Leadership For Quality

1. Leadership For Quality Edward F. Crooks MD, CMQ, CLSSBB,

2. Leadership for Quality Leadership • Definition – “working with people and systems to produce needed change” (Wessner 1998). • Every system is perfectly designed to produce the results it gets – if better results are to be expected, systems and the people in them, must change • Essential to QI • Small team working to improve care for a particular condition. • QI at the level of an entire organization, aiming to improve performance on system level measures (mortality rates, cost per capita)

3. Leadership for Quality • Studies of leaders and leadership have produced many theories and models of what is required to “work with people and systems to produced needed change” • The complex mix of theories can be considered at two levels: • Individual leadership. • Organizational leadership systems.

4. Leadership for Quality Individual Leadership • This set of leadership ideas is about what people must be, and what they must know how to do. • Having strong personal leadership attributes without knowing how to use it, is not enough. • Knowing the leadership toolbox without authentically embodying the characteristics required of leaders is insufficient for successful leadership. • Both being and doing are needed especially when the changes required for QI involve reframing core values or remaking professional team.

5. Leadership for Quality What Leaders Must Be • Authentic embodiment of core values • Trustworthy: consistent in thought, word and deed • In love with the work, rather than the position, of leadership • Someone who adds energy to a team, rather than suck it out • Humble, but not insecure; able to say “I was wrong” • Focused on results, rather than popularity • Capable of building relationships • Passionately committed to the mission

6. Leadership for Quality What Leaders Must Know How to Do. • Understand the system context in which improvement work is being done. • Explain how the work of the team fits into the aims of the whole system • Use and teach improvement methods • Develop new leaders • Explain and challenge the current reality • Inspire a shared vision • Enable other to act • Model the way • Encourage the heart • Manage complex projects (Kouzes and Posner 1987)

7. Leadership for Quality Organizational Leadership • Not about individual leaders and what they must be and do. • Its creating a supportive organizational environment in which hundreds of capable individual leaders’ work can thrive • This environment is at the system-of-leadership level. • This level can be viewed as a complex set of interrelated activities in five broad categories. • Set direction • Establish the foundation • Build will • Generated ideas • Execute change

8. Leadership for Quality Set the direction • Every healthy organization has a sense of direction • Mission – a statement of purpose of the institution: the reason it exists. It usually rest on the core needs of the institution and on the core values of its vision. IOM – “A place with no needless deaths, no needless pain, no needless helplessness, no needless delays, and no waste, for every one we serve” • Vision – a statement describing a future picture of the institution or care delivery system. • Strategy – Organization’s hypothesis about the causative relationship between a set of actions (process redesign) and achievement of system-level, mission-driven aims (improved levels of safety).

9. Leadership for Quality Establish the Foundation • Reframing operating values • Build improvement capability • Do personal preparation • Choose and align the senior team • Build relationships • Develop future leaderships

10. Leadership for Quality Build Will • Transform yourself and your team. • Adopt board system-level aims. • Publicly commit to the aims. • Define the business case for quality.

11. Leadership for Quality Generate Ideas • Read and scan widely, learn from other industries and discipline • Benchmark to find ideas • Listen to customers • Invest in research and development • Know the best in the world • Try ideas quickly

12. Leadership for Quality Execute Change • Use model for improvement for design and redesign • Use change leadership model • Channel leadership attention to quality • Spread ideas • Focus on and communicate results • Make quality a line responsibility

13. Leadership for Quality Concepts and Definitions Leadership • Working with people and systems to produce needed change. Management • Working with people and system to produce predictable results. Governance • The process through which the representatives of the owners of an organization (board of directors or board of trustees) oversee the mission, strategy, executive leadership, quality performance and financial stewardship of the institution.

14. Leadership for Quality Technical leadership challenges • Change situation in which there is a high degree of agreement about the nature of goals, as well as a high level of certainty about how to achieve the goal. Adaptive leadership challenges • Change situations that require new learning, resolution of conflicts, and resolution of deep differences in goals, and methods of achieving the goals. Change leadership • A framework or method for planning and executing major change. Leadership development • The processes by which an organization identifies, improves, evaluates, rewards, hold accountable and promote leaders.

15. Leadership for Quality Transformation • Change that involves fundamental reframing of values, beliefs, and habits or behavior, along with radical redesign of care processes and systems, to achieve dramatic levels of improvement.

16. Leadership for Quality • Effective leadership at both the individual and system of leadership levels is essential to QI. • Leadership involves those in formally designated senior position of authority and hundreds of capable individual leaders throughout the organization supported by a well-aligned leadership system. • Care delivery systems are “complex adaptive systems” – therefore behave unpredictably, in large part because of the powerful influence of the professional, community and macro-system context of each organization and care system (regulator, policy, markets) . • Leaders will not be able to transform their organization to a dramatically higher level of quality performance, by working within their organization alone.

17. Leadership for Quality HCO Complex System Leadership System Individual Leaders Leaders Senior positions of Authority Strategic Operational

18. Leadership for Quality Crossing the Quality Chasm • Transformational change will come about not as a result of a detailed leadership plan but because of the convergence of multiple factors, some planned and others completely unplanned.

19. Leadership for Quality Leaders & Leadership system Influence Direct Control HCO-CAS Context Strategic Plan Operations Where we are Where we ought to be Transformation

20. Leadership for Quality The Four Route to Transformational Change • Route 1: Revolution (Leadership from Below) • Route 2: Friendly Takeover (Leadership from outside) • Route 3: Intentional Organizational Transformation (Leadership from above) • Route 4: Intentional Macrosystem Transformation (Leadership from high above)

21. Leadership for Quality Route 1: Revolution • Dramatic change in the culture of the workforce. The central theme of that cultural change are: • From individual autonomy to shared decision making • From professional hierarchies to teamwork • From professional disengagement in systems aims to “system citizenship” Cultural change in workforce HCO Status Quo Tension

22. Leadership for Quality Route 1 is important for two of the three principal strategies of the Crossing the Quality Chasm report: • Use all the science we know • Cooperate as a system Health care leaders cannot wait for this cultural change to move through medicine but should be aware of it and take steps both within and outside the organizational boundaries to support and accelerate that cultural change. HCL should harness the energy from this slow shift in the culture of medicine and use it to drive needed changes inside their organization.

23. Leadership for Quality Route 2: Friendly Takeover • This route constitute the profound shift in power from the professional and organization to the patient and family. • Health care is already well down this route – families have broken into the medical “holy of holies” – the special knowledge that has defined physicians’ source of professional power. • The power of information is already in the hand of the public.

24. Leadership for Quality Route 2: Friendly Takeover • This shift in power is positive and needs to drive a broad range of changes. • This power shift to patient and families will give them as much control of their care as we wish them to have. • Route 2 is the route we must go down to implement the patient-centeredness strategy of Crossing the Quality Chasm report.

25. Leadership for Quality Route 3: Intentional Organizational Transformation • One most familiar to CEOs and other senior executive. • This set of leadership strategies, if implemented with constancy of purpose over some years can drive organization transformation. • However transformation is an emergent property of a complex adaptive system – don’t assume that a well built, well traveled route 3 will get you to the vision without the convergence from other routes.

26. Leadership for Quality Route 4: Intentional Macrosystem Transformation • This route of transformation is a results of intentional acts of policymaker, regulators and others in position of authority outside of the healthcare delivery system. • In general, measurement, payment, and accountability regulations that encourage and reward those who demonstrate evidence-based practices, patient-centeredness and cooperation are powerful drivers of deep organizational change. • Healthcare delivery system leaders cannot design or travel this policy route 4 directly, but can harness its power to accelerate the changes they want to realize in their organization.

27. Leadership for Quality Clinical and Operational Issues • Professional Silos • Physicians, nurses, pharmacist and other clinicians go through separate and distinct training processes. Physicians Nurses Pharmacists

28. Leadership for Quality • Power Gradient • Namely that all other professionals’ actions are ultimately derivatives of physicians’ order. • The net effect is to diminish teamwork and reduce free flow of information , both of which is vital for safety and quality. • QIL must be capable of establishing effective multidisciplinary teams.

29. Leadership for Quality Physician Autonomy • Physicians are taught to take personal responsibility for quality. • Highly developed attachment to individual professional autonomy. • This attribute (culture) have an enormous negative effect on the speed and reliability with which physician adopt and implement evidence-based practices. • The resulting variation causes great complexity in the work of nurses, pharmacists, and other in the system, and is a major source of errors and harm. • QIL will need to reframe this professional value.

30. Leadership for Quality Leaders and Role Conflict in Organizations Clinicians (HCO) • Tend to see the organization as a platform for their individual work. • Seldom feel corresponding sense of responsibility for the performance of the organization as a whole. • Expect their leaders to protect them form the predations of the organization versus contributing to the accomplishment of the organization’s goals. • The questions becomes are these middle-management leaders to represent the interest of their department or units to the organization, or they to represent the interests of the organization to their departments?

31. Leadership for Quality Keys to successful Quality Leadership and Lessons Learned • Transform yourself • Adopt and Use a Leadership Model • Grow and Develop Your Leadership Skills • Avoid the Seven Deadly Sins of Leadership

32. Leadership for Quality Keys to successful Quality Leadership and Lessons Learned Transform yourself • Cannot lead others through the quality transformation unless you are transformed and has made an authentic, public, and permanent commitment to achieving the aims of improvement. • Design experiences that will both transform and sustain the transformed state. • Interview patient who has experienced serious harm in your institution. • Personally interview staff at the sharp end of an error that cause serious harm. • Listen to a patient every day • Read and reread both IOM reports: To Err is Human and Crossing the Quality Chasm. • Learn and use QI methods • View and discuss the Video First, Do No Harm • Perform regular safety rounds with your care team.

33. Leadership for Quality Adopt and Use a Leadership Model • There many useful models and framework for leadership. • Heifetz’s model (1994) • Step One: Identify the Problem • Step Two: Focus attention • Step Three: Frame the Issues • Step Four: Secure ownership • Step Five: Manage stakeholder conflict and maintain stress • Step Six: Create a Safe Haven

34. Leadership for Quality Grow and Develop Your Leadership Skills • Learn new ideas and information • Read about, talk to and observe leaders • Take courses • Find other means of importing ideas • Try out the ideas • Take what you learn and use it the laboratory of your practice. • Use the results to decide which ideas to keep and which to discard • Reflect • Maintain a lifelong habit of reflection - the important aspect of which is the regularity, purpose and seriousness. • Private journaling, private meditation, written reports to peers, dialog with mentors and coaches.

35. Leadership for Quality Avoid the Seven Deadly Sins of Leadership • Indulging in victimhood • Mismatching words and deeds • Loving the job more than the work. • Confusing leadership with popularity • Choosing harmony rather than conflict • Inconstancy of purpose • Unwillingness to say “I don’t know” or “I made a mistake”.