A Model Program for Improving Hospital Performance or

1. A Model Program for Improving Hospital Performanceor The Key to Creating Breakthrough Improvement is in Culture

2. David M. Boan, Ph.D.Vice President for Research and DevelopmentDelmarva FoundationMatthew Fitzgerald, DrPH Senior Director of QualityAmerican College of CardiologyEd Huff, Ph.D.Science Officer and Government Task Leader CMS

3. Presentation Overview • Project origin and history • The project model • Assessment instrument • Six hospital case studies • Interventions • Lessons learned and next steps • Q & A

4. The Project Roots • Best Practice Methods, Year One • Findings from QIO Survey • Decided to add QIO Teamwork to BPM • Developed instrument • Best Practice Methods, Year Two • Continuing teamwork effort • Adding effort to enhance cross-QIO teams

5. The Program • Began with QIO Training Program • Reviewed assessment materials from AHRQ / Hopkins • Recruited 6 hospitals, 14 units • Created within hospital controls • One hospital dropped out after several senior staff resigned

6. Assumptions • Culture is the context for clinical care • Teams - accessible unit for culture change • Right conditions - team evolves towards high reliability / performance • Wrong conditions – team performance suffers

7. Teamwork Dimensions • Vision • Leadership • Mindfulness • Inclusion • Communication

8. Expanded to 10 Dimensions in Hospitals • Vision: Team share a common vision of success. • Safety Information: People see and report events that impact safety and quality. • Learning: When a problem is identified, people learn from it and make improvements. • Team Communication: Communication is respectful and mutual versus competitive and aggressive. • Leadership Consistency: Leadership is available and clearly consistently driving quality and safety.

9. Hospital Team Dimensions 6 - 10 • Teamwork and Hierarchy: Ideas and information come from all levels not just the senior people. • Openness: Staff at all levels perceives that it is acceptable for them to speak up about problems. • Cross Unit Handoff: Communication between units is open and clear. • Management Support: Management presents a clear and consistent commitment to safety and quality. • Information Exchange: Information moves easily across barriers (shifts changes; units; etc).

10. Engagement • Report – shows their unit / team scores with comparative benchmarks • Report / assessment generated discussion • Emphasized self perception nature of survey results – How your team sees itself - not a diagnosis

11. Status • Surprise, surprise!! • Poor hospitals thought they were better • Best hospitals surprised they were good • Five hospitals working on six units • Reassess culture in June • Interim feedback – this is needed!!

12. The Stories: Six Hospitals, Seven Units

13. Case 1: “Cross-Unit Conflict” • Strong team - In conflict with other units • The “Myth of Disrespect” • Cultural Identity – “we are not respected” • Intervention addressed; • Communication and relationships • Joint project - cooperation required for reward

15. Case 2: “Polarized High Performer” • Expectation: Excellent unit /No need for improvement • Reality: Quickly assessed performance – Identified need for improvement • Broad participation • Dynamic team communication lacking

17. Case 3: “Management Denial” • Staff trying to send a message • Most difficulty seeing need for improvement • Management dismissed staff concerns • Staff see themselves as professionals whose legitimate concerns are discounted

19. Case 4: “Strong VP Vision, Blind Team” • Rated poorly as a team • No feedback, no owned outcomes • Intervention = Creating targets • Create expectation of: • feedback on performance. • “engaging” each other in improvement

21. Case 5: “Strong but Closed” • Strong performing unit • Communication concerns • No system for feedback to staff • Junior/Novice staff avoid direct communication with senior staff / physicians

23. Case 6: “Team-less Psych Unit” • Team in conflict • Recognized: • Team weakness • Importance of social environment to psych unit success • Criticality of teamwork to quality clinical services “This aint rocket science – it’s social science”

25. Case 7: “Flamed Out” • Highly motivated Hospital • High staff turnover • Three mid-managers resignations • Project to address turnover problem • Perceived as adding burden by staff

26. Interventions Or “So What’s a QIO to do about all this?”

27. Intervention Method • Listen • Listen • Listen i.e. Help the staff tell their story

28. The Intervention Model • Declare Your Culture (Feedback and discussion) • Identify Gaps between current and ideal • Target specific behaviors related to key culture elements • Promote those behaviors • Track and use feedback • Instill model with the front line staff

29. Key Considerations • Emphasize creating conditions for team success • Team identifies targets (gaps) • Team coached to: • make process improvements, • gather and use data, and • revise as needed • Ultimate goal - an effective team process

30. Isn’t This Just PDSA? • NO, it is different. • But - PDSA is a management tool • And – PDSA can help build team culture • This program combines behavior management and team dialog • BM to develop key behaviors • Dialog to impact the team’s self perception

31. Isn’t This Just Baldrige or ISO? • NO, it is different. • It’s about relationships and interactions • Not processes and measurement • Team vision comes closest

32. So How Does the Culture Change? • When a team agrees on values and aims, and • Agrees on how they need to improve to achieve those aims, and • Defines, monitors, and promotes specific actions to achieve the improvement, and • Engages in a dialog about the feedback and what is says about their improvement effort, then, slowly, very slowly - Culture changes

33. Lessons Learned

34. Hospitals Want This, But Not Sure What “It” Is • Increasing awareness of “culture”, but not sure what that is or what to do about it. • Recognize something “more” is needed for breakthrough improvement, but don’t know how to go about it. • Looking for a model and assistance • Potential for confusion, be very clear about expectations

35. High Performing Environments are “Feedback Rich” • Two types of feedback: • performance metrics (clinical) and • social feedback (cultural) • Highest performing teams have both • Units “dense” in feedback, such as ICU’s, report stronger cultures

36. A Strong Performance Vision Unifies a Team and Produces Excellence • Common vision – common core values • Agreement creates foundation for: • Common expectations • Decreasing conflict • Links personal values to team values • Increases commitment

37. Senior Leadership is Important, but not Absolute • Strong team leadership can compensate for poor senior leadership (but not vice versa) • Ex.: The highest performing team was next to a poor performing team in a hospital with leadership in conflict • Very important to distinguish between unit management and senior leadership • Unit manager a critical position. They MUST lead the change effort

38. And now, a word from our sponsor….

39. For more information, contact David Boan Delmarva Foundation 9240 Centreville Rd Easton, MD 21601 Dboan@dfmc.org