Seven Leadership Leverage Points for Organization-Level Improvement in Health Care Presented by: Robert L. Colones, MBA President and Chief Executive Officer Florence, South Carolina

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care A Quality Leadership Challenge We have become good at making improvement happen for one condition, on one unit, for a while. We have not learned how to get measured results, quickly, and ‘sustainably’, across many conditions for the whole organization.

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care ‘Give me a lever long enough, and I shall move the world.’ ARCHIMEDES The leverage points are offered as a sort of hypothesis … If leaders are to bring about system-level performance improvement, they must channel attention to and take action on these points.

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care 1 Establish and Oversee System- Level Aims for Improvement at the Highest Board and Leadership Level

1 - System-Level Aims for Improvement

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care 2 D evelop an Executable Strategy to Achieve System Level Aims at Highest Level of Leadership

2 – Executable Strategy: Four Critical Steps 1A few, focused breakthrough quality and safety aims 2Senior Team develops a ‘rational portfolio of projects’ with scale and pace to achieve breakthrough aims 3Key projects are resourced with leaders and infrastructure 4Senior Team monitors and responds

2 – Executable Strategy Reliability Theory Quality as a Core Value Prioritization Physician & Executive Engagement Change Theory Improvement Methodology Core Success Factors

2 – Executable Strategy: Quality is a Core Value Service Science Safety “Just Culture” Executive Team Engagement Physician Leadership

2 – Executable Strategy: Prioritization A few, focused breakthrough quality and safety aims Quality & Safety … Building a Strategic Advantage through Enterprise Wide Improvement Clinical Effectiveness (CE) Operational Effectiveness (‘Lean’ or OE)

2 – Executable Strategy: CE Prioritization A few, focused breakthrough quality and safety aims Opportunity Driven by Clinical Data ComplicationsReadmissions CostLength of Stay Mortality

2 – Executable Strategy: CE Prioritization A few, focused breakthrough quality and safety aims The total potentially avoidable days are distributed across numerous DRGs, but 45% of days are in the top twenty DRGs. High Opportunity DRGs: Potentially Avoidable Days DRG 106CABG with Cath DRG 116PTCA with Stent/Pacemaker DRG 107CABG without Cath DRG 144Other Circulatory Dx DRG 143Chest Pain DRG 075Major Chest Procedures DRG 209Major Joint and Limb Procedures DRG 475Resp. System with Vent DRG 174GI Hemorrhage DRG 122Circulatory Disorder with AMI DRG 493Laparoscopic Cholecystectomy DRG 121Circulatory disorder AMI DRG 385Neonates DRG 239Path Fx and MS Malignancy DRG 005Extracanial Vascular Procedures DRG 298Nutritional and Metabolic-Peds DRG 088COPD DRG 316Renal Failures DRG 026Seizures and Headache-Peds 841.4DRG 110Major Cardiovascular Procedure Total Days Opportunity: 10,543 days Example Data

2 – Executable Strategy: CE Prioritization A few, focused breakthrough quality and safety aims EXAMPLE

2 – Executable Strategy: OE Prioritization A few, focused breakthrough quality and safety aims Creating Efficiency of Work: Operational Effectiveness 1.Deployment of “Lean” methodology 2.Eliminate waste or non-value added work 3.Make processes flow smoothly 4.Involve staff in redesign of work

2 – Executable Strategy: OE Prioritization A few, focused breakthrough quality and safety aims ‘A3’ Opportunity Driven by Operational Data Access to Care Make the Work More Enjoyable Better Use of Resources

2 – Executable Strategy: OE RIE Results from Cardiac Value Stream – Nursing Documentation Time Saved fromto Pre-population of fields60.0 minutes12.0 Electronic documentation Peds Questions ED TBA paperwork Room orientation Speech screens Diabetic bundle/flow sheet Plans of care Plus other … Total Time Savings: Admission History, 60 minutes per patient admitted to 27 minutes; Plan of care, 24 minutes to 8 minutes

2 – Executable Strategy: Four Critical Steps 1A few, focused breakthrough quality and safety aims 2Senior Team develops a ‘rational portfolio of projects’ with scale and pace to achieve breakthrough aims 3Key projects are resourced with leaders and infrastructure 4Senior Team monitors and responds

2 – Executable Strategy: Key Projects Resourced with Leaders, Infrastructure Clinical Effectiveness -Teams are Physician-Led -Work for 3 months at 2 week intervals -4 to 5 Physicians -Care Manager RN, MSN -Educator -Implementer -Multi-disciplinary Team -VP Champion Operational Effectiveness -Team Leader -Work for 6 to 12 months in 1 RIE/month -OE Facilitator with certification in ‘lean’ -9 members with 3 in the area of focus, 3 up/downstream, and 3 ‘fresh eyes’ -VP Champion

2 – Executable Strategy: Key Projects Resourced with Leaders, Infrastructure 1. Establishing a Sense of Urgency 2. Forming a Powerful Guiding Coalition 3. Creating a Vision 4. Communicating the Vision 5. Empowering Others to Act on the Vision 6. Planning and Creating Short-Term Wins 7. Consolidating Improvements and Producing Still More Change 8. Institutionalizing New Approaches –John Kotter, Leading Change

2 – Executable Strategy: Monitor and