The Role of Leadership and Execution in Improving Care Delivery

1
The Role of Leadership and Execution
in Improving Care Delivery

• Cheryl Hermann, RN
• Tom Holets, MA, MBA
• Bruce McCarthy, MD, MPH

2
Allina Hospitals and Clinics

• Allina Medical Clinic
• 700 providers (600 MDs)
• 46 clinics
• Clinic size 4 to 80 providers
• Twin Cities area Urban, suburban, rural
• Allina hospitals
• Twin Cities area Urban, suburban, rural
• Home Care, Hospice Palliative Care, Medical
  Transportation
• Epic EMR implementation 2004 - 2007

3
(No Transcript)
4
Challenges

• We needed to move from a collection of mostly
  purchased entities to a single group
• We had to implement an EMR in 46 clinics and 11
  hospitals over three years
• Our quality performance metrics were average

5
(No Transcript)
6
(No Transcript)
7
Care system change
Improving Chronic Illness Care, Ed
Wagner, MD (GHCPS)
8
Allina Medical Clinicimprovement theory

• Develop a Vision
• ?
• Design the Systems
• ?
• Align Leadership
• ?

Execute to Outcomes
9
Diabetes care improvement
individual measures
Type 1 and 2 diabetes ages 18 to 75
10
(No Transcript)
11
Other measures improved
12
Principles of change

• Diffusion of innovation in medicine is
  ponderously slow Rundall, Lee
• Designing a new care system and achieving a new
  care system are not the same QI Teams fail as
  often as they succeed Mills, Hroscikoski
• Designing new processes easier
• Changing behaviors harder

13

• Why is change so hard?

14
Systems tend to stay in equilibrium unless
activation energy is applied
More Work
Less Work
15
Leadership imperatives

• Establish the why
• Develop the vision
• Align leadership
• Set and focus on goals
• Communicate
• Provide feedback
• Focus on the what, how, who
• Teach leaders to lead
• Check back

16
Leadership Where do you start?

• Making the case and establishing the moral high
  ground
• Rather than first asking, Where should we go
  and how should we get there? leaders begin with
  the question, What do we stand for...?
  Souba

17
Develop a vision

• Deliver the best care science has to offer
• Evidence-based medicine
• Develop the best systems based on evidence
• Evidence-based practice management
• Deliver care in the way we would want for
  ourselves or our family

18
Aligning the right leadership

• Paired leadership shared clinical and business
  responsibility
• District medical director and district director
• Site physician lead and clinic manager
• Clinical practice council
• Moral authority to impose standards and process
• Multidisciplinary
• Clinical services council and nursing leadership

19
Execution Goal setting

• Joint accountability of physician and
  administrative leadership.
• Same goals on evaluations
• Absolute performance not relative to improvement
  all clinics at 25 percent optimal diabetes care
  by 12/31/07

20
Percent optimal diabetes care by site 12/31/07
21
Communicate

• Craft simple consistent messages that are easily
  transmissible
• Memes A unit of cultural information that can
  propagate from one mind to another in a manner
  analogous to genes Richard Dawkins,
  1976
• All change eventually requires one clinician to
  talk to another about changing behavior

22
Communicate

• Good
• Allina Vision We serve our communities by
  providing exceptional care, as we prevent
  illness, restore health and provide comfort to
  all who entrust us with their care.
• Better
• Allina Mission We will put the patient first

23
Communication

• The use of inhaled corticosteroids has been shown
  to reduce pediatric ER and inpatient visits by up
  to 50.
• In patients with vascular disease and BPs of
  140-159/90-99, a sustained reduction of 12mmHG in
  systolic BP over 10 years will prevent 1 death
  for every 9 patients treated.
• The PHQ9 depression tool is 88 sensitive and
  specific highly correlated with improvement.

