This is a legacy publication from the NHS Institute for Innovation and Improvement. It outlines a framework of five models for thinking about making change happen, based on the work of McKinsey and Co
Is a Medical Writer the Missing Accelerant to Your Outcome Improvement Efforts?Health Catalyst
Quality improvement efforts are more important than ever. However, even improvement efforts that have the right people, processes, and technology can struggle to make progress. A medical writer with healthcare knowledge and strong information design skills may be the missing ingredient that can help speed time to adoption and value.
This article discusses the functions a medical writer can fulfill, and why they matter. You will also learn:
The four skills that a medical writer with strong information design skills brings to an improvement team.
Examples of output of medical writers in a healthcare setting.
The skills a medical writer needs.
Additionally, you will learn how to find this unique skill set and where you might find this key person.
Essay on Positive Thinking | Short and Long Essays on Positive Thinking .... Importance Of Positive Thinking for Success Free Essay Example. 8 Positive Thinking Assignments for Students - Brookes Publishing Co.. The Power of Positive Thinking for Those Diagnosed with Challenges Free .... Write a short essay on Positive Thinking | Essay Writing | English .... Essay On Positive Thinking in English for Students | 500 Words Essay.
1Running head CHANGE MANAGEMENT PROPOSAL2CHANGE M.docxdrennanmicah
1
Running head: CHANGE MANAGEMENT PROPOSAL
2
CHANGE MANAGEMENT PROPOSAL
Change Management Proposal
HR006: Leadership, System Thinking, and Change Management
Yasmin Abdulghafour
Walden University Comment by Dr. Steve: Yasmin – this report is intended to be one paper (two parts) – please combine your Part I and Part II into a single document when you re-submit.
Executive Summary
Organizational change is the process in which any organization brings or desires to bring changes in its organizational culture, structure, strategies, functions or technologies to cause the change within the company to achieve certain goals and improve the overall performance of the company. This study is based on proposing a change management model for Ronald Reagan UCLA medical Medical center Center which is located in Los Angeles. UCLA medical Medical center Center is focused on continuously improving its services by implementing the concept of “True North” which suggests to improve and idealize different aspect of services including quality, equity, care experience, safety, financial stewardship, and workforce development and care.
This change management proposal recommends the use of Kotter's 8-step change model to bring the change in the organizational culture of the UCLA Health System. This proposal also highlights the role of communication in bringing change in the organization. Moreover, this study suggests the strategies to motivate employees to embrace the process of change and recommends the training strategies that can be used to implement the process of change successfully. This study also provides a guideline of how the change process can be evaluated and measured on the basis of organizational and individual performances. Comment by Dr. Steve: Good
Change Management Proposal
Introduction of the Organization
Ronald Reagan UCLA medical Medical centerCenter, a 520-bed facility, is a medical service providing organization located in Los Angeles. It was founded in 1955 and initially started as UCLA medical Medical center Center but, later it became Ronald Reagan UCLA Medical center Center in 2008. The medical center has highly qualified staff which provides 24 hours of medical services. This center offers many clinical services including cancer services, cardiovascular services, pediatric services, transplantation facilities, men and women health services, and weight management programs, etc. the facility has about ten 10 floors, and every floor contains dialysis storage, satellite pharmacy, respiratory therapy workrooms, and restrooms for doctors and residents. What is your resource for this information? Comment by Dr. Steve: Run on sentence – try re-writing this as two sentences
The mission of UCLA health Health is to deliver timely and leading research, education, and patient care. It is aimed at healing humankind by providing medical services and acts of kindness. UCLA Health is focused on providing the best health care services throu.
This is a legacy publication from the NHS Institute for Innovation and Improvement. It outlines a framework of five models for thinking about making change happen, based on the work of McKinsey and Co
Is a Medical Writer the Missing Accelerant to Your Outcome Improvement Efforts?Health Catalyst
Quality improvement efforts are more important than ever. However, even improvement efforts that have the right people, processes, and technology can struggle to make progress. A medical writer with healthcare knowledge and strong information design skills may be the missing ingredient that can help speed time to adoption and value.
This article discusses the functions a medical writer can fulfill, and why they matter. You will also learn:
The four skills that a medical writer with strong information design skills brings to an improvement team.
Examples of output of medical writers in a healthcare setting.
The skills a medical writer needs.
Additionally, you will learn how to find this unique skill set and where you might find this key person.
Essay on Positive Thinking | Short and Long Essays on Positive Thinking .... Importance Of Positive Thinking for Success Free Essay Example. 8 Positive Thinking Assignments for Students - Brookes Publishing Co.. The Power of Positive Thinking for Those Diagnosed with Challenges Free .... Write a short essay on Positive Thinking | Essay Writing | English .... Essay On Positive Thinking in English for Students | 500 Words Essay.
1Running head CHANGE MANAGEMENT PROPOSAL2CHANGE M.docxdrennanmicah
1
Running head: CHANGE MANAGEMENT PROPOSAL
2
CHANGE MANAGEMENT PROPOSAL
Change Management Proposal
HR006: Leadership, System Thinking, and Change Management
Yasmin Abdulghafour
Walden University Comment by Dr. Steve: Yasmin – this report is intended to be one paper (two parts) – please combine your Part I and Part II into a single document when you re-submit.
Executive Summary
Organizational change is the process in which any organization brings or desires to bring changes in its organizational culture, structure, strategies, functions or technologies to cause the change within the company to achieve certain goals and improve the overall performance of the company. This study is based on proposing a change management model for Ronald Reagan UCLA medical Medical center Center which is located in Los Angeles. UCLA medical Medical center Center is focused on continuously improving its services by implementing the concept of “True North” which suggests to improve and idealize different aspect of services including quality, equity, care experience, safety, financial stewardship, and workforce development and care.
This change management proposal recommends the use of Kotter's 8-step change model to bring the change in the organizational culture of the UCLA Health System. This proposal also highlights the role of communication in bringing change in the organization. Moreover, this study suggests the strategies to motivate employees to embrace the process of change and recommends the training strategies that can be used to implement the process of change successfully. This study also provides a guideline of how the change process can be evaluated and measured on the basis of organizational and individual performances. Comment by Dr. Steve: Good
Change Management Proposal
Introduction of the Organization
Ronald Reagan UCLA medical Medical centerCenter, a 520-bed facility, is a medical service providing organization located in Los Angeles. It was founded in 1955 and initially started as UCLA medical Medical center Center but, later it became Ronald Reagan UCLA Medical center Center in 2008. The medical center has highly qualified staff which provides 24 hours of medical services. This center offers many clinical services including cancer services, cardiovascular services, pediatric services, transplantation facilities, men and women health services, and weight management programs, etc. the facility has about ten 10 floors, and every floor contains dialysis storage, satellite pharmacy, respiratory therapy workrooms, and restrooms for doctors and residents. What is your resource for this information? Comment by Dr. Steve: Run on sentence – try re-writing this as two sentences
The mission of UCLA health Health is to deliver timely and leading research, education, and patient care. It is aimed at healing humankind by providing medical services and acts of kindness. UCLA Health is focused on providing the best health care services throu.
Running Head BELLEVUE HOSPITAL AND THE HEART HEALTH SERVICES .docxhealdkathaleen
Running Head: BELLEVUE HOSPITAL AND THE HEART HEALTH SERVICES 1
BELLEVUE HOSPITAL AND THE HEART HEALTH SERVICES 2
Bellevue Hospital And The Heart Health Services
Introduction of Bellevue hospital and the heart health service
Bellevue Hospital is the oldest public hospital in the USA and boasts having the most effective staff in line with the goals of the hospital in caregiving. Located at 462 First Avenue in the Kip bay of Manhattan in New York City. Currently, it serves an average of 460000 outpatients and has grown to be one of the most efficient hospitals in New York City. The heart health service is housed in the cardiology, and cardiothoracic surgery department which is world-renowned and the heart health program is among the few departments in the world and has a state of the art labs and have “our door to STEMI” produces better services beyond the average (Root, Schonfeld, Williams, & Poppers, 2017).
Mission, vision and strategic goal of the organisation
The mission of the hospital is to provide the highest quality of care to all the needy people in New York and all over the world with honesty, integrity, and with dignity even if the patient is not in a position to pay for the service that has been provided to them. The vision of the hospital is to be among the top ten hospitals in the country as far as the provision of quality service is concerned. Further, the hospital has a strategic goal of making the hospital the most popular in terms of compliance and service delivery so that all the people would work better at all time without any failure (Bellevue, 2016). Another strategic goal is improving communication so that the service delivery can be first, efficient and up to date.
The current state of the service using the marketing framework
The current state of the service is that it has invested in technology to serve the goals and ambitions of the hospital. It has incorporated technology to come up with the state of the art lab where people all over the country can be served. It is one of the hospitals where open-heart surgery is performed. Since the need of the hospital is to be the go-to place, it has ensured that the appropriate technology, leadership, and correct values to ensure that the correct virtues of the hospitals are maintained for better service delivery.
Stakeholders of the organization using the marketing framework
The Bellevue hospital has several stakeholders who interact in a very effective way to maintain the business in the hospital. The first stakeholders are the patients who pay for the services and the physicians who work around the clock to ensure that the patients always get what they pay for. The government is yet another stakeholder mainly mandated to monitor and ensure that the organization operates within the dictates of the law. Insurance companies and pharmaceutical companies all work together to ensure that the goals of the o ...
Running head APPRECIATIVE INQUIRY 1 APPRECIATIVE INQUIRY6.docxhealdkathaleen
Running head: APPRECIATIVE INQUIRY 1
APPRECIATIVE INQUIRY 6
Appreciative Inquiry
Kristine Ruche
Leadership and Management for Nurse Executives
Capella University
April, 2020
Appreciative Inquiry
In the highly unpredictable global business environment, it is quite tempting to approach strategic decision making with a specific goal already in mind. In most cases, these strategies are aimed at mitigating the problems as they are problem-focused. Organizations typically focus on areas that are not working as intended while adopting a root cause mindset only to find themselves faced with a set of different, but related questions down the line. An appreciative inquiry model is one of the critical positive enterprise approaches to development and collective learning (Ruhe, Bobiak, Litaker, Carter, Wu, Schroeder, Zyzanski, Weyer, Werner, Fry, & Stange, 2011). An appreciative inquiry is a collaborative and strength-based approach that aims at changing the organizations and other human systems. One of the fundamental proponents behind the appreciative inquiry is that with time it has come to be increasingly adopted by organizations as to approach changes and growth from a problem-solving perspective. Form appreciative inquiry approach organizations should strongly focus on improving efficiency, surviving, and better performance and not just solving what is wrong, which is a deficit-based approach.
Appreciative inquiry in health care
The appreciative inquiry in the health care facility in which I work as a nurse will mainly focus on improving care services, especially to underserved women. The approach will focus on the positive and creativity as the driving forces for an improved future of healthcare services as is described and embraced for execution as an intervention for the achievement of behavioral health change at the individual levels. Guiding proponent for its application with clients is offered with an example of its use demonstrated in improving care services for the women of low economic status in improving their lifestyle.
Leadership skills to promote effective healthcare
Some of the qualities and skills that are useful in ensuring there is effective healthcare delivery include: great communication skills, being able to set the vision for the healthcare organization and emotional intelligence skills (Adair, 2016). The leaders should have people management skills which enables them to focus efforts of the healthcare workforce and resources towards a common goal. To make projects a success the leaders must have adequate knowledge and experience in project management such as budgetary skills and effective decision-making skills. Having effective analytical skills enable a leader to effectively analyze all possible alternatives that can make any project successful.
Strategies for healthcare teams to achieve set goals
Some of the strategies for ensuring that the healthcare teams are able to meet organizational goals include training ...
Section #2To be completed by Learner2.1 ProjectWrite app.docxkenjordan97598
Section #2
To be completed by Learner
2.1 Project
Write approximately one paragraph that describes the action research project and the basis for it being addressed.
The action research project seeks to explore pertinent leadership effectiveness issue created by the healthcare reform process in healthcare institutions across the United States. The reform process has created a dynamic environment that is in constant flux. Essentially, healthcare reform institutionalization has proven to be very beneficial when it comes to reducing the rising cost of healthcare. Additionally, it helps ensure that effective delivery of primary care is achieved so as to diminish the prevalence of chronic illnesses such as diabetes and cardiac-related health problems. The shift towards preventive care for the reduction of chronic illnesses requires more engagement between the patients and the doctors and closer follow-ups of patient outcomes. This requires effective leadership when it comes to the creation a workforce that is responsive to long-term patient needs. This means the healthcare professionals such as the physicians and nurses need effective leadership in hospital management so as to ensure they are motivated and engaged in the change process through teamwork and partnerships within hierarchical structures. Nonetheless, the purpose of this action research is assess Micheal E. DeBakey VA Medical Center of Houston’s leadership so as to provide a leadership model that includes the most appropriate leadership qualities that can be adopted by the organization to create a dynamic healthcare environment. Essentially, the action research project will involve a qualitative analysis of case studies related to leadership mechanisms within the institution and how they influence employee and patient outcomes. Based on the findings of the studies conducted, the possibility of using the proposed leadership model to improve outcomes will also be gauged. Comment by Nita Stika: What example would you use to demonstrate how this is true? Comment by Nita Stika: Management, observation or as Dr. Z suggests. Comment by Nita Stika: To assess Comment by Nita Stika: Current administrative structure so as to construct a leadership model that includes the most compatible qualities to be adopted? Comment by Nita Stika: Again, a forgone conclusion, could.
Reference
Thompson, J.M. (2007). Health Services Administration. Sudbury, MA: Jones and Bartlett.
Dageling, P. and Carr, A. (2004). Leadership for the systemization of health care: the unaddressed issue in health care reform. Journal of Health Organization and Management, 18(6), 399 – 414.
