Leadership and Communication for Internal Spread Chinook LS 5 Mike Davies, MD FACP Mark Murray and Associates

2Copyright Mike Davies, MD Decreased Vision Pre-op PE Questions RN over phone F/U Phone Call Optimist for glasses Decreased Vision Optimist for glasses Ophthalmologist Dx Cataract & Completes Pre surgery Form & Books Surgery Surgery GP Consults Ophthalmologist Surgery Post-op Ophthalmologist Visit Nurse does PE Pre-op visit Ophthalmologist Confirms DX Optometrist DX Cataract/Refers to GP 12 Months vs 2 Months For Cataract Care Simplification of the process in healthcare……….

3Copyright Mike Davies, MD It’s NOT POSSIBLE to “Transfer” this Knowledge……. Why? Will to change Will to change Leadership to create aim Leadership to create aim Involvement of all Involvement of all Time to work Time to work Measurement of right things Measurement of right things Unable to form new relationships needed Unable to form new relationships needed ….New knowledge not generated….. ….New knowledge not generated…..

4Copyright Mike Davies, MD “Spread” is really adoption (creation of new knowledge)… New knowledge must be created by each team itself (adopted) rather than just “listened to” and implemented. New knowledge must be created by each team itself (adopted) rather than just “listened to” and implemented. Adoption implies EFFORT and CHANGE Adoption implies EFFORT and CHANGE The knowledge ONLY EXISTS in the context of a team The knowledge ONLY EXISTS in the context of a team

5Copyright Mike Davies, MD Vision Skills ResourcesIncentivesAction Plan Incentives Resources Action Plan CHANGE CONFUSION ANXIETY GRADUAL CHANGE FRUSTRATION FALSE STARTS Managing Complex Change

6Copyright Mike Davies, MD Late Majority Early Majority Early Adopters Historians Innovators Adopter Categories 2.5%13.5%34% 16%

7Copyright Mike Davies, MD Team Exercise 2-3 Volunteers to “sell” something 2-3 Volunteers to “sell” something Volunteers to listen and decide if they want to buy Volunteers to listen and decide if they want to buy

8Copyright Mike Davies, MD What we learn Diffusion curve shape Diffusion curve shape Make a decision in 10 seconds Make a decision in 10 seconds Triggers of relative advantage Triggers of relative advantage People in the middle need more information People in the middle need more information People can be innovators on one thing and laggards on another thing People can be innovators on one thing and laggards on another thing People don’t like to be called laggards People don’t like to be called laggards

9Copyright Mike Davies, MD How you interact the first 4 minutes dictates how your relationship will go the rest of your day will go. Dr Phil Dr Phil

10Copyright Mike Davies, MD Expert team or individual Receiving Team A Receiving Team B Receiving Team C Knowledge

11Copyright Mike Davies, MD Team B Team D Team A Team C Team F Team E Knowledge

12Copyright Mike Davies, MD The above maps represent the answers for two questions asked within the same physician network Map of Technical Advice Seeking NetworkMap of Trust and Friendship Network Figure 2

13Copyright Mike Davies, MD

14Copyright Mike Davies, MDSpread “BETTER IDEAS Happens over time COMMUNICATED Thru a SOCIAL system Adapted from Rogers, 1995 In a certain way (C) 2001, Sarah W. Fraser

15Copyright Mike Davies, MD Spread Readiness Checklist Access improvement is a key initiative Senior Leaders are responsible for, and engaged in spreading the access/efficiency improvements Clear intent to spread the work of the pilot team The pilot team is successful and relatively self sufficient

16Copyright Mike Davies, MD Where to Start The single biggest problem with communication is the illusion that it has taken place - Bernard Shaw The single biggest problem with communication is the illusion that it has taken place - Bernard Shaw Tri-ability Tri-ability Compatible with values/beliefs Compatible with values/beliefs Social System Social System 15-20% at each site is critical mass 15-20% at each site is critical mass Innovators not listened to Innovators not listened to Early adopters ARE listened to Early adopters ARE listened to Spend most time with leaders Spend most time with leaders

17Copyright Mike Davies, MD Influencing Language “Toward” (Achiever) “Toward” (Achiever) “Away” (Problem Solver) “Away” (Problem Solver) “Internal” (Leader) “Internal” (Leader) “External” (Follower) “External” (Follower) “Procedures” “Procedures” “Options” “Options”..achieve, accomplish..wouldn’t be too hard..you might consider..thousands of others..step-by-step..pick and choose

18Copyright Mike Davies, MD Influencing Language Traditionalist Traditionalist Evolutionary Evolutionary Revolutionary Revolutionary..same, similar, familiar..improved, better, new, breakthrough!

