: A Guide for Hospital Leaders. The Disparities Solutions Center at Massachusetts General Hospital Boston, Massachusetts, USA. </li></ul><ul><li>Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C. A Framework for Spread: From Local Improvements to System-Wide Change. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available on www.IHI.org ). </li></ul><ul><li>McCannon J. The key to winning the Campaign. Healthcare Executive. 2007 Sept/Oct:61-65. </li></ul>
    82. 89. References/Bibliography/Webliography <ul><li>Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results . IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org ). </li></ul><ul><li>Nolan, T., Martin, L, Mountford, J, Neumann, C, Schummers, D. A three-part approach to patient safety: Balanced strategy improves value, reduces costs. Healthcare Executive. 2008 Sep/Oct;23(5):70-74. </li></ul><ul><li>Nolann T, Martin L, Mountford J, Neumann C, Schummers D. The Key to Winning the Campaign: How executive leadership can transform hospital care in America. Healthcare Executive. 2007 Sept/Oct. (Available on www.ihi.org). </li></ul><ul><li>Pugh M, Reinertsen JL. Reducing harm to patients. Healthcare Executive. 2007;22(6):62, 64-65. </li></ul><ul><li>Reinertsen J. Engaging physicians: How the team can incorporate quality and safety. Healthcare Executive. 2008 May/June;23(3):78-81. </li></ul><ul><li>Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2008. (Available on www.IHI.org ) </li></ul>
    83. 90. Conclusion Thank you ?Questions?
    84. 91. Contact Information <ul><li>Todd M. Grivetti, MSN, RN, CCRN, CNML </li></ul><ul><li>Clinical Nurse Manager – Regional Neurosciences Center </li></ul><ul><li>Poudre Valley Health System </li></ul><ul><li>Fort Collins, CO </li></ul><ul><li>E-mail: [email_address] </li></ul><ul><li>Office: 970-495-8325 </li></ul>

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