2.2 Contribution to Society
Using citations, answer the following questions in order:
1. How does your project improve a current practice?
2void . If your action research project is successful, how could your project impact your field of interest?
3. What are the practical implications of your project? For example, what will be the impa.
The Top Five Insights into Healthcare Operational Outcomes ImprovementHealth Catalyst
Effective, sustainable healthcare transformation rests in the organizational operations that power care delivery. Operations include the administrative, financial, legal, and clinical activities that keep health systems running and caring for patients. With operations so critical to care delivery, forward-thinking organizations continuously strive to improve their operational outcomes. Health systems can follow thought leadership that addresses common industry challenges—including waste reduction, obstacles in process change, limited hospital capacity, and complex project management—to inform their operational improvement strategies.
Five top insights address the following aspects of healthcare operational outcomes improvement:
Quality improvement as a foundational business strategy.
Using improvement science for true change.
Increasing hospital capacity without construction.
Leveraging project management techniques.
Features of highly effective improvement projects.
Improving Strategic Engagement for Healthcare CIOs with Five Key QuestionsHealth Catalyst
A healthcare CIO’s role can demand such an intense focus on technology that IT leaders may struggle to find natural opportunities to engage with their C-suite peers in non-technical conversations. To bridge the gap, healthcare CIOs can answer five fundamental questions to better align their programs with organizational strategic goals and guide IT services to their full potential:
Whom do we serve?
What services do we provide?
How do we know we are doing a great job?
How do we provide the services?
How do we organize?
Effective Healthcare Decision Support for Executives: Three Problems that Lea...Health Catalyst
In the high-pressured world of value-based care, healthcare leadership is more important than ever. Leaders need to make data-driven decisions and respond to the increasing demands of patients while cutting costs.
The right tools–ones that support today’s outcome-focused healthcare environment–can help leaders break through the noise to make effective decisions. This article shares three common problems faced by healthcare leadership and how Leading Wisely, an executive decision support tool helps them make informed decisions and guide their organizations forward. Three effective strategies for healthcare leadership include:
How to prevent communication breakdown.
How to break through measure madness.
How to alleviate information overload and siloed reporting.
A Nurse’s Role in the Systems Development Life CycleWhile the proc.docxJospehStull43
A Nurse’s Role in the Systems Development Life Cycle
While the process of developing and implementing a health information technology system may seem overwhelming at first, the systems development life cycle (SDLC) provides organizations with a framework to deliver efficient and effective information systems. Though the SDLC is a common overarching structure for implementing information systems, it is not a one-size-fits-all process. In fact, there are a multitude of approaches that can be used to guide the systems development life cycle. The SDLC approach that is most appropriate for a particular organization will be highly contextual and subject to organization-specific differences.
This week prompts you to analyze the process of selecting an appropriate health information technology and then evaluate techniques that positively impact the steps of the systems development life cycle in an EHR implementation. You also determine what barriers might occur at each stage and how these could be overcome.
Learning Objectives
Students will:
Analyze how a nurse can contribute to each stage of the systems development life cycle
Photo Credit: Jose Luis Pelaez Inc]/[Brand X Pictures]/Getty ImagesCredit
Learning Resources
Note:
To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
McGonigle, D., & Mastrian, K. G. (2015).
Nursing informatics and the foundation of knowledge
(3rd ed.). Burlington, MA: Jones and Bartlett Learning.
Chapter 10, “Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making”
This chapter explains the systems development life cycle and explores various methods of applying it. The chapter also examines the importance of interoperability in implementing HITECH.
Chapter 11, “Administrative Information Systems”
This chapter provides an overview of agency-based health information systems. The text also details how administrators can use core business systems in their practice.
Boswell, R. A. (2011). A physician group’s movement toward electronic health records: A case study using the transtheoretical model for organizational change.
Consulting Psychology Journal: Practice and Research, 63
(2), 138–148.
Retrieved from the Walden Library databases.
The authors of this article present a case study on an EHR implementation in a multispecialty physician group. The case study attempts to determine actions that promote successful EHR implementation and the pros and cons of implementation.
Hsiao, J., Chang, H., & Chen, R. (2011).A study of factors affecting acceptance of hospital information systems: A nursing perspective.
Journal of Nursing Research, 19
(2), 150–160.
Retrieved from the Walden Library databases.
The focus of this article is to determine what factors are most important in predicting the acceptance of new health information technology. The results of the study indicated .
SYSTEMS THEORYAs noted in the Learning Resources, systems theory p.docxjonghollingberry
SYSTEMS THEORY
As noted in the Learning Resources, systems theory provides a meaningful and beneficial means of examining challenges in health care organizations. To do this effectively, however, it is essential to assess
all
system components, as some may be relatively healthy while others are problematic.
For this Assignment, you apply systems theory to the examination of a problem in a department or a unit within a health care organization. (
Note:
You may use the same problem you identified for the Discussion as long as it meets the criteria for this assignment.)
To prepare:
·
Review the Meyer article, “Nursing Services Delivery Theory: An Open System Approach,” in this week’s Learning Resources. Focus especially on the information presented in Table 1 (p. 2831) and Figure 2 (p. 2833).
·
Reflect on your organization or one with which you are familiar. Within a particular department or unit in this organization, identify a problem the staff is encountering.
·
Using Table 1 in the Meyer article as a guide, analyze the department or unit, identifying inputs, throughput, output, cycles of events, and negative feedback. Consider whether the problem you have selected relates to input, throughput, output, cycles of events, and/or negative feedback.
·
Think about how you could address the problem: Consider what a desired outcome would be, then formulate related goals and objectives, and translate those goals into policies and procedures.
·
Research professional standards that are pertinent to your identified problem.
·
Reflect on the organization’s mission statement and values. In addition, consider how addressing this problem would uphold the mission and values, while improving the organizational culture and climate. (Depending on the organization you have selected, you may have explored these in the Week 1 Discussion.)
To complete:
Write a 3- to 5-page paper (page count does not include title and reference page) that addresses the following:
·
Describe a department or unit within a health care organization using systems theory terminology. Include a description of inputs, throughput, output, cycles of events, and negative feedback.
·
Describe the problem you identified within the department or unit using an open- systems approach, and state where the problem exists using the systems theory model (input, throughput, output, cycles of events, or negative feedback).
·
Based on this information, explain how you would address the problem as follows:
o
Formulate a desired outcome.
o
Identify goals and objectives that would facilitate that outcome.
o
Translate those goals and objectives into policies and procedures for the department or unit.
o
Describe relevant professional standards.
·
Explain how your proposed resolution to the problem would uphold the organization’s mission and values and improve the culture and climate.
*This paper must include a title page, introduction, summary, and references.
* Follow APA 6
th
ed for the ci.
Issues Identify at least seven issues you see in the case1..docxbagotjesusa
Issues: Identify at least seven issues you see in the case
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
What is the Key issue you see in the case: __________________________
What facts pertain to the case: Identify at least three important facts that pertain to the case
1.
2.
3.
4.
5.
What assumptions do you plan to make in your analysis: None is an acceptable answer
1.
2.
3
What people and organizations may have an impact on the case: There should be at least five.
1.
2.
3.
4.
5.
6.
7.
8.
9.
You are writing the case from the perspective of which person or organization:______________
What tools of Analysis would you use in this case: You only need to identify them and explain what information each will give you that you feel is important.
Based upon the above information – provide three alternatives
Alternative 1 is the Status Quo or to do nothing different that the current situation.
Identify at least three arguments in favor and three against this approach
Pros
1.
2.
3.
4.
5.
Cons
1.
2.
3.
4.
5.
Alternative 2 ____________________________________________________
Identify at least three arguments in favor and three against this approach
Pros
1.
2.
3.
4.
5.
Cons
1.
2.
3.
4.
5.
Alternative 3 ______________________________________________
Identify at least three arguments in favor and three against this approach
Pros
1.
2.
3.
4.
5.
Cons
1.
2.
3.
4.
5.
Given the information above select your recommended alternative and explain why you feel it is the best alternative: This should take three to five paragraphs and be based upon the information presented in your case.
.
Issues and disagreements between management and employees lead.docxbagotjesusa
Issues and disagreements between management and employees lead to formation of labor unions. Over the decades, the role of labor unions has been interpreted in various ways by employees across the globe.
What are some of the reasons employees join labor unions?
Did you ever belong to a labor union? If you did, do you think union membership benefited you?
If you've never belonged to a union, do you think it would have benefited you in your current or past employment? Why or why not?
.
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Running Head BELLEVUE HOSPITAL AND THE HEART HEALTH SERVICES .docxhealdkathaleen
Running Head: BELLEVUE HOSPITAL AND THE HEART HEALTH SERVICES 1
BELLEVUE HOSPITAL AND THE HEART HEALTH SERVICES 2
Bellevue Hospital And The Heart Health Services
Introduction of Bellevue hospital and the heart health service
Bellevue Hospital is the oldest public hospital in the USA and boasts having the most effective staff in line with the goals of the hospital in caregiving. Located at 462 First Avenue in the Kip bay of Manhattan in New York City. Currently, it serves an average of 460000 outpatients and has grown to be one of the most efficient hospitals in New York City. The heart health service is housed in the cardiology, and cardiothoracic surgery department which is world-renowned and the heart health program is among the few departments in the world and has a state of the art labs and have “our door to STEMI” produces better services beyond the average (Root, Schonfeld, Williams, & Poppers, 2017).
Mission, vision and strategic goal of the organisation
The mission of the hospital is to provide the highest quality of care to all the needy people in New York and all over the world with honesty, integrity, and with dignity even if the patient is not in a position to pay for the service that has been provided to them. The vision of the hospital is to be among the top ten hospitals in the country as far as the provision of quality service is concerned. Further, the hospital has a strategic goal of making the hospital the most popular in terms of compliance and service delivery so that all the people would work better at all time without any failure (Bellevue, 2016). Another strategic goal is improving communication so that the service delivery can be first, efficient and up to date.
The current state of the service using the marketing framework
The current state of the service is that it has invested in technology to serve the goals and ambitions of the hospital. It has incorporated technology to come up with the state of the art lab where people all over the country can be served. It is one of the hospitals where open-heart surgery is performed. Since the need of the hospital is to be the go-to place, it has ensured that the appropriate technology, leadership, and correct values to ensure that the correct virtues of the hospitals are maintained for better service delivery.
Stakeholders of the organization using the marketing framework
The Bellevue hospital has several stakeholders who interact in a very effective way to maintain the business in the hospital. The first stakeholders are the patients who pay for the services and the physicians who work around the clock to ensure that the patients always get what they pay for. The government is yet another stakeholder mainly mandated to monitor and ensure that the organization operates within the dictates of the law. Insurance companies and pharmaceutical companies all work together to ensure that the goals of the o ...
Running head APPRECIATIVE INQUIRY 1 APPRECIATIVE INQUIRY6.docxhealdkathaleen
Running head: APPRECIATIVE INQUIRY 1
APPRECIATIVE INQUIRY 6
Appreciative Inquiry
Kristine Ruche
Leadership and Management for Nurse Executives
Capella University
April, 2020
Appreciative Inquiry
In the highly unpredictable global business environment, it is quite tempting to approach strategic decision making with a specific goal already in mind. In most cases, these strategies are aimed at mitigating the problems as they are problem-focused. Organizations typically focus on areas that are not working as intended while adopting a root cause mindset only to find themselves faced with a set of different, but related questions down the line. An appreciative inquiry model is one of the critical positive enterprise approaches to development and collective learning (Ruhe, Bobiak, Litaker, Carter, Wu, Schroeder, Zyzanski, Weyer, Werner, Fry, & Stange, 2011). An appreciative inquiry is a collaborative and strength-based approach that aims at changing the organizations and other human systems. One of the fundamental proponents behind the appreciative inquiry is that with time it has come to be increasingly adopted by organizations as to approach changes and growth from a problem-solving perspective. Form appreciative inquiry approach organizations should strongly focus on improving efficiency, surviving, and better performance and not just solving what is wrong, which is a deficit-based approach.
Appreciative inquiry in health care
The appreciative inquiry in the health care facility in which I work as a nurse will mainly focus on improving care services, especially to underserved women. The approach will focus on the positive and creativity as the driving forces for an improved future of healthcare services as is described and embraced for execution as an intervention for the achievement of behavioral health change at the individual levels. Guiding proponent for its application with clients is offered with an example of its use demonstrated in improving care services for the women of low economic status in improving their lifestyle.
Leadership skills to promote effective healthcare
Some of the qualities and skills that are useful in ensuring there is effective healthcare delivery include: great communication skills, being able to set the vision for the healthcare organization and emotional intelligence skills (Adair, 2016). The leaders should have people management skills which enables them to focus efforts of the healthcare workforce and resources towards a common goal. To make projects a success the leaders must have adequate knowledge and experience in project management such as budgetary skills and effective decision-making skills. Having effective analytical skills enable a leader to effectively analyze all possible alternatives that can make any project successful.
Strategies for healthcare teams to achieve set goals
Some of the strategies for ensuring that the healthcare teams are able to meet organizational goals include training ...
Section #2To be completed by Learner2.1 ProjectWrite app.docxkenjordan97598
Section #2
To be completed by Learner
2.1 Project
Write approximately one paragraph that describes the action research project and the basis for it being addressed.
The action research project seeks to explore pertinent leadership effectiveness issue created by the healthcare reform process in healthcare institutions across the United States. The reform process has created a dynamic environment that is in constant flux. Essentially, healthcare reform institutionalization has proven to be very beneficial when it comes to reducing the rising cost of healthcare. Additionally, it helps ensure that effective delivery of primary care is achieved so as to diminish the prevalence of chronic illnesses such as diabetes and cardiac-related health problems. The shift towards preventive care for the reduction of chronic illnesses requires more engagement between the patients and the doctors and closer follow-ups of patient outcomes. This requires effective leadership when it comes to the creation a workforce that is responsive to long-term patient needs. This means the healthcare professionals such as the physicians and nurses need effective leadership in hospital management so as to ensure they are motivated and engaged in the change process through teamwork and partnerships within hierarchical structures. Nonetheless, the purpose of this action research is assess Micheal E. DeBakey VA Medical Center of Houston’s leadership so as to provide a leadership model that includes the most appropriate leadership qualities that can be adopted by the organization to create a dynamic healthcare environment. Essentially, the action research project will involve a qualitative analysis of case studies related to leadership mechanisms within the institution and how they influence employee and patient outcomes. Based on the findings of the studies conducted, the possibility of using the proposed leadership model to improve outcomes will also be gauged. Comment by Nita Stika: What example would you use to demonstrate how this is true? Comment by Nita Stika: Management, observation or as Dr. Z suggests. Comment by Nita Stika: To assess Comment by Nita Stika: Current administrative structure so as to construct a leadership model that includes the most compatible qualities to be adopted? Comment by Nita Stika: Again, a forgone conclusion, could.
Reference
Thompson, J.M. (2007). Health Services Administration. Sudbury, MA: Jones and Bartlett.
Dageling, P. and Carr, A. (2004). Leadership for the systemization of health care: the unaddressed issue in health care reform. Journal of Health Organization and Management, 18(6), 399 – 414.
2.2 Contribution to Society
Using citations, answer the following questions in order:
1. How does your project improve a current practice?
2void . If your action research project is successful, how could your project impact your field of interest?
3. What are the practical implications of your project? For example, what will be the impa.
The Top Five Insights into Healthcare Operational Outcomes ImprovementHealth Catalyst
Effective, sustainable healthcare transformation rests in the organizational operations that power care delivery. Operations include the administrative, financial, legal, and clinical activities that keep health systems running and caring for patients. With operations so critical to care delivery, forward-thinking organizations continuously strive to improve their operational outcomes. Health systems can follow thought leadership that addresses common industry challenges—including waste reduction, obstacles in process change, limited hospital capacity, and complex project management—to inform their operational improvement strategies.
Five top insights address the following aspects of healthcare operational outcomes improvement:
Quality improvement as a foundational business strategy.
Using improvement science for true change.
Increasing hospital capacity without construction.
Leveraging project management techniques.
Features of highly effective improvement projects.
Improving Strategic Engagement for Healthcare CIOs with Five Key QuestionsHealth Catalyst
A healthcare CIO’s role can demand such an intense focus on technology that IT leaders may struggle to find natural opportunities to engage with their C-suite peers in non-technical conversations. To bridge the gap, healthcare CIOs can answer five fundamental questions to better align their programs with organizational strategic goals and guide IT services to their full potential:
Whom do we serve?
What services do we provide?
How do we know we are doing a great job?
How do we provide the services?
How do we organize?
Effective Healthcare Decision Support for Executives: Three Problems that Lea...Health Catalyst
In the high-pressured world of value-based care, healthcare leadership is more important than ever. Leaders need to make data-driven decisions and respond to the increasing demands of patients while cutting costs.
The right tools–ones that support today’s outcome-focused healthcare environment–can help leaders break through the noise to make effective decisions. This article shares three common problems faced by healthcare leadership and how Leading Wisely, an executive decision support tool helps them make informed decisions and guide their organizations forward. Three effective strategies for healthcare leadership include:
How to prevent communication breakdown.
How to break through measure madness.
How to alleviate information overload and siloed reporting.
A Nurse’s Role in the Systems Development Life CycleWhile the proc.docxJospehStull43
A Nurse’s Role in the Systems Development Life Cycle
While the process of developing and implementing a health information technology system may seem overwhelming at first, the systems development life cycle (SDLC) provides organizations with a framework to deliver efficient and effective information systems. Though the SDLC is a common overarching structure for implementing information systems, it is not a one-size-fits-all process. In fact, there are a multitude of approaches that can be used to guide the systems development life cycle. The SDLC approach that is most appropriate for a particular organization will be highly contextual and subject to organization-specific differences.
This week prompts you to analyze the process of selecting an appropriate health information technology and then evaluate techniques that positively impact the steps of the systems development life cycle in an EHR implementation. You also determine what barriers might occur at each stage and how these could be overcome.
Learning Objectives
Students will:
Analyze how a nurse can contribute to each stage of the systems development life cycle
Photo Credit: Jose Luis Pelaez Inc]/[Brand X Pictures]/Getty ImagesCredit
Learning Resources
Note:
To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
McGonigle, D., & Mastrian, K. G. (2015).
Nursing informatics and the foundation of knowledge
(3rd ed.). Burlington, MA: Jones and Bartlett Learning.
Chapter 10, “Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making”
This chapter explains the systems development life cycle and explores various methods of applying it. The chapter also examines the importance of interoperability in implementing HITECH.
Chapter 11, “Administrative Information Systems”
This chapter provides an overview of agency-based health information systems. The text also details how administrators can use core business systems in their practice.
Boswell, R. A. (2011). A physician group’s movement toward electronic health records: A case study using the transtheoretical model for organizational change.
Consulting Psychology Journal: Practice and Research, 63
(2), 138–148.
Retrieved from the Walden Library databases.
The authors of this article present a case study on an EHR implementation in a multispecialty physician group. The case study attempts to determine actions that promote successful EHR implementation and the pros and cons of implementation.
Hsiao, J., Chang, H., & Chen, R. (2011).A study of factors affecting acceptance of hospital information systems: A nursing perspective.
Journal of Nursing Research, 19
(2), 150–160.
Retrieved from the Walden Library databases.
The focus of this article is to determine what factors are most important in predicting the acceptance of new health information technology. The results of the study indicated .
SYSTEMS THEORYAs noted in the Learning Resources, systems theory p.docxjonghollingberry
SYSTEMS THEORY
As noted in the Learning Resources, systems theory provides a meaningful and beneficial means of examining challenges in health care organizations. To do this effectively, however, it is essential to assess
all
system components, as some may be relatively healthy while others are problematic.
For this Assignment, you apply systems theory to the examination of a problem in a department or a unit within a health care organization. (
Note:
You may use the same problem you identified for the Discussion as long as it meets the criteria for this assignment.)
To prepare:
·
Review the Meyer article, “Nursing Services Delivery Theory: An Open System Approach,” in this week’s Learning Resources. Focus especially on the information presented in Table 1 (p. 2831) and Figure 2 (p. 2833).
·
Reflect on your organization or one with which you are familiar. Within a particular department or unit in this organization, identify a problem the staff is encountering.
·
Using Table 1 in the Meyer article as a guide, analyze the department or unit, identifying inputs, throughput, output, cycles of events, and negative feedback. Consider whether the problem you have selected relates to input, throughput, output, cycles of events, and/or negative feedback.
·
Think about how you could address the problem: Consider what a desired outcome would be, then formulate related goals and objectives, and translate those goals into policies and procedures.
·
Research professional standards that are pertinent to your identified problem.
·
Reflect on the organization’s mission statement and values. In addition, consider how addressing this problem would uphold the mission and values, while improving the organizational culture and climate. (Depending on the organization you have selected, you may have explored these in the Week 1 Discussion.)
To complete:
Write a 3- to 5-page paper (page count does not include title and reference page) that addresses the following:
·
Describe a department or unit within a health care organization using systems theory terminology. Include a description of inputs, throughput, output, cycles of events, and negative feedback.
·
Describe the problem you identified within the department or unit using an open- systems approach, and state where the problem exists using the systems theory model (input, throughput, output, cycles of events, or negative feedback).
·
Based on this information, explain how you would address the problem as follows:
o
Formulate a desired outcome.
o
Identify goals and objectives that would facilitate that outcome.
o
Translate those goals and objectives into policies and procedures for the department or unit.
o
Describe relevant professional standards.
·
Explain how your proposed resolution to the problem would uphold the organization’s mission and values and improve the culture and climate.
*This paper must include a title page, introduction, summary, and references.
* Follow APA 6
th
ed for the ci.
Issues Identify at least seven issues you see in the case1..docxbagotjesusa
Issues: Identify at least seven issues you see in the case
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
What is the Key issue you see in the case: __________________________
What facts pertain to the case: Identify at least three important facts that pertain to the case
1.
2.
3.
4.
5.
What assumptions do you plan to make in your analysis: None is an acceptable answer
1.
2.
3
What people and organizations may have an impact on the case: There should be at least five.
1.
2.
3.
4.
5.
6.
7.
8.
9.
You are writing the case from the perspective of which person or organization:______________
What tools of Analysis would you use in this case: You only need to identify them and explain what information each will give you that you feel is important.
Based upon the above information – provide three alternatives
Alternative 1 is the Status Quo or to do nothing different that the current situation.
Identify at least three arguments in favor and three against this approach
Pros
1.
2.
3.
4.
5.
Cons
1.
2.
3.
4.
5.
Alternative 2 ____________________________________________________
Identify at least three arguments in favor and three against this approach
Pros
1.
2.
3.
4.
5.
Cons
1.
2.
3.
4.
5.
Alternative 3 ______________________________________________
Identify at least three arguments in favor and three against this approach
Pros
1.
2.
3.
4.
5.
Cons
1.
2.
3.
4.
5.
Given the information above select your recommended alternative and explain why you feel it is the best alternative: This should take three to five paragraphs and be based upon the information presented in your case.
.
Issues and disagreements between management and employees lead.docxbagotjesusa
Issues and disagreements between management and employees lead to formation of labor unions. Over the decades, the role of labor unions has been interpreted in various ways by employees across the globe.
What are some of the reasons employees join labor unions?
Did you ever belong to a labor union? If you did, do you think union membership benefited you?
If you've never belonged to a union, do you think it would have benefited you in your current or past employment? Why or why not?
.
ISSA Journal September 2008Article Title Article Author.docxbagotjesusa
ISSA Journal | September 2008Article Title | Article Author
1�1�
ISSA The Global Voice of Information Security
Extending the McCumber Cube
to Model Network Defense
By Sean M. Price – ISSA member Northern Virginia, USA chapter
This article proposes an extension to the McCumber
Cube information security model to determine the best
countermeasures to achieve a desired security goal.
Confidentiality, integrity, and availability are the se-curity services of a system. In other words they are the security goals of system defense, intangible at-
tributes� providing assurances for the information protected.
Each service is realized when the appropriate countermea-
sures for a given information state are in place. But, it is not
enough to select countermeasures ad hoc. Countermeasures
should be selected to defend a system and its information
against specific types of attacks. When attacks against partic-
ular information states are considered, the necessary coun-
termeasures can be selected to achieve the desired security
service or goal. This article proposes an extension to the Mc-
Cumber Cube information security model as a way for the
security practitioner to consider the best countermeasures to
achieve the desired security goal.
Security models
Models are useful tools to help understand complex topics. A
well-developed model can often be represented graphically,
allowing a deeper understanding of the relationships of the
components that make the whole. A formal security model
is broadly applicable and rigorously developed using formal
methods.2 In contrast, an informal model is considered lack-
ing one or both of these qualities. There are a variety of in-
formal models in the information security world which are
regularly used by security practitioners to understand basic
information and concepts.
� Security goals often lack explicit definitions and are difficult to quantify. They are
usually based on policies with broad interpretations and tend to be qualitative. It is
true that security goals emerge from the confluence of information states and coun-
termeasures which have measurable attributes. But, the subjective nature of security
goals combined with informal modeling characterizes their attributes as intangible.
2 P. T. Devanbu and S. Stubblebine, “Software Engineering for Security: A Roadmap,”
Proceedings of the Conference on The Future of Software Engineering (2000), 227-239.
One such informal model is the generally accepted risk as-
sessment framework. This model is used to assess risk by
estimating asset values, vulnerabilities, threats with their
likelihood of exploiting a vulnerability, and losses. Figure �
illustrates this model. Note that this commonly used model
requires a substantial amount of estimating on the part of
the risk assessment participants. This is problematic when
reliable estimates cannot be obtained. Another problem with
this model is that it does not guide th.
ISOL 536Security Architecture and DesignThreat Modeling.docxbagotjesusa
ISOL 536
Security Architecture and Design
Threat Modeling
Session 6a
“Processing Threats”
Agenda
• When to find threats
• Playing chess
• How to approach software
• Tracking threats and assumptions
• Customer/vendor
• The API threat model
• Reading: Chapter 7
When to Find Threats
• Start at the beginning of your project
– Create a model of what you’re building
– Do a first pass for threats
• Dig deep as you work through features
– Think about how threats apply to your mitigations
• Check your design & model matches as you
get close to shipping
Attackers Respond to Your Defenses
Playing Chess
• The ideal attacker will follow the road you
defend
– Ideal attackers are like spherical cows — they’re a
useful model for some things
• Real attackers will go around your defenses
• Your defenses need to be broad and deep
“Orders of Mitigation”
Order Threat Mitigation
1st Window smashing Reinforced glass
2nd Window smashing Alarm
3rd Cut alarm wire Heartbeat signal
4th Fake heartbeat Cryptographic signal integrity
By Example:
• Thus window smashing is a first order threat, cutting
alarm wire, a third-order threat
• Easy to get stuck arguing about orders
• Are both stronger glass & alarms 1st order
mitigations? (Who cares?!)
• Focus on the concept of interplay between
mitigations & further attacks
How to Approach Software
• Depth first
– The most fun and “instinctual”
– Keep following threats to see where they go
– Can be useful skill development, promoting “flow”
• Breadth first
– The most conservative use of time
• Best when time is limited
– Most likely to result in good coverage
Tracking Threats and Assumptions
• There are an infinite number of ways to
structure this
• Use the one that works reliably for you
• (Hope doesn’t work reliably)
Example Threat Tracking Tables
Diagram Element Threat Type Threat Bug ID
Data flow #4, web
server to business
logic
Tampering Add orders without
payment checks
4553 “Need
integrity controls on
channel”
Info disclosure Payment
instruments sent in
clear
4554 “need crypto”
#PCI
Threat Type Diagram Element(s) Threat Bug ID
Tampering Web browser Attacker modifies
our JavaScript order
checking
4556 “Add order-
checking logic to
server”
Data flow #2 from
browser to server
Failure to
authenticate
4557 “Add enforce
HTTPS everywhere”
Both are fine, help you iterate over diagrams in different ways
Example Assumption Tracking
Assumption Impact if it’s
wrong
Who to talk
to
Who’s
following up
Follow-up
by date
Bug #
It’s ok to
ignore
denial of
service
within the
data center
Availability
will be
below spec
Alice Bob April 15 4555
• Impact is sometimes so obvious it’s not worth filling out
• Who to talk to is not always obvious, it’s ok to start out blank
• Tracking assumptions in bugs helps you not lose track
• Treat the assumption as a bug – you need to resolve it
The Customer/Vendor Boundary
• There is always.
ISOL 533 Project Part 1OverviewWrite paper in sections.docxbagotjesusa
ISOL 533 Project Part 1
Overview
Write paper in sections
Understand the company
Find similar situations
Research and apply possible solutions
Research and find other issues
Health network inc
You are an Information Technology (IT) intern
Health Network Inc.
Headquartered in Minneapolis, Minnesota
Two other locations
Portland Oregon
Arlington Virginia
Over 600 employees
$500 million USD annual revenue
Data centers
Each location is near a data center
Managed by a third-party vendor
Production centers located at the data centers
Health network’s Three products
HNetExchange
Handles secure electronic medical messages between
Large customers such as hospitals and
Small customers such as clinics
HNetPay
Web Portal to support secure payments
Accepts various payment methods
HNetConnect
Allows customers to find Doctors
Contains profiles of doctors, clinics and patients
Health networks IT network
Three corporate data centers
Over 1000 data severs
650 corporate laptops
Other mobile devices
Management request
Current risk assessment outdated
Your assignment is to create a new one
Additional threats may be found during re-evaluation
No budget has been set on the project
Threats identified
Loss of company data due to hardware being removed from production systems
Loss of company information on lost or stolen company-owned assets, such as mobile devices and laptops
Loss of customers due to production outages caused by various events, such as natural disasters, change management, unstable software, and so on
Internet threats due to company products being accessible on the Internet
Insider threats
Changes in regulatory landscape that may impact operations
Part 1 project assignment
Conduct a risk assessment based on the information from this presentation
Write a 5-page paper properly APA formatted
Your paper should include
The Scope of the risk assessment i.e. assets, people, processes, and technologies
Tools used to conduct the risk assessment
Risk assessment findings
Business Impact Analysis
.
Is the United States of America a democracyDetailed Outline.docxbagotjesusa
Is the United States of America a democracy?
Detailed Outline:
-Introduction (2-3 Paragraphs):
Define and discuss the criteria for democracy.
What does a country need to be democratic?
-Thesis Statement (1 Paragraph):
Clearly state whether or not you think America is a democracy. Briefly preview the three pieces of evidence you are going to use. Your thesis statement is your argument. It must be clear and strongly stated so I know what you are arguing.
-Supporting Evidence 1 (1-3 Paragraphs)
Using Freedom House’s 2021 (2020 if 21 is not available)analysis of the U.S., support your argument regarding democracy in the U.S analysis of the U.S., support your argument regarding democracy in the U.S.
Supporting Evidence 2 (1-3 Paragraphs)
Choose a news article and explain the event covered in the article and how it
supports your argument.
Supporting Evidence 3 (1-3 Paragraphs)
Choose another news article
-Conclusion (1-2 Paragraphs)
Summarize your supporting evidence and how it supports your overall argument. This should include a brief discussion about how the other argument could be right
Citations: You will need outside sources for this paper. All sources must be properly cited. This means that the sources need to be parenthetically cited in the text of the paper and need to be included in a bibliography page. You are not allowed to use any user edit web sites (Wikipedia, Yahoo Answers, Ask.com, etc.) or social media as sources
4-5 papers
.
Islamic Profession of Faith (There is no God but God and Muhammad is.docxbagotjesusa
Islamic Profession of Faith (There is no God but God and Muhammad is his prophet.)
1. [contextualize] How are they a reflection of the time and culture which produced them?
2. [evaluate] What were the implications of these beliefs and values during the Middle Ages?
3. [compare] How do the beliefs and values of these cultures compare to your own?
.
IS-365 Writing Rubric Last updated January 15, 2018 .docxbagotjesusa
IS-365 Writing Rubric
Last updated: January 15, 2018
Student:
Score (out of 50):
General Comments:
Other comments are embedded in the document.
Criterion <- Higher - Quality - Lower ->
Persuasiveness The reader is
compelled by solid
critical reasoning,
appropriate usage of
sources, and
consideration of
alternative
viewpoints.
The document is
logical and coherent
enough that the
reader can accept its
points and
conclusions
Gaps in logic and
uncritical review of
sources cause the
reader to have some
doubts about the
points made by the
document, or
whether they’re
relevant to the
question asked.
The reader is unsure
of what the document
is trying to
communicate, or is
wholly unconvinced
by its arguments
Not
applicable
Evidence and support Exceptional use of
authoritative and
relevant sources,
properly cited,
providing strong
support of the
document’s points
Sufficient relevant
and authoritative
sources give
confidence that the
document is based
on adequate
research
Sources are
insufficient in
number, not
authoritative, not
relevant, or
improperly cited
No sources are used,
undermining the
document’s
foundations
Not
applicable
Writing Word choices, flow
of logic, and
sentence and
paragraph structure
engage the reader,
making for a
pleasurable
experience
Writing is clear and
adequately fulfills
the document’s
purpose
Some issues with
word choice and
sentence and
paragraph structure
interfere with the
conveyance of the
document’s ideas
Frequent questionable
choices in writing
make it difficult to
read and understand
Not
applicable
Language Essentially free of
language errors
Minor errors in
grammar,
punctuation, or
spelling
Noticeable language
errors that detract
from the readability
of the document
Significant language
errors that call the
credibility of the
document into
question
Not
applicable
Formatting (heading
styles, fonts, margins,
white space, tables
and graphics)
Professional and
consistent formatting
that enhances
readability.
Appropriate use of
tables and graphics.
Generally acceptable
formatting choices.
Some missed
opportunities for
displaying data via
tables or graphics.
Inconsistent or
questionable
formatting choices
that detract from the
document’s
readability
Critical formatting
issues that make the
document
unprofessional-
looking
Not
applicable
Page 1
Page 1
Page 2
(Name deleted)
IS-365
Art Fifer
2/17/2017
Technical Documents for Varying Audiences
In this paper, I’ll be exploring the differences in presenting technical communications to audiences of varying knowledge. The topic of these two general summaries will be the manner in which computers connect to each other, including summaries of several communication protocols, how information traverses the network, and how it arrives at its destination and is read by th.
ISAS 600 – Database Project Phase III RubricAs the final ste.docxbagotjesusa
ISAS 600 – Database Project Phase III Rubric
As the final step to your proposed database, you submitted your Project Plan. This document should communicate how you intend to complete the project. Include timelines and resources required.
Area
Does not meet expectations
Meets expectations
Exceeds expectations
A. Analysis - how will you determine the needs of the database
Did not identify appropriate plan for analysis phase
Identified appropriate plan for analysis phase
Identified appropriate plan for analysis phase and included additional content
Design - what process will you use to design the database (tables, forms, queries, reports)
Did not sufficiently identify detail on the appropriate process for design phase
Identified appropriate process for design phase
Identified appropriate process for design phase and included additional detail
Prototype/End user feedback - Will you show users a prototype before building the system?
Did not sufficiently identify method for feedback and prototypes during building of the system
Identified method for feedback and prototypes during building of the system
Identified method for feedback and prototypes during building of the system and provided additional detail
Coding - what process will you use to build the database?
Did not sufficiently identify appropriate process for coding the database
Identified appropriate process for coding the database
Identified appropriate process for coding the database and provided additional detail.
Testing - How will you test it?
to build the database?
Did not sufficiently identify appropriate process for testing the database
Identified appropriate process for testing the database
Identified appropriate process for testing the database and provided additional detail.
User Acceptance - describe the final step of determining if you met the user's needs?
Did not sufficiently identify an appropriate process for User Acceptance phase - How to determine if the database meets user’s needs.
Identified appropriate process for User Acceptance phase - How to determine if the database meets user’s needs.
Identified appropriate process for User Acceptance phase - How to determine if the database meets user’s needs. Answer provided additional detail
Training - what is the plan for training end users?
Did not identify appropriate detail for training plan
Identified appropriate detail for training plan
Identified appropriate detail for a training plan and provided additional detail.
Project close out - what steps will you take to finalize the project?
Did not sufficiently identify appropriate steps for closing out the project
Identified appropriate steps for closing out the project
Identified appropriate steps for closing out the project and provided additional detail.
Entity Relationship Diagram1
ERD:
Normalization:
1NF:
For the 1st NF we will have to check the tables’ attributes, like there must not be any multivalued attribute, if there is any multivalued at.
Is teenage pregnancy a social problem How does this topic reflect.docxbagotjesusa
Is teenage pregnancy a social problem? How does this topic reflect the social construction of problems? How does social location impact if you view this as a social problem?
Explain why media representation of social problems is an important issue using the example of teenage pregnancy. What is an example of a problematic representation? Does this vary across race, ethnicity, religion, socioeconomic status and gender?
.
Is Texas so conservative- (at least for the time being)- as many pun.docxbagotjesusa
Is Texas so conservative- (at least for the time being)- as many pundits and observers claim? Or is that just an opinion not supported by analysis and facts? Not only does Texas vote Republican in many elections but has done so for many years. It is also the birthplace of the so-called Tea Party movement and of Ron Paul's campaigns for president. Texas also appears to espouse conservative approaches to government and to issues. You will need to define in a concrete and operational way what conservative means as conservative is more than voting behavior or party affiliation.
Texas is the 2nd largest state in population compared to California and.like California made up of many differing migrant and immigrant groups. Texas like California was also part of Northern Mexico. but Texas is very, very different from California in voting behavior and positions on social issues. Why? Texas and California are good comparisons or are they? Provide explanations of the differences and similarities in this ideological context
Texas was once "Democratic" but even that was not really the case in terms of either past or current Democratic ideals and goals but a historic reaction to the consequences of the civil war and the fact that Texas was on the losing side in that war and of the attempt to defend agrarian interests in the form of slavery.. Being Democratic from post civil war to the middle of the 20th century in part meant for decades being in favor of inequality for minorities and defenders in spirit, if not in fact, of slavery.net
So Texas was never "Democratic" and never a more liberal interpretation of reality but a reflection of conservative thought and a particular view of individualistic man.
Is Texas conservative and why? ( you will need a social, cultural, historical and economic analysis here
with supporting evidence)?
? Need much more than opinions here.
.
Irreplaceable Personal Objects and Cultural IdentityThink of .docxbagotjesusa
Irreplaceable: Personal Objects and Cultural Identity
Think of a
personal object
that is
irreplaceable
to you.
Please answer the following:
1. Describe the item and tell a brief story, memory, or ritual related to the item.
2. How does this possession influence your identity?
3. How does this item represent your cultural identity?
4. How is your selection of this item influenced by your identity and culture?
Instructions:
please answer all 4 questions accordingly. Each answer should have the question re-typed following the answer. A minimum of 500 words in all excluding the re-typed questions. No reference is needed.
.
IRB is an important step in research. State the required components .docxbagotjesusa
IRB is an important step in research. State the required components one should look for in a project to determine if IRB submission is needed. Discuss an example of a research study found in one of your literature review articles that needed IRB approval. Specifically, describe why IRB approval was needed in this instance.
.
irem.org/jpm | jpm® | 47
AND
REWARD
RISK
>>
BY KRISTIN GUNDERSON HUNT
THE FIGHT TO FILL VACANT COMMERCIAL REAL ESTATE SPACE IN RECENT YEARS
HAS FORCED REAL ESTATE OWNERS AND MANAGERS TO CONSIDER NEW USES
FOR THEIR PROPERTIES—EVEN IF THEY REQUIRE TAKING ADDITIONAL RISKS.
especially vacancies,” said Janice
Ochenkowski, managing director
for Jones Lang LaSalle and the com-
mercial real estate firm’s director of
global risk management in Chicago.
“But property owners and manag-
ers have been very creative in how
to use their existing facilities.”
Traditional retail stores have been
transformed into everything from
medical office space and churches
to fitness centers and breweries. In
addition, special events and pop-
up stores are more commonplace;
traditional office spaces have been
converted to daycare centers; in-
dustrial warehouses are being used
as practice facilities for youth base-
ball teams; and the list goes on.
“From a risk management per-
spective, these new uses can bring
new challenges,” Ochenkowski said.
“However, it is the primary goal
of the risk manager to support the
business, which means we need to
be more creative in the way we deal
with these risks.”
DOESN’T MEAN YOU HAVE TO WALK AWAY.”–JANICE OCHENKOWSKI, JONES
LANG LASAL
LE
DO THE ASSESSMENT HONESTLY. JUST BECAUSE THERE IS A HI
GHER RISK
“DON’T BE AFRAID TO THINK ABOUT WHAT THE RISKS ARE.
the tough economy has resulted in a lot of challenges—“
DUE DILIGENCE
The risks associated with new-use tenants are as varied as the tenants them-
selves.