19Copyright Mike Davies, MD

20Copyright Mike Davies, MD Culture “A force to be reckoned with” “A force to be reckoned with” “How we do things around here” “How we do things around here” “Culture eats strategy for lunch every day” “Culture eats strategy for lunch every day”

21Copyright Mike Davies, MD Culture is… The unwritten values reinforced every day The unwritten values reinforced every day What it takes to “fit in” What it takes to “fit in” What it takes to “get along” What it takes to “get along” Columbia/Challenger story Columbia/Challenger story

22Copyright Mike Davies, MD Observations About Medical Cultures Current Cultures Current Cultures Physician autonomy above all Physician autonomy above all Financial incentives “magic bullet” Financial incentives “magic bullet” Consensus decision making Consensus decision making Conflict Averse Conflict Averse Hierarchical Hierarchical Focus inward Focus inward Desirable Culture Customer focus Continuous quest for improvement Collaboration Personal responsibility Acknowledgement Adapted from Jack Silverstein

23Copyright Mike Davies, MD The Way It Is With Culture Culture change not for the fainthearted Culture change not for the fainthearted QI projects alone unlikely to shift deeply held culture values and behaviors QI projects alone unlikely to shift deeply held culture values and behaviors Senior leaders are key to shape culture two ways: Senior leaders are key to shape culture two ways: Signal generators Signal generators Hardwire into the organization Hardwire into the organization Adapted from Jack Silverstein

24Copyright Mike Davies, MD Signal Generation and Hardwiring

25Copyright Mike Davies, MD Hardwiring Leadership Leadership Structure for communication Structure for communication Structure for measures Structure for measures Acknowledgement and recognition Acknowledgement and recognition

26Copyright Mike Davies, MD Leaders…. Set priorities Set priorities Remove barriers and facilitate others taking responsibility Remove barriers and facilitate others taking responsibility Build trust Build trust Go first Go first Communicate Communicate

27Copyright Mike Davies, MD Three Critical Roles

28Copyright Mike Davies, MD Key Change Team Members Sponsors “I believe this is right” Sponsors “I believe this is right” Align resources – financial, people, environ. Align resources – financial, people, environ. Monitor progress Monitor progress Communicate Communicate Change agents “I will be the staff help” Change agents “I will be the staff help” No authority, but interpersonal skill No authority, but interpersonal skill Champions “I will sponsor change locally” Champions “I will sponsor change locally” Opinion leaders inside departments Opinion leaders inside departments

29Copyright Mike Davies, MD Develop the Messengers Choose the right messengers Choose the right messengers Opinion leaders Opinion leaders Connectors Connectors Educate the messengers to deliver the message Educate the messengers to deliver the message Include peer-to-peer communication Include peer-to-peer communication

30Copyright Mike Davies, MD SHARE INFORMATION SHAPE BEHAVIOR “Marketing” flyers newsletters videos articles posters Personal Appeal letters cards Postcards Interactive Activities telephone visits seminars learning sets modeling Face-to-face one-to-one mentoring shadowing Channels of Communication Public Events Road shows Fairs Conferences Exhibitions Mass mtgs From Sarah W. Frasier

If I were king for a day……

32Copyright Mike Davies, MD I would… Make reduction of delay one of the top priorities for the organization Make reduction of delay one of the top priorities for the organization Establish an influential oversight committee (with resources devoted to support it) Establish an influential oversight committee (with resources devoted to support it) Develop organization or service wide goals outlining the steps to implementation Develop organization or service wide goals outlining the steps to implementation Develop a robust system-wide compass of measures Develop a robust system-wide compass of measures