24
Communicate

• Present message in a way that is meaningful.
• 3-5 year Impact of of Better Diabetes Control for
  our 17,000 diabetic patients
• 130 fewer strokes
• 400 fewer heart attacks
• 200 fewer deaths
• 300 fewer cases of diabetic eye disease

25
Communicate

• Hardwire communication
• The Bulletin
• Use multiple levels and pathways
• Leadership meetings, site meetings, nursing
  meetings
• Create a drumbeat
• Check that the message has been transmitted
• Leader Rounding
• Communication is your responsibility

26
Cullum, L. The New Yorker May 9, 2005
27
Communication

• Teachable Point of View (TPOV) Tischy
• Why things need to change
• Where we are going
• How we are going to get there
• What I need from you

28
Provide feedback

• Regular and frequent
• Specific
• Verifiable

29
Provide feedback
30
(No Transcript)
31
Focus on the What, how and who

• Diseases registries and reports
• EMR templates and prompts
• Standard staff training and operating procedures,
  e.g. rooming standards
• Planned chronic care visits
• Patient self-management support
• Manage the panel

32
Execution Identify the must haves

• A way of naming the elements that facilitate
  communication, set
  expectations and create the behavioral norm
• Diabetes 7 must haves
• 1. Support staff follows the Diabetes Visit
  Workflow
• Standard rooming protocol with prompts for last
  lab results
• Automatic point-of-care A1c prior to seeing
  provider, if due
• 2. Use EMR smart tools to make documentation and
  lab ordering easier
• 3. Treat aggressively use diabetes management
  algorithm
• 4. Limit prescription refills to a maximum of six
  months
• 5. Give progress cards or visit summaries to the
  patient
• 6. Schedule future labs, provider and CDE
  appointments before the patient leaves
• 7. Provider and support staff team routinely
  receives and acts on its diabetes exception report

33
Execution Breaking down the play

• Giving feedback alone wasnt enough for many
• physicians to improve
• What specifically must the physician and support
  staff do?
• What specifically must leaders do to get this
  process change or behavior to occur?

34
Execution Breaking down the play

• Examples
• Must Have 7 Provider and support staff team
  routinely receive and acts on its diabetes
  exception report
• 11 meetings between RN CDE with physician and
  his/her clinical assistant to share best of
  practice in workflows helped these teams get
  unstuck
• Must Have 3 Treat aggressively
• Mandatory (compensated) two hour diabetes CME
  for physicians with low percentage optimal
  diabetes care taught tempo and timing

35
Execution Teaching leaders to lead

• Meeting skills and action logs
• Influencing skills
• Teachable point of view (TPOV) Tischy
• Giving feedback and coaching
• Execution skills
• Dealing with resistance
• All change eventually requires one clinician to
  talk to another about changing behavior

36
Execution Teaching leaders to lead

• Leadership P-D-S-A
• Planning a coaching encounter and learning from
  it
• Use physician leadership meetings as learning
  groups (support groups)
• Review the techniques of implementation and
  leadership skills

37
Primary care physicians by district
38
Building support through site demonstrations/pilot
s

• Work with the willing and able first
• Have the pioneers tell their own story
• Creates new evidence for evidence-based practice
  management

39
Execution Checking back

• As I know more of mankind I expect less of
  them, and am ready now to call a man a good man
  upon easier terms than I was formerly.
• Samuel Johnson (1709 - 1784)

40
Execution Checking back

• Create accountability for action
• Review action logs and metrics of implementation
  of the elements, not just the quality measures
  themselves
• Keep lists and check on each and every team
• Is it being done? How do you know?
• A policy not observed is much worse than no
  policy at all

41
Execution Checking back

• Be tenacious
• Use leadership rounding to convey the
  importance of the quality initiative, test for
  understanding of frontline staff and recognize
  accomplishment
• Chlamydia example

42
(No Transcript)
43
Lessons learned

• The importance of Memes
• The usefulness of real time measures, including
  individual patient data, rather than summary
  measures
• Incentives dont have to be financial to work
• How to overcome inertia through breaking down
  the play and coaching
• Improvement is social change
• Necessary to keep focus and manage to a few
  dont bite off more than you can chew
• All change eventually requires one clinician to
  talk to another about changing behavior

44
Lessons learned

• The power of nursing
• Understanding What we are fighting for
• Empowerment Tools, training, leadership support
• Accountability It goes both ways

45
(No Transcript)