First and foremost, certain tenants could present additional life safety
risks, said Jeffrey Shearman, a Pittsburgh-based senior risk engineering con-
sultant and real estate industry practice leader for commercial insurance
provider, Zurich.
For example, restaurant tenants create increased exposure to fire; church
and/or educational institutions might spur egress concerns because they en-
courage large gatherings in spaces formerly used for different occupancy;
and hazardous waste can be a risk with some medical tenants.
“You have to recognize that certain types of work are going to create cer-
tain types of hazards,” Shearman said.
Beyond life safety risks, certain tenants might be more susceptible than
previous tenants to codes and regulations imposed by state or federal laws,
such as licensing regulations for daycares or American Disabilities Act re-
quirements for medical tenants, said Pat Pollan, CPM, principal at Pollan
Hausman Real Estate Services in Houston.
New-use tenant risks don’t stop there: financial risks also exist. Replac-
ing a unique tenant with a similar occupant after the lease expires can be
difficult—a particular concern if a lot of money was spent customizing the
space for an alternative use.
“It’s not just the risk of liability, it’s the risk of the tenant going out of busi-
ness and losing any money you put into the tenant, or its space, .
IoT References:
https://www.techrepublic.com/article/how-to-secure-your-iot-devices-from-botnets-and-other-threats/
https://www.peerbits.com/blog/biggest-iot-security-challenges.html
https://www.bankinfosecurity.asia/securing-iot-devices-challenges-a-11138
https://www.sumologic.com/blog/iot-security/
https://news.ihsmarkit.com/press-release/number-connected-iot-devices-will-surge-125-billion-2030-ihs-markit-says
https://cdn.ihs.com/www/pdf/IoT_ebook.pdf
https://go.armis.com/hubfs/Buyers%E2%80%99%20Guide%20to%20IoT%20Security%20-Final.pdf
https://www.techrepublic.com/article/smart-farming-how-iot-robotics-and-ai-are-tackling-one-of-the-biggest-problems-of-the-century/
Video Resources:What is the Internet of Things (IoT) and how can we secure it?
https://www.youtube.com/watch?v=H_X6IP1-NDc
What is the problem with IoT security? - Gary explains
https://www.youtube.com/watch?v=D3yrk4TaIQQ
Classmate 1
The Rise of the Republican Party
The Republican Party was formed due to a split in the Whig Party. The anti-slavery
“Conscience Whigs” split from the pro-slavery “Cotton Whigs”. Some anti-slavery Whigs joined
the American “Know-Nothing” Party, while the remainder joined with independent Democrats
and Free-Soilers to form a new party, the Republicans. The initial members stood for one
principle: the exclusion of slavery from the western territories (Shi, p. 462). Knowing the
Republicans ideology, we will look at how the events leading up to the Kansas-Nebraska Act led
to greater political division that eventually caused the formation of the Republican Party and it’s
rise to the presidency in 1860.
In the 1850’s, America was becoming increasingly divided between those for and against
slavery. The Compromise of 1850 had temporarily appeased both sides by admitting California
as a free state, allowing no slavery restrictions in New Mexico and Utah, paying Texas,
abolishing slave trade but no slavery in the District of Columbia, establishing the Fugitive Slave
Act, and denying congress authority to interfere with interstate slave trade (Shi, p. 457). This
Fugitive Slave Act was highly contested, although very few slaves were returned to the south
under this Act. In fact, it ended up uniting anti-slavery people, more than aiding the South. It was
during this time that Uncle Tom’s Cabin was written, selling more than a million copies
worldwide and detailing the harsh brutality of slavery (Shi, p. 460-461).
In the mid-1850’s, the Kansas-Nebraska Act was passed. The main reason for it was to the
settle the vast territory west of Missouri and Iowa, and to create a transcontinental railroad to
capitalize on Asian markets and goods. New territories brought up questions of whether slavery
would be allowed, with many supporting “popular sovereignty” where voters chose whether they
would have slavery or not. The issue here was that the 1820 Missouri Compromise had said there
would be no new slaver.
In two paragraphs, respond to the prompt below. Journal entries .docxbagotjesusa
In two paragraphs, respond to the prompt below. Journal entries must contain proper grammar, spelling and capitalization.
Consider the communication pattern within your family of origin. How does your family's conversation orientation (how open your family is to discuss a range of topics) and conformity orientation (how strongly your family reinforces the uniformity of attitudes, values and beliefs) affect your interactions with your partner? If you don't think there is any effect, explain your reasoning.
.
Investigative Statement AnalysisInitial statement given by Ted K.docxbagotjesusa
Investigative Statement Analysis
Initial statement given by Ted Kennedy in reference to the accident that occurred on July 18, 1969 in Chappaquiddick, Massachusetts.
Date:
October 30, 2007
Analyst Comments:
Narrative Balance: The Prologue begins with sentence #1 and ends with sentence #3. The Central Issue begins with sentence #4 and ends with sentence #9. The Epilogue begins with sentence #10 and ends with sentence #14. Thus the breakdown is:
Prologue = 3 sentences
Central Issue = 6 sentences
Epilogue = 5 sentences
The narrative is somewhat unbalanced due to the short Prologue and thus can be considered to be possibly deceptive on its face. It is not unbalanced enough to say this conclusively.
Mean Length of Unit:
The narrative has 14 sentences and 237 words, thus giving a MLU of 16.9 rounded to 17. Thus any sentences 23 words or longer and any sentences 11 words or less can be considered deceptive on their face.
Structure of Analysis:
The actual sentences from the narrative are in bold italicized type. After each sentence are the number of words in the sentence, whether or not it is deceptive on its face, and the analyst’s comments. All of these will be in normal type.
1.
On July 18th, 1969, at approximately 11:15 P.M. in Chappaquiddick, Martha’s Vineyard, Massachusetts, I was driving my car on Main Street on my way to get the ferry back to Edgartown.
30 words – Deceptive on its face. There is no mention of the passenger in this sentence. All of the pronouns are singular. It is “my car” “on my way”, etc. When the passenger is mentioned later, it is almost an afterthought. The deception in this sentence may be the last part of the sentence where he relates why he was driving the car. He very well may have been driving for some reason other than to get the ferry. This would be an area to be further explored in an interview.
2.
I was unfamiliar with the road and turned right onto Dike Road, instead of bearing hard left on Main Street.
20 words. “I was unfamiliar with the road” is an explanatory phrase telling us why he ended up on Dike Road. The phrase “instead of bearing hard left on Main Street” is a strange way of phrasing. Most people would say something like “instead of staying on Main Street.”
3.
After proceeding for approximately one-half mile on Dike Road I descended a hill and came upon a narrow bridge.
20 words. There is nothing particularly deceptive about this sentence. The phrasing of the sentence is very formal. The phrasing is almost like a police type report or a legal/lawyer way of phrasing. It also appears that the phrase “came upon a narrow bridge” is almost a passive way of phrasing that indicates he was taken by surprise and had no control over what he was doing.
4.
The car went off the side of the bridge.
9 words – This sentence is deceptive on its face. This is the very first sentence of the Central Issue. It is interesting to note that four of the six s.
Investigating Happiness at College SNAPSHOT T.docxbagotjesusa
Investigating Happiness at College
SNAPSHOT:
TOPIC Either a specific group related to college or a factor within
college life that possibly affects a specified group of college
students or students in general.
PITCH Present your topic and your research question to the class—
shark tank! Sound too scary? How about guppy tank ?).
Tentative due date: 2/5 & 2/7
ESSAY 1 The prospectus and the annotated bibliography.
Tentative due date: 2/21
ESSAY 2 Change in your topic or conducting your own study
Tentative due date: 3/16
ESSAY 3 Argument about a specific controversy within your topic
Tentative due date: 4/6
ESSAY 4 Answers and argues your refined research question about the
importance of your topic.
Tentative due date: 4/24
♥ Rough drafts with reflections about what is working and not working and
WHY will be required for the prospectus and essays 2 and 3. The work
on the rough draft and the reflections will count toward your essay grade.
♥ Final reflections submitted the class period after you submit your final
draft for essays 2-4 will also count as part of your essay grade.
♥ You will upload your drafts on Moodle. You will be asked to identify the
portions of the sources you used and submit hard copies of your sources
in a folder or files of your sources online.
Investigating Happiness at College:
Some questions that will help you form your own research
questions:
● Is happiness a necessity or a perk in college life?
● What do the expectations of happiness and the pursuit of
happiness reveal about a specific college group, college
students in general, or another college-related group?
● Considering both on-campus factors and off-campus factors
(at least at first), what most influences your group’s
happiness (or unhappiness)?
● Is there one major factor (on campus or off campus) you
would want to investigate that affects students’ happiness?
● How do the expectations about happiness that society has in
general or a certain specific segment of society (for
instance, parents) has, relate to college or college students?
● How much do preconceived notions and expectations about
college life affect student happiness?
● Hard work is hard to enjoy. So how do students balance that
hard work with the .
Investigate Development Case Death with Dignity Physician-Assiste.docxbagotjesusa
Investigate Development Case: Death with Dignity / Physician-Assisted Suicide
MAKE A DECISION: Is Ben's decision making being affected by his depression?
Yes
No
Why? Give reasons for why you chose the way you did. Consider the following factors in your reasons:
The effects of depression on decision making
Other stresses in Ben's life contributing to his state of mind
Ben's current quality of life
The family's values and beliefs
Your own values and beliefs
Please see attachment
.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
2. Acknowledgements:
IHI thanks staff members Jane Roessner, PhD, and Val Weber
for their editorial review and assistance
with this paper.
For print requests, please contact:
Institute for Healthcare Improvement, 20 University Road, 7th
Floor, Cambridge, MA 02138
Telephone (617) 301-4800, or visit our website at www.ihi.org
The Institute for Healthcare Improvement (IHI) is a not-for-
profit organization leading the
improvement of health care throughout the world. IHI helps
accelerate change by cultivating
promising concepts for improving patient care and turning those
ideas into action. Thousands of
health care providers participate in IHI’s groundbreaking work.
We have developed IHI's Innovation Series white papers as one
means for advancing our mission.
The ideas and findings in these white papers represent
innovative work by IHI and organizations
with whom we collaborate. Our white papers are designed to
share the problems IHI is working to
address, the ideas we are developing and testing to help
organizations make breakthrough improve-
ments, and early results where they exist.
Innovation Series 2008
Authors:
James L. Reinertsen, MD: Senior Fellow, IHI; President, The
3. Reinertsen Group
Maureen Bisognano: Executive Vice President and Chief
Operating Officer, IHI
Michael D. Pugh: President and CEO, Verisma Systems, Inc.
Seven Leadership
Leverage Points
For Organization-Level Improvement in Health Care
Second Edition
Innovation Series: Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second
Edition)1
Foreword to Second Edition
It is almost three years since we published the First Edition of
our white paper, Seven Leadership
Leverage Points for Organization-Level Improvement in Health
Care, and in that time we have learned
a great deal about what it takes to achieve results in quality and
safety at the level of entire organizations
and care systems. A primary source of our learning has been the
application by committed leaders
of one or more of these leverage points in the 100,000 Lives and
5 Million Lives Campaigns, in the
course of which hundreds of organizations have achieved major
improvements in system-level measures
such as mortality rates and prevalence of harm. The Campaigns
continue to be an extraordinarily rich
source of learning to improve and extend our theory—and it is a
theory—of “leverage” for leaders.
4. In addition to the Campaigns, the Institute for Healthcare
Improvement (IHI) has also learned a
great deal about what works (and, importantly, what doesn’t)
from a diverse set of sources ranging
from our involvement in national initiatives such as the The
Health Foundation’s Safer Patients
Initiative in the UK, large-scale collaborative programs such as
the 200+ organizations in IHI’s
IMPACT network that are participating in Learning and
Innovation Communities, in-depth work
with IHI’s Strategic Partners, and direct fieldwork and
interviews with health care clients as well as
industry leaders outside health care. We have noticed, for
example, that many of the leverage points
work well in the field without much modification, whereas
others seem to need some reframing, or
a special emphasis on particular elements within the leverage
point, or even substantial revision.
Much of this ongoing learning about the role of leaders in
quality has been distilled into three IHI
white papers that deal either directly or indirectly with one or
more of the original Seven Leadership
Leverage Points. The 5 Million Lives Campaign’s “Get Boards
on Board” intervention, for example,
expands Leverage Point One, on the adoption and oversight of
aims at the highest levels of governance,
into the exceptionally detailed Governance Leadership “Boards
on Board” How-to Guide.1 Leverage
Point Six, on engaging physicians, has been the subject of
intense interest, which in turn has led
to the publication of IHI’s white paper, Engaging Physicians in
a Shared Quality Agenda.2 And the
work of Tom Nolan and the IHI Innovation Team has resulted in
a very thoughtful new framework
and white paper on the critically important issue of Execution
6. incorporating our learning since
the original white paper was published in 2005, particularly the
learning on the subject of
execution.
• Provide a number of specific examples of the field application
of each leverage point (rather
than the extended “for example” of the 100,000 Lives Campaign
that we employed in the
First Edition).
• Describe the relationship between the Seven Leadership
Leverage Points and other IHI
leadership frameworks.
Finally, it is important to point out that this new and improved
set of leverage points is still a
theory, and a theory at the “descriptive” stage of development,
at that.4 By “descriptive” we mean
that we are able to describe associations between each leverage
point and results, but we are NOT
able to ascribe specific cause and effect. In other words, the
leverage points theory is not yet a
“normative” theory, in that we cannot make the following
statement: “If you as a leader do these
seven things, you will get dramatic system-level results.” But
we can say, with perhaps greater
confidence than three years ago, “Where organizations are
getting significant results, several of
these leverage points appear to be strongly in place.”