33Copyright Mike Davies, MD I would (cont.)……….. Communicate the priority and goals at every meeting Communicate the priority and goals at every meeting Communicate to key individuals privately Communicate to key individuals privately Solve the problems effectively Solve the problems effectively Celebrate success publicly and privately by significantly acknowledging those responsible for change Celebrate success publicly and privately by significantly acknowledging those responsible for change Promote leaders of like mind in this area Promote leaders of like mind in this area

34Copyright Mike Davies, MD Furthermore! Insist on regular meetings Insist on regular meetings Rely on measurements to improve Rely on measurements to improve Continually look for improvement opportunities Continually look for improvement opportunities Acknowledge and celebrate successes Acknowledge and celebrate successes

35Copyright Mike Davies, MD VA Experience MDRC… 78 Medical Centers 78 Medical Centers Interviews, survey (3870 staff), databases for wait time & patient satisfaction Interviews, survey (3870 staff), databases for wait time & patient satisfaction Found important predictors were: Found important predictors were: Extent of leadership support Extent of leadership support Extent of teams having & using performance data Extent of teams having & using performance data Extent of knowledge Extent of knowledge Time Time Carol VanDusen Lukas, Mark Meterko

36Copyright Mike Davies, MD How do we get there? Your team believes in making Access work (WILL) Your team believes in making Access work (WILL) Your team makes reducing waits the top priority from now on (WILL) Your team makes reducing waits the top priority from now on (WILL) You must have the support of leadership (WILL) You must have the support of leadership (WILL) You must understand high leverage changes (IDEAS) You must understand high leverage changes (IDEAS) Your “team” includes a physician, nurse and clerk at a minimum (EXECUTION) Your “team” includes a physician, nurse and clerk at a minimum (EXECUTION) Your team has data – a compass of measures (EXECUTION) Your team has data – a compass of measures (EXECUTION) Your team tries and fails and tries again (EXECUTION) Your team tries and fails and tries again (EXECUTION)

37Copyright Mike Davies, MD Practical Strategies for Internal Spread

38Copyright Mike Davies, MD Defender NeutralSupporter Influence Person A xx xx Person B x x x x xx x x x

39Copyright Mike Davies, MD Bibliography and References Berwick. A Primer on Leading the Improvement of Systems. BMJ, 312: pp , Berwick. A Primer on Leading the Improvement of Systems. BMJ, 312: pp , Dixon. Common Knowledge. Boston: Harvard Business School Press, Dixon. Common Knowledge. Boston: Harvard Business School Press, Fraser S. Spreading good practice; how to prepare the ground, Health Management, June 2000 Fraser S. Spreading good practice; how to prepare the ground, Health Management, June 2000 Gladwell. The Tipping Point. Boston: Little, Brown and Co., Gladwell. The Tipping Point. Boston: Little, Brown and Co., 2000.

40Copyright Mike Davies, MD Bibliography and References Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers., Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers., Rogers. Diffusion of Innovations. NY: The Free Press, 1962, 1983, and Rogers. Diffusion of Innovations. NY: The Free Press, 1962, 1983, and Scholtes. The Leader’s Handbook: A Guide to Inspiring Your People and Managing the Daily Workflow Scholtes. The Leader’s Handbook: A Guide to Inspiring Your People and Managing the Daily Workflow

41Copyright Mike Davies, MD References References Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992 Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business School Press, Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 – 1982, Organization Science, Vol.8, No. 5, September - October Dixon, N. Common Knowledge. Boston: Harvard Business School Press, Fraser S. Spreading good practice; how to prepare the ground, Health Management, June 2000 Gladwell, M. The Tipping Point. Boston: MASS Little, Brown and Company, 2000.

42Copyright Mike Davies, MD References References Kreitner, R. and Kinicki, A. Organizational Behavior (2 nd ed.) Homewood, Il:Irwin,1978. Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco: Jossey-Bass Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg Myers, D.G. Social Psychology (3 rd ed.) New York: McGraw-Hill, Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September, Rogers E. Diffusion of Innovations. New York: The Free Press, Wheeler, Donald J. Understanding Variation SPC Press Knoxville, TN: