North Dakota National Improvement Leader Fellowship (ILF) Wednesday, August 13, 2014

1. American Hospital Association (AHA)/ Health Research & Educational Trust (HRET) Hospital Engagement Network (HEN) North Dakota National Improvement Leader Fellowship (ILF) Wednesday, August 13, 2014

2. Objectives Identify opportunities and tactics for coaching front line teams on the useful application of improvement methods Understand approaches to coaching improvement teams through examples from HEN hospitals Use questions to drive learning Identify models and resources for developing an organizational strategy for developing improvement capability

3. North Dakota ILF Achievements • Number of Improvement Leader Fellows: 36 • Number of HAB Templates*: 11 • Number of IHI Open School Registrants: 13 • Hospitals with highest number of OS modules completed: Northwood Deaconess Health Center (7); Catholic Health Initiatives – Mercy Hospital (6); Sanford (6); Essentia Health (5) * HAB Count as of 8/1/2014

4. What is IHI Open School? • Online courses focused on • Improvement capability • Patient safety • Tripe aim for populations • Person- and family-centered care • Leadership • Quality, cost and value • 12 month subscription • Continuing education units provided through IHI

5. Visit www.ihi.org/hretilf

6. Presented by: Jane Taylor Improvement Advisor (IA) Institute for Healthcare Improvement (IHI) Coaching and Building Capability at the Front line

7. Reflection on Last Month’s ILF Discuss at your tables: • What did you learn about working styles (or other tools to improve teamwork) last month? Have you changed anything about your approach to working with your teams? • What changes have been effective?

8. Fellowship Participation: Themes for Coaching and Capability Building

9. Fellowship Participation: Open School Modules

10. Fellowship Participation: Open School Modules

11. Table Discussion If you have taken any of the IHI Open School modules, share one thing you found useful.

12. Coaching Interventions Doing tasks for the team Consulting Training Coaching Facilitating Increasing client responsibility for providing content and managing the process Coach in role of “doing for to get it done” Coach in role of “empowering, eliciting, enabling to get it done”

13. Definitions

14. Coach’s PurposeBuilding Capacity for Change plus Quality Improvement Skills • Building capacity for change means the process of a team and organization taking on the tasks and functions necessary for sustainable change. • More is needed… • incorporating quality improvement principles and methods are necessary to know a change is an improvement and that improvement is sustained.

15. Execution: Model for Improvement Langley, et al, The Improvement Guide, 2009 Improvement Guide. 2nd Edition, 2009

16. Using the Lens of Profound Knowledge Appreciation of a system Theory of Knowledge Psychology Understanding Variation Aim or Values

17. Hospital Story coaching and capacity-building

18. Essentia Health - Fargo Teresa Nelson, RN Clinical Quality Analyst

19. About Us Essentia Health – Fargo is a 105 bed acute care hospital located in Fargo, North Dakota. Part of an integrated health system serving patients in Minnesota, North Dakota, Wisconsin and Idaho. Joint Commission accredited, Level II trauma center, providing a variety of inpatient and outpatient specialized services (including Advanced Primary Stroke Center, Certified Breast Cancer Center, Certified CAP Laboratory, only hospital in ND to have an Interventional Neurologist).

20. Harm Across the Board

21. ADE Project

22. Our Teambuilding Success Key Implementations to the ADE Project What Made our Team Successful Monthly reviews of all inpatient records with elevated INRs (>5) Were they potentially preventable? If so for what reason (predictable drug interaction; inappropriate dose ordered; administration error; inappropriate time to next appointment) Invited Coumadin Clinic to be part of our team Inpatient and outpatient protocols – reviewed and updated Entering into incident database as an ADE and providing feedback/education to providers and staff Pharmacy involvement with the management of inpatients on warfarin

23. Our Approach How do we get people engaged to do improvement work? Transparency of Data: Clinical quality dashboard posted in all units; results = buy-in Essentia Performance System (EPS): Huddles, Flow Boards and Gemba Rounds. Using the EPS allows staff to see how their work directly impacts performances (department-level initiatives tie into system-wide goals). How do we build on strengths? Know your team members and their working styles It takes ‘everyone’ to succeed (analytical, driver, amiable, expressive)

24. Essentia HealthMission Statement “We are called to make a healthy difference in people’s lives.” QUESTIONS?

25. Judge a man by his questions rather than by his answers.-Voltaire

26. Use of Questions • Socratic method: a method of inquiry using questions to guide someone to a solution • 5 Whys • Drawing out rationale behind testing, conclusions and actions • Questions, Not Answers, Drive Thinking • Questions that stimulate our thought promote deeper thinking about the issue • Questions help define tasks, express problems and delineate issues • Questions can be used to reframe the thought processes to move in a different direction

27. Use of Questions, cont. • Answers can arrest further thinking • Only when an answer generates a further question does thought continue its life as such • There are times when specific answers facilitate moving teams forward

29. Turn and talk • 1 person describes a recent PDSA cycle or dilemma related to your HEN work • Examples of tests or dilemmas might include reducing falls, pressure ulcers or VTEs, or personalizing care • The partner listens and asks questions Refer to the ICF Handout – Section C: Communicating Effectively 5 minutes, then switch

30. Debrief When you were describing your test or dilemma, what was the effect of the questions? Did the questions spark ideas for future tests? What was it like to be the questioner? What did you notice about the interaction?

31. Building Capability for Improvement

32. Our Hospital Association includes * 25 bed Critical Access Hospital * 80 Bed Skilled Care Center * 68 bed Basic Care Center * 37 Assisted Living Units * Family Practice Clinic in 3 locations * Surgical Clinic

37. Agenda

38. LinkageGrid

43. Table Discussion How do you currently build improvement capability? Success and Challenges?

44. The Leadership Challenge To build a renewable infrastructure that produces a highly reliable quality and safety system by (fill in the date). How good? By when?

45. The Journey To Organizational Excellence Excellence Sustainability Capability Capacity “We are what we repeatedly do. Excellence then, is not an act but a habit! Aristotle (384 – 322 BC)

46. Key Terms: Helen Bevan Capacity – having the right number and level of people who are actively engaged and able to take action. Capability – the people have the confidence and the knowledge and skills to lead the change. Helen Beven, “How can we build skills to transform the healthcare system?” Journal of Research in Nursing 15(2) 139-148, 2010.

47. Key Questions for Building Capacity and Capability • Will you involve everyone or just a few targeted groups? • Who needs to know what? • What methods do you plan to use to build capacity and capability? • Do you have a model or framework to guide your journey? • How will you make sure the learning system can be sustained? Adapted and expanded from a conversation with Tom Nolan, Associates in Process Improvement on material he presented at the IHI Strategic Partners Roundtable, April 17-18, 2006.

48. Improvement concepts, methods and applications must be woven into the fabric of daily life and at all levels of the organization. • From point where care is delivered, • To management meetings and strategy sessions • And, in the board and governance level decisions

49. Therefore, a cascading system to build capacity and capability is needed!

50. Many organizations start the cascade at the top… …and, trickle downward!