We hope you find the Second Edition of the Seven Leadership
Leverage Points white paper useful
in your own leadership work, and we invite all readers to give
us feedback from their own field
observations, so that this management theory can continue to
10. • Measure System
Per formance
• Provide Encouragement
• Make Financial Linkages
• Learn Subject Matter
• Work on the Larger System
4. Generate Ideas
• Read and Scan Widely,
Learn from Other
Industries and Disciplines
• Benchmark to Find Ideas
• Listen to Customers
• Invest in Research
and Development
• Manage Knowledge
• Understand Organization
as a System
5. Execute Change
• Use Model for Improvement
for Design and Redesign
• Review and Guide Key
Initiatives
11. • Spread Ideas
• Communicate Results
• Sustain Improved Levels
of Per formance
2. Establish the Foundation
• Reframe Operating Values
• Build Improvement Capability
• Prepare Personally
• Choose and Align the Senior Team
• Build Relationships
• Develop Future Leaders
Innovation Series: Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second
Edition)5
Figure 2. A Framework for Execution
The Seven Leadership Leverage Points framework, on the other
hand, was developed in large part to
answer a second type of question that leaders were asking:
• “This is a very broad framework; are there one or two places
where I could get started, where
my actions might have the greatest effect?”
13. choose the right system attributes
(“leverage points”) and make small, perhaps difficult, but
important changes, very large performance
change might result.
2. Observed Performance of Leaders and Health Systems: We
have been able to watch the actions of
leaders in organizations participating in IHI’s Pursuing
Perfection and IMPACT initiatives, as
well as in the 100,000 Lives and 5 Million Lives Campaigns,
and simultaneously to observe the
performance of those systems. Where system-level change has
occurred, we have attempted to
infer from these sources what some of the leadership leverage
points for improvement might have
been. For example, we have observed that system-level
improvement does not occur without a
declared aim to achieve it, and that how the aim is declared and
adopted by leaders appears to be
very important. These leverage points are based largely on
qualitative data—more anecdotes and
stories about the work of leaders than a solid research base.
Nevertheless, these stories are
powerful, and serve to support and refine the theory.
3. Hunches, Intuition, and Collective Experience: The authors
come from a variety of backgrounds
in health care and have tapped into our collective experience to
postulate some of these leverage
points—particularly those that surface as recurrent “difficult
moments” for leaders. For
example, it is our sense that the business case for quality is still
fragile in many health care
organizations, and therefore that if the chief financial officer
(CFO) were somehow to become
a champion for system-level improvement in quality, dramatic
15. organizations in which the
leverage points would be applied are assumed to have adopted a
coherent quality framework.
Finally, we would emphasize that we have framed these as
leadership leverage points. In other words,
we believe that these activities are the particular responsibility
of the senior leaders of organizations.
This paper has three sections:
1. A detailed explanation of the Seven Leadership Leverage
Points and specific examples of their
application in health care, where available
2. A brief overview of the changes to the Seven Leadership
Leverage Points from the First Edition
(2005) to the Second Edition (2008)
3. A self-assessment tool (Appendix A) to help administrative,
physician, and nursing leaders of
health care organizations design and plan their work using the
Seven Leadership Leverage Points
Leverage Point One: Establish and Oversee Specific System-
Level Aims
at the Highest Governance Level
A broad quality aim is part of the mission statement of most
health care organizations. But if leaders
are to achieve new levels of performance at the system level, we
believe that governing boards must:
• Establish solid measures of system-level performance—for
example, hospital mortality rate, cost
per adjusted admission, adverse drug events per 1,000 doses—
18. Quality
Patient-Centered
Whole System Measure
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.”]
Toyota Specification
72% of Patients Report, “They
give me exactly the help I want
(and need) exactly when I want
(and need) it.”
Effective and
Equitable
Functional Health Outcomes Score 5% of Adults Self-Rate
Their Health
Status as Fair or Poor
[Self-rating will not differ by income]†
Efficient Health Care Cost per Capita
[Surrogate measure: Medicare
Reimbursement per Enrollee per Year]‡
$3,150 per Capita per Year
$5,026 per Enrollee per Year
19. Innovation Series: Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second
Edition)9
Table 2. Whole System Measures and Toyota Specifications:
Component Level
Several aspects of Leverage Point One deserve emphasis, based
on what has been learned over the
last three years:
• The responsibility for adopting aims and overseeing measures
cannot be delegated by the board.
What the governance board pays attention to gets the attention
of management, physician
leaders, and, ultimately, the entire organization.
• Aims must be focused. It is unrealistic to set breakthrough
aims across the entire spectrum
of performance. In fact, it is highly unusual for any
organization, in or out of health care,
to achieve breakthrough levels of performance in more than one
or two dimensions during
any one year.
• It is impossible to overemphasize the importance of the data
feedback loop that boards use to
oversee the achievement of system-level aims. For strategic
breakthrough aims, the primary
question that the data must answer for boards is “Are we
improving? Are we on track to achieve
our aim(s)?” To allow boards to answer this question,
measurement of performance must:
22. in members who are experts in quality methods in
manufacturing and other industries, and are
investing in education of all the trustees.
• It is often helpful to develop specific scorecards of measures
to track progress on efforts such
as a hospital’s work on the 5 Million Lives Campaign, or its
major strategic goal to reduce
hospital-acquired infections, rather than have key data elements
related to these initiatives
simply reported out and mixed together with all other quality
and reporting metrics. Initiative-
specific scorecards create context, which facilitates both
understanding and monitoring of progress.
• When boards start holding management accountable for
achievement of breakthrough aims,
the trustees start asking tough questions. This sends signals
throughout the organization that
can be a powerful force for culture change.
Ascension Health’s board provides us with an excellent example
of the practices described above.
In 2003, the board of this 70-hospital system adopted a specific,
focused breakthrough aim: zero
preventable deaths and injuries by the end of 2008. The boards
in each region have incorporated
review of patient stories about preventable deaths into their
meeting agendas, and the boards must
approve the action plan to prevent similar events in the future.
Furthermore, the regional boards do
not simply accept every action plan passively, but often send
the management team back to develop
more robust solutions to serious safety risks. The Ascension
system tracks the risk-adjusted mortality
rate on a monthly basis, and has built the achievement of their
24. 3. Key projects must be resourced with capable leaders, both at
the large project level and at
the day-to-day microsystem level.
- 0 . 9 0 0 0
- 0 . 8 0 0 0
- 0 . 7 0 0 0
- 0 . 6 0 0 0
- 0 . 5 0 0 0
- 0 . 4 0 0 0
- 0 . 3 0 0 0
Ac tu al Mon thly D iffer enc e p-b ar ( C e nte r L in e for D
iffere nc e) LC L UC L
CareScience Observed minus Expected Mortality Rate per 100
Discharges
Ascension Health
Baseline
1,038 Mortalities
Avoided (Year 2)
374 Mortalities Avoided
(9 mos. of Year 3)
1,412 Mortalities
Avoided Since
32. “Are we executing our strategy?” (data about the progress of the
portfolio of projects) and
“If we’re executing the strategy, is it working?” (data about the
system-level measures that
the organization is trying to move to a new level).
From field observations over the past three years of how senior
executives go about building
executable strategies and getting results, we emphasize the
lessons that follow about the four critical
steps to successful execution.
• Just as the board cannot delegate the adoption and oversight of
system-level quality aims,
the executive team cannot delegate the building and execution
of a plan to achieve the aims.
The era when quality aims could be delegated to “quality staff,”
while the executive team
works on finances, facility plans, and growth, is over. System-
level breakthrough aims are
by their very nature strategic, and require the energy and
attention of the entire organization,
led by the CEO and the entire executive team.
• One good way to build a rational portfolio of projects is to
develop a cascaded series of
goals and drivers (see Figure 4). In this method, the senior
executive team adopts one or
two breakthrough goals and for each goal posits up to three
“drivers”—structures, processes,
or cultural patterns that would need to be put in place, or
changed, in order to achieve the
goals. Each of the chosen drivers is assigned to an individual
member of the senior executive
team as a goal to be achieved, and that executive then brings a
group together at the next
33. level to address a new driver question, “What would have to be
changed or put in place in
order to achieve this goal?” The conversations about goals and
drivers then cascade in a similar
fashion through additional levels of the organization, until the
answer to the driver question
looks like a project—i.e., something that could be executed by a
specific team in a focused
manner over, say, 90 days. The result of this cascaded series of
goals and drivers is not only
a good project plan, but also a highly visible, well-
communicated logic of the plan wherein
each person, at every level, knows their part and how those
parts fit into the whole.
• IHI’s experience in the field keeps reinforcing the old truth:
“Culture eats strategy for lunch.”
When thinking through drivers of major system-level quality
and safety aims, cultural drivers
should be near the top of any leader’s list. Patterns of behavior
that are driven by underlying
values, habits, and beliefs—the organization’s culture—will
dominate every other possible
driver and may jeopardize changes to processes and structures
unless they are explicitly
addressed. Some examples of such patterns of behavior around
safety practices might be
the following:
Innovation Series: Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second
Edition)13
o “We follow the safety rules…unless we’re really busy.”
34. o “Those are good rules for infection prevention, but they
really don’t apply to me.”
• The Framework for Execution describes other methods by
which an executable project portfolio
can be developed, but all effective methods seem to share the
two features described below.
1. A good method for execution ensures that the system-level
aims have a powerful influence on
choices of projects throughout the organization. Managers are
not being asked, “How does
what you’re already working on in your department support the
system-level aim?” Instead,
the primary question is, “What do we need to do in order to
accomplish the aim?” The first
question results in what one frustrated manager reported: “We
do all this strategic planning,
and set these grand goals, and then the plan to accomplish the
goals looks pretty much like
every department simply rationalized its pet projects.” The
second question results in a
portfolio of projects with the scale and pace needed to
accomplish the stated aim.
2. A good method forces focus. The example in Figure 4 depicts
the logic chain for only one
driver at each organization level. In reality, a cascaded set of
conversations, with two or three
drivers at each level, will branch many times, resulting in a
fairly large number of projects
once the process has played out to the project level. If leaders
do not focus on one or two
aims, supported by three or fewer drivers, then the cumulative
burden of projects that results
35. is overwhelming for front-line staff (especially when added on
top of their daily work!).
• Large, complex projects must be led by capable leaders who
are given the time to do the
projects or the projects will not be successfully executed.
Outside of health care, in companies
capable of execution, the individuals chosen to lead a project of
strategic importance are
carefully chosen, and given time (for example, 50 percent to
100 percent of their time for
six months) to complete a major strategic project. In contrast,
health care organizations
often ask leaders to take on major projects as “add-ons” to
already daunting workloads.
• Even with careful attention to developing a logical portfolio of
projects, creating focused aims,
and enabling well-resourced and supported project leadership, a
plan to achieve system-level
breakthrough aims requires guidance and oversight from the
senior executive team. A successful
leadership system for execution has two critical components: 1)
obtain data and feedback
regularly on whether a) the strategic project portfolio is being
executed, and b) the strategy
is working; and 2) have senior executives regularly review and
respond to timely, useful data
on these two questions. 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 projects seem
to be executed well, but little
progress on system-level measures is seen, the senior team then
takes action to revise the
38. Department Chairs,
Nursing VPs
ICU Unit Manager,
Medical Director
Leader’s Goal
Reduce mortality rate
by 20% in 2 years
Reduce hospital-acquired
infections by 50% in
12 months
Fully deploy Ventilator
Bundle and Central Line
Bundle to all units within
six months
Project:
Achieve 10-2 reliability in
the Ventilator Bundle and
Central Line Bundle within
three months
Innovation Series: Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second
Edition)15
hospital-acquired infections”) as part of its strategic planning
process and the CEO and other
senior executives continue to do exactly what they did the year
before—attend the same meetings,
39. visit the same project teams, read and ask questions about the
same reports, ask for data about
the same performance measures—then the staff ’s interpretation
of this new goal is,
“Well, it’s a nice thing to aim for, but they don’t really take it
seriously, so why should we?”
Executives are constantly sending signals about what they
believe to be important. Some signals are
negative (e.g., arriving late to the meeting, not asking
questions, taking a phone call during the
meeting, and leaving early). Other signals tell the staff that
executives really care about achieving the
stated quality aim. Examples of positive signals might include
the following:
• Prioritize Calendars: Leaders can change their personal
schedules to make time for data review,
meetings with project leaders, and other activities that support
the work.
• Conduct Project Reviews: Senior executives can send
powerful signals by personally performing
reviews with project teams—asking about their project aims,
connecting the work of the team
to the overall organization aims, focusing on results, helping
the team to overcome barriers, and
providing encouragement.
• Tell Stories: Positive organizational “buzz” can be created by
the stories that executives tell in
their formal and informal communications. If the stories
reinforce the cultural changes and
practices needed to achieve breakthrough aims (e.g., a story
about a manager’s willingness to do
multiple rapid tests of change and the great results achieved),
41. 16Institute for Healthcare Improvement Cambridge,
Massachusetts
they are for quality and safety—the reliability and timeliness of
measurement and reporting, the
frequency and depth of management reviews, and so forth.
In organizations that achieve system-level results, the key data
related to quality and safety tend to be
“top of mind” for executives, not just for the quality staff. The
COO of an extremely high-performing
community hospital—when asked about the most recent data for
several key performance measures,
which he quickly rattled off without reference to documents or
other support—said the following
about the basic elements of a good system for channeling
leadership attention to system-level
improvement:
“We get the key measures updated monthly. At each weekly
management meeting we go over
one of the categories—safety, for example—in depth, and take
actions to make sure we’re on
track. We post the numbers each month on every bulletin board
in the hospital, so I get a lot
of questions about them as I walk around. Besides, I just
finished up our quarterly staff
communication meetings where the main priority is to explain
these numbers to all the staff.
After all, a portion of my paycheck, and of all the staff ’s
paychecks, depends on how we do
against these numbers!”
Transparency
Perhaps the most powerful method of channeling leadership
42. attention is to harness the power of
transparency. (In fact, this is such a potent tactic that we
debated whether “Harness the Power of
Transparency” might stand alone as a new Leverage Point
Eight.) The fundamental force behind this
method is simple: if the public (regulators, media, community,
patients) are paying attention to all
of your quality and safety performance data (and not just the
numbers that you’re proud of ), then
those people inside the organization will tend to work with
greater urgency to improve performance
(especially the numbers they aren’t proud of ). Or, put more
memorably: “If you’re going to be
naked, it’s good to be buff.”7
The Wisconsin Collaborative for Healthcare Quality provides an
excellent example of the power
of transparency. A group of health care systems worked with
employers to design and publicize a
40-item quality and safety report. The systems agreed to report
all the data they had, good or bad,
and also agreed that they would not use any of the data for
marketing. When the first reports went
to the public, each organization was the best in the state in at
least one of the 40 measures, and each
was also the worst in the state in another of the 40 measures.
John Toussaint, CEO of ThedaCare,
a participant in the Collaborative, describes the internal
reaction at ThedaCare to having publicly
displayed data they were not proud of:
“Within hours, the doctors in that department were in my office
angrily asking me, ‘How dare
you send out those numbers to the public? We look bad!’ After I
calmed them down a bit, I
said, ‘Well, maybe the numbers are bad because we are bad.’ It
44. and respected when they are treated
with honesty about hospital performance.
Leverage Point Four: Put Patients and Families on the
Improvement Team
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,
healthy relationships, and deep personal commitments to
achievement of the goals. CEOs who want
to achieve quality and safety goals must constantly ask
themselves, “Do I have the right senior team
in place to get the job done?” Getting this difficult judgment
correct, and acting on it, is a critical
task for the CEO, and is therefore a key leverage point for
system-level performance improvement.
We recognize that while getting the senior leadership team right
is extremely important, this chal-
lenge is fairly broad and universal (i.e., every CEO faces this
question, for every kind of strategic
aim). We therefore reframed Leverage Point Four to make it
less “generic” and much more focused.
Instead of “Get the Right Team on the Bus,” we have zeroed in
on team members who usually aren’t
even considered candidates to be on the bus—patients—and
have restated Leverage Point Four as
“Put Patients and Families on the Improvement Team.”
Our rationale for this change is straightforward. Quite simply,
we have observed that in a growing
number of instances where truly stunning levels of improvement
have been achieved, organizations
have asked patients and families to be directly involved in the
46. have on the executives themselves, who
typically feel energized and inspired to improve the care system
with much greater urgency and
commitment than they would without the patients’ words
ringing in their ears every morning.
The results at McLeod’s 550-bed hospital are spectacular: a 40
percent drop in mortality rate,
some of the very best CMS Core Measure scores in the nation,
and a dramatic drop in adverse
drug events—including a seven-month run with zero harm from
medications.10
Family-Centered Rounds
At Cincinnati Children’s Hospital in Ohio, it has become
routine to give parents the choice to be
full participants in the daily “work rounds” as nurses, house
staff, and teaching faculty give progress
reports, do examinations, discuss differential diagnoses, and
make treatment plans. The process
provides parents with direct, unfiltered communication about
everything that is happening with
their child, and also invites parents to provide information and
participate in decisions in an
unprecedented fashion. Parents are involved in ensuring that
medication orders are correct and
helping to create discharge goals. Families routinely say they
now feel they are truly part of the care
team. In the words of Steve Muething, a pediatrician and
Assistant Vice President of Patient Safety:
“Family-centered rounds began as a flow initiative and there
was much resistance. Five years later
it is a core value of our organization. Nurses and physicians
believe care is better and safer and the
teaching improves when parents are active participants in
rounds. Teams are now uncomfortable
48. years since they began this structural and
cultural change, and philanthropic support (by many of the same
volunteers who help to run
the organization) reached the astounding level of $160 million
in 2006—without a major
capital campaign.11
Patient Stories at Board Meetings
Every meeting of the Board Quality Committee at Delnor-
Community Health System in Geneva,
Illinois, features a patient story about a harm event, helping the
organization “put a face on the
problem” rather than just seeing abstract reports of
measurements. Typically, a patient (or family
member) is invited to tell what it was like for them to
experience a surgical site infection, or some
other quality defect. Board members then ask questions to
clarify their understanding of the experience.
Although these conversations take only 20 to 30 minutes during
the actual meeting, there is a lot
of preparation involved—to invite a patient or family member
(not all want to participate), prepare
the patient and family for the meeting, discipline the board not
to get into ad hoc problem-solving
during the meeting, and so forth. The effect on the board
members has been powerful. They now
ask questions of the medical staff and administration with
greater passion and urgency, and they
expect results. It might be a coincidence, but it is over a year
since Delnor has had a ventilator-
acquired pneumonia or a central line infection, and the
mortality rate at Delnor has dropped some
40 percent in two years.12 There are other ways in which boards
and senior leaders can hear patient
stories,13 but none are as powerful as having the patient in the
49. room.
The principles behind Leverage Point Four are nicely
articulated in the “Patient- and Family-
Centered Care” approach of the American Hospital
Association,14 as follows:
• All people (patients, families, and staff ) will be treated with
dignity and respect.
• Health care providers will communicate and share complete
and unbiased information
with patients and families in ways that are affirming and useful.
• Patients and families participate in experiences that enhance
control and independence.
• Collaboration among patients, family members, and providers
occurs in policy and program
development and professional education, as well as in the
delivery of care.
The most important learning from the last three years of
experience 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 structural and process
changes—the one with the most
20Institute for Healthcare Improvement Cambridge,
Massachusetts
leverage—is to “Put the Patient in the Room.”15 At least four
things happen when patients and
50. families work alongside health care professionals to improve
quality and safety:
• 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
with which we compete”) sound
unseemly when patients and families are in the room.
• The Whole System of Care Comes into Play: Patients
experience care across multiple 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, if we listen to their
voices.
• 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.
For all these reasons, we believe that Leverage Point Four—Put
Patients and Families on the
Improvement Team—is not only an important force in driving
the achievement of measured results,
it is also the leverage point with the greatest potential to drive
the long-term transformation of the
entire care system.
Leverage Point Five: Make the Chief Financial Officer a
Quality Champion
52. Innovation Series: Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second
Edition)21
and so forth. To a large extent, the core processes of health
care—diagnosing, treating, communicat-
ing with patients, etc.—have been something of a “black box”
and off limits to health care CFOs.
Figure 5. CFO Cost Reduction Efforts: Health Care vs. Other
Industries
Leverage Point Five reflects our belief that health care
organizations would be far more likely to
achieve dramatic improvement in system-level measures of both
financial and quality performance if
health care CFOs 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.17
The strongest examples of Leverage Point Five in action tend to
come from organizations such as Virginia
Mason Medical Center in Washington, Park Nicollet Health
Services in Minnesota, ThedaCare in
Wisconsin, and McLeod Regional Medical Center in South
Carolina that have adopted lean management
principles (in particular, the Toyota Production System).18 In
these health care systems, efforts to both
reduce costs and to improve quality are primarily focused on the
processes of care. Any reduction in input
costs (supplies, personnel, etc.) comes about as a result of
having removed waste from the process, not as a
new constraint on an unimproved process. Examples of what
54. • ...
Outputs
• Quality Results
• Safety Results
• Costs
• ...
22Institute for Healthcare Improvement Cambridge,
Massachusetts
• Improving throughput and avoiding capital costs: By using
lean techniques to manage flow,
Park Nicollet now routinely processes 64 patients per day
through the same endoscopy facility
that once struggled to care for 30 to 32 patients per day, with
less strain and effort on the part
of nurses and physicians. Patients and staff are delighted, and
$3 million in capital expenditures
were avoided.20
• Making more secure long-term financial plans: ThedaCare has
seen so much reduction in waste
from their first couple of years of widespread application of the
lean methodology that the CFO
has built a long-range financial plan that does not require any
price increases.21
Some patterns are emerging from these examples and others like
them:
• Organizations with CFOs who are engaged in improvement
efforts have adopted quality as the
55. strategy, not one of many strategies. The key marker of this
strategy is seen when times get
tough: these organizations invest more, not less, in quality when
they are under financial
pressure.
• These CFOs take a personal role in process improvement and
waste removal. It isn’t enough to
cheer on the sidelines; CFOs must be teachers and practitioners
of quality methods, and actively
seek out process improvement opportunities. A good example at
Park Nicollet has been the
huge reduction in administrative waste that resulted from the
elimination of the entire budgeting
process—three months of management time and energy
expended every year in what the CFO
realized was pure waste.22
• These CFOs encourage serious investment in development of
improvement capability. When quality
is the strategy, organizations recognize the significant
investment that must be made to develop
capable leaders of improvement at all levels and they make the
commitment to build this capability
(see Leverage Point Seven).
• CFOs are beginning to shift their focus to cost per unit as
opposed to revenue per unit. Because most
hospital payment systems involve a fixed form of payment (e.g.,
DRGs, case rates, bundled outpatient
rate, Ambulatory Surgical Center rate, per diem rate), many
CFOs are making the connection that
eliminating infections, medication errors, falls, and delays in
care are strategies for reducing their average
per unit cost of production and increasing the margin on care
delivery. Taking it one step further,
58. 3.1 Use the 20/80 rule
3.2 Identify and activate
champions
3.3 Educate and inform
structural leaders
3.4 Develop project
management skills
3.5 Identify and work
with “laggards”
4. Use “Engaging” Improvement Methods:
4.1 Standardize what is standardizable, no
more
4.2 Generate light, not heat, with data
(use data sensibly)
4.3 Make the right thing easy to try
4.4 Make the right thing easy to do
6. Adopt an Engaging Style:
6.1 Involve physicians from
the beginning
6.2 Work with the real leaders,
early adopters
6.3 Choose messages and
messengers carefully
59. 6.4 Make physician
involvement visible
6.5 Build trust within each
quality initiative
6.6 Communicate
candidly, often
6.7 Value physicians’
time with your time
5. Show Courage:
5.1 Provide backup all the way
to the board
Engaging
Physicians
in Quality
and Safety
24Institute for Healthcare Improvement Cambridge,
Massachusetts
Each of the six elements of this framework is important by
itself, but physician engagement is more
likely when leaders work across all the elements. Specific
examples of how hospital and health care
system leaders are using the framework to engage physicians
are described below.
Discover Common Purpose
60. The key idea here is to learn what the physicians’ quality
agenda is, and to harness your quality
efforts to their agenda. “Physicians’ quality agenda” is not an
oxymoron. Doctors care deeply
about their patients’ outcomes, and they also care deeply about
wasted time (especially their own).
In contrast, doctors are less excited about improving the
hospital’s publicly reported quality scores,
reducing length of stay, or removing waste in the supply
chain—all of which they tend to think
of as “the hospital’s problem, not mine.”
Hospital leaders can address this gap by how they frame aims
and measure results. Physicians care
about mortality and harm—quality and safety outcomes—much
more deeply than they care about
process measures, and one way to engage them is to make sure
that the organization’s aims focus on
outcomes that are meaningful to doctors. For example, instead
of aiming to “be in the top tenth
percentile of CMS Core Measures,” a hospital might establish
an aim to “reduce the risk of needless
deaths in the hospital.” One strategy to accomplish this aim
might be to improve the reliability of
CMS Core Measures for acute myocardial infarction and
pneumonia.
Reframe Values and Beliefs
Both administrators and doctors need to reexamine and reframe
some of their core values and
beliefs if true engagement in quality and safety is to occur.
Administrators must begin to think of
doctors as partners rather than as customers. Doctors must begin
to see their responsibility for the
62. do not need to be engaged in exactly
the same way. The idea is to develop a segmented plan for
engaging physicians—one plan for a few
physician champions, another plan for the physicians who might
be members of the actual improvement
team, yet another plan for the structural leaders of the medical
staff who might need to adopt a
new hospital policy based on the work of the team, and so forth.
It is important when designing
each of these segmented plans to include a plan to engage those
physicians who are likely to block
recommendations that emerge from the project team or policies
recommended by the structural leaders.
Use “Engaging” Improvement Methods
Executives realize that doctors have often been cynical about
quality improvement in the past
because the methods—ways of involving physicians in
improvement work, data reporting, etc.—are
almost guaranteed to disengage them. For example, asking busy
doctors to join an improvement
team that meets every two weeks during the time doctors would
otherwise be making rounds; using
the vast majority of the meeting time for activities that don’t
require physician input; gathering data
month after month without testing any changes, then sending
out flawed performance data on quality
measures to individual doctors and asking them to improve.
The process for standardizing clinical processes is another
example where redesign is needed to
better engage physicians. Typically, when doctors are asked to
standardize their approach to a clinical
situation, they design a protocol, care pathway, or guideline—a
specification of what should be
65. R E A L W O R L D
Design Design Design Design Approve
Implement
C O N F E R E N C E R O O M S
R E A L W O R L D
C O N F E R E N C E R O O M S
R E A L W O R L D
Innovation Series: Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second
Edition)27
Show Courage
Change is required to make improvements in quality and safety;
this change is not easy, especially
when one powerful voice speaks out against it. Physicians are
among the most powerful voices in
health care organizations and their collegial nature makes them
reluctant to challenge other doctors.
“Monovoxoplegia,” or “paralysis by one loud voice,” is a
common phenomenon that occurs in doctors’
meetings, improvement teams, executive team meetings, and
even in board rooms, where lay board
members often sit silent when one doctor speaks up against a
proposed change.
There is no simple answer to overcome “monovoxoplegia,” but
66. the basis of an effective approach
relies on building an organizational culture of courage—the
courage to ask questions, to challenge
the status quo, and to support the doctors and nurses who do
wish to make improvements. Courage
of this sort is beautifully illustrated by Donna Isgett at McLeod
Regional Medical Center, and the
question she now asks physicians when they balk at using
evidence-based practices: “Are you saying
that you value your individual autonomy more than you value
your patients’ outcomes?” Knowing
that they will be supported all the way to the board enables all
clinicians, including doctors, to ask
tough questions. Courage is infectious.
Adopt an Engaging Style
To achieve the best improvement results, leaders must keep in
mind certain characteristics in the
physician professional culture, including their focus on
individual patients, a deep sense of individual
responsibility for patient outcomes, the tendency to
overestimate the risk of changes in practice,
and valuing individual experience over data and formal studies.
Below are some ideas, more fully
described in the Engaging Physicians in a Shared Quality
Agenda white paper, for developing a “style”
that engages physicians in improvement.
• Involve Physicians from the Beginning: Don’t hand them a
final or near-final version of proposed
changes.
• Work with the Real Leaders: In most groups of physicians,
there are typically one or two opinion
leaders. They might not be the “titled” leaders within the
68. Leverage Point Seven: Build Improvement Capability
Three years of field experience have reinforced the critical
importance of Leverage Point Seven.
It would do little good for an organization to implement
Leverage Points One through Six—adopt
aims at the board level; develop brilliant plans to achieve the
aims at the executive level; channel
attention to the aims with transparency and executive time;
engage patients in designing changes
to achieve the aim; link financial and clinical improvements to
the aim; and engage physicians in
the aim—if no one in the organization were technically capable
of making, sustaining, and
spreading improvements (Leverage Point Seven).
To effectively execute improvement projects throughout an
organization, leaders must devote
resources to establishing capable leaders of improvement in
every microsystem. If successful projects
are to scale up, spread, and change the performance of the entire
system, then leaders must build a
system of leaders capable of rapidly recognizing, translating,
and locally implementing change
concepts and improved designs. The list of capabilities required
of senior leaders to drive system-level
improvement is long, but includes at a minimum the ability to
know, use, and teach the following:
• The Model for Improvement and small-scale rapid tests of
change23
• A coherent improvement strategy such as the Toyota
Production System24
• Concepts and practices of high-reliability organizations25
71. Learning about what it takes to execute change on a large scale:
• Focus on one or two major aims
• Rigorous steering of the execution plan using good data
from the field
• Resourcing strategic improvements with capable improvers
and
change leaders as their primary job responsibility
Three Channel Leadership Attention
to System-Level Improvement: Personal
Leadership, Leadership Systems, and
Transparency
• Confirmation and examples of the power of leadership
attention
to improvement aims
• A major new emphasis on the power of transparency to drive
improvement and change
Four Put Patients and Families on the
Improvement Team
• Original leverage point focused on establishing the most
effective senior leadership team
• Revised leverage point focuses exclusively on the
transformational
role of patients and families on leadership and improvement
teams
Five Make the Chief Financial Officer
a Quality Champion
73. rate, harm rate, nosocomial infection
rate, or chronic disease outcome measure). The self-assessment
should be completed by the senior
leadership team of the organization, first as individuals and then
together as a group to review the
results and plan actions that will address any leadership
leverage points that need attention.
Leadership Leverage Points Action Needed / Action Planned By
Whom By When
1. Establish and Oversee
Specific System-Level Aims
for Improvement at the
Highest Governance Level
Senior leadership team has
developed specific “how much,
by when” aims for system-level
measures of quality and safety.
Board has adopted the aims and
is overseeing their achievement
using system-level measures of
progress against the aim.
Patient stories about harm or
quality issues (either in person,
by videotape, or as told by
front-line personnel) are part
of every board meeting.
Accountability for achieving the
78. The medical staff are regarded
as partners in the delivery of
care, not as customers of the
hospital.
There is a clear plan for devel-
oping physician engagement
that recognizes the multiple
“segments” of the physician
staff (champions, structural
leaders, others).
We use quality methods
that encourage physician
engagement in quality rather
than drive them away
(sensible use of data, make
the right thing easy to do).
Executive, physician, and
nurse managers are confident
of support all the way to the
board level, and have the
courage to engage physicians
in difficult conversations and
avoid “monovoxoplegia”
(paralysis by one loud voice).
Capable physician leaders
have been appointed to each
project, and are supported
with good data and analytic
resources.
81. icImprovementInitiativesWhitePaper.htm.
4 Carlile PR, Christensen CM. Practice and Malpractice in
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5 Provost L, Miller D, Reinertsen J. A Framework for
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dership/EmergingContent/AFramew
orkforLeadershipofImprovement.htm.
6 Martin LA, Nelson EC, Lloyd RC, Nolan TW. Whole System
Measures. IHI Innovation Series
white paper. Cambridge, Massachusetts: Institute for Healthcare
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http://www.ihi.org/IHI/Results/WhitePapers/WholeSystemMeas
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7 Tapscott D, Ticoll D. The Naked Corporation: How the Age
of Transparency Will Revolutionize
Business. New York, New York: The Free Press; 2003.
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publishing patient care performance data improves quality of
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2008;148(2):111-123.
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15 Reinertsen J, Schellekens W. 10 Powerful Ideas for
Improving Patient Care. Chicago, Illinois: Health
Administrative Press with the Institute for Healthcare
Improvement; 2005.
16 Norling R. Keynote presentation at the CEO Summit,
Institute for Healthcare Improvement
National Forum, Orlando, Florida. December 11, 2007.
17 Nolan T, Bisognano M. Finding the balance between quality
and cost. Healthcare Financial
Management. 2006 Apr;60(4):66-72.
18 Going Lean in Health Care. IHI Innovation Series white
paper. Cambridge, Massachusetts:
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retrieved February 19, 2008.
http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealth
Care.htm.
19 Personal communication with Donna Isgett, Vice President
for Clinical Effectiveness, McLeod
Health. December 2007.
20 Personal communication with David Wessner, CEO, Park
Nicollet. June 2006.
21 Toussaint J. Presentation at the Institute for Healthcare
Improvement Executive Quality Academy,
Boston, Massachusetts. June 2006.
22 McVay G, Cooke DJ. Beyond budgeting in an IDS: The Park
84. Nicollet experience. Healthcare
Financial Management. 2006 Oct;60(10):100-102.
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ds/HowToImprove/.
24 Spear S, Bowen HK. Decoding the DNA of the Toyota
Production System. Harvard Business
Review. September 1, 1999.
Innovation Series: Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second
Edition)39
25 Nolan T, Resar R, Haraden C, Griffin FA. Improving the
Reliability of Health Care. IHI Innovation
Series white paper. Boston, Massachusetts: Institute for
Healthcare Improvement; 2004. Online
information retrieved February 19, 2008.
http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheRelia
bilityofHealthCare.htm.
26 Optimizing Patient Flow: Moving Patients Smoothly Through
Acute Care Settings. IHI Innovation
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lowMovingPatientsSmoothlyThroughA
cuteCareSettings.htm.
27 Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C. A
86. Acute Care Settings
3 The Breakthrough Series: IHI’s Collaborative Model for
Achieving Breakthrough Improvement
4 Improving the Reliability of Health Care
5 Transforming Care at the Bedside
6 Seven Leadership Leverage Points for Organization-Level
Improvement in Health Care (Second Edition)
7 Going Lean in Health Care
8 Reducing Hospital Mortality Rates (Part 2)
9 Idealized Design of Perinatal Care
10 Innovations in Planned Care
11 A Framework for Spread: From Local Improvements to
System-Wide Change
12 Leadership Guide to Patient Safety
13 IHI Global Trigger Tool for Measuring Adverse Events
14 Engaging Physicians in a Shared Quality Agenda
15 Execution of Strategic Improvement Initiatives to Produce
System-Level Results
16 Whole System Measures
All white papers in IHI's Innovation Series are available online
at www.ihi.org and can be downloaded at no charge.
87. 2016
National Healthcare
Quality
and Disparities
Report
This document is in the public domain and may be used and
reprinted without permission.
Citation of the source is appreciated. Suggested citation: 2016
National Healthcare Quality and
Disparities Report. Rockville, MD: Agency for Healthcare
Research and Quality; July 2017.
AHRQ Pub. No. 17-0001.
2016 NATIONAL HEALTHCARE
QUALITY AND DISPARITIES REPORT
88. U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
AHRQ Publication No. 17-0001
July 2017
www.ahrq.gov/research/findings/nhqrdr/index.html
A final typeset version of this report will be available by
September 2017.
http://www.ahrq.gov/research/findings/nhqrdr/index.html
ACKNOWLEDGMENTS
89. The National Healthcare Quality and Disparities Report (QDR)
is the product of collaboration among agencies from
the U.S. Department of Health and Human Services (HHS),
other federal departments, and the private sector. Many
individuals guided and contributed to this effort. Without their
magnanimous support, the report would not have
been possible.
Specifically, we thank:
Primary AHRQ Staff: Sharon Arnold, Jeff Brady, Erin Grace,
Karen Chaves, Nancy Wilson, Darryl Gray, Barbara
Barton, Doreen Bonnett, and Irim Azam.
HHS Interagency Workgroup for the QDR: Girma Alemu
(HRSA), Nancy Breen (NIH-NIMHD), Victoria
Cargill (NIH), Hazel Dean (CDC), Kirk Greenway (IHS), Chris
Haffer (CMS-OMH), Edwin Huff (CMS), DeLoris
Hunter (NIH-NIMHD), Sonja Hutchins (CDC), Ruth Katz
(ASPE), Shari Ling (CMS), Darlene Marcoe (ACF),
Tracy Matthews (HRSA), Ernest Moy (CDC-NCHS), Curt
Mueller (HRSA), Ann Page (ASPE), Kathleen Palso
(CDC-NCHS), D.E.B Potter (ASPE), Asel Ryskulova (CDC-
NCHS), Adelle Simmons (ASPE), Marsha Smith
(CMS), Caroline Taplin (ASPE), Emmanuel Taylor (NCI),
Nadarajen Vydelingum (NIH-NCI), Barbara Wells
90. (NIH-NHLBI), and Ying Zhang (IHS).
QDR Team: Irim Azam (CQuIPS), Barbara Barton (CQuIPS),
Doreen Bonnett (OC), Cecilia Casale (OEREP),
Xiuhua Chen (SSS), Frances Chevarley (CFACT), James
Cleeman (CQuIPS), Diane Cousins (CQuIPS),
Noel Eldridge (CQuIPS), Camille Fabiyi (OEREP), Zhengyi
Fang (SSS), Ann Gordon (BAH), Erin Grace
(CQuIPS), Darryl Gray (CQuIPS), Kevin Heslin (CDOM), Bara
Hur (BAH), Anil Koninty (SSS), Lan Liang
(CFACT), Emily Mamula (BAH), Kamila Mistry (OEREP),
Atlang Mompe (SSS), Heather Plochman (BAH),
Susan Raetzman (Truven), Margie Shofer (CQuIPS), Lily
Trofimovich (SSS), and Nancy Wilson (CQuIPS).
HHS Data Experts: Cuong Bui (HRSA), Lara Bull (CDC),
Frances Chevarley (AHRQ), Robin Cohen (CDC-
NCHS), Joann Fitzell (CMS), Elizabeth Goldstein (CMS), Irene
Hall (CDC-HIV), Norma Harris (CDC-HIV),
Jessica King (NPCR), Amanda Lankford (CDC), Denys Lau
(CDC-NCHS), Lan Liang (AHRQ), Sharon Liu
(SAMHSA), Marlene Matosky (HRSA), Tracy Matthews
(HRSA), Robert Morgan (CMS), Richard Moser (NIH-
NCI), Kathleen Palso (CDC-NCHS), Robert Pratt (CDC), Neil
Russell (SAMHSA), Asel Ryskulova (CDC-NCHS),
Alek Sripipatana (HRSA), Reda Wilson (CDC-ONDIEH-
91. NCCDPHP), Emily Zammitti (CDC-NCHS), and
Xiaohong (Julia) Zhu (HRSA).
Other Data Experts: Mark Cohen (ACS NSQIP), Ashley Eckard
(University of Michigan), Sheila Eckenrode
(MPSMS-Qualidigm), Michael Halpern (American Cancer
Society), Clifford Ko (ACS NSQIP), Vivian Kurtz
(University of Michigan), Robin Padilla (University of
Michigan KECC), Bryan Palis (NCDB, American College of
Surgeons), and Yun Wang (MPSMS-Qualidigm).
Other AHRQ Contributors: Cindy Brach, Iris Mabry-Hernandez,
Edwin Lomotan, Karen Migdail, Pamela Owens,
Wendy Perry, Mary Rolston, Bruce Seeman, Randie Siegel, and
Michele Valentine.
Data Support Contractors: Booz Allen Hamilton (BAH), Social
& Scientific Systems (SSS), Truven Health
Analytics, and Westat, Inc.
iii
CONTENTS
EXECUTIVE SUMMARY
...............................................................................................
..............1
92. Key Findings
...............................................................................................
.................................1
About the National Healthcare Quality and Disparities Report
..................................................1
OVERVIEW OF QUALITY AND ACCESS IN THE U.S.
HEALTH CARE SYSTEM ..............2
Three Aims for Improving Health Care
.......................................................................................2
Variation in Health Care Quality and Disparities
........................................................................8
ACCESS AND DISPARITIES IN ACCESS TO HEALTH CARE
.............................................10
QUALITY AND DISPARITIES IN QUALITY OF HEALTH
CARE ........................................14
Trends in Quality
...............................................................................................
........................15
Trends in Disparities
...............................................................................................
...................18
LOOKING FORWARD
...............................................................................................
.................23
REFERENCES
...............................................................................................
...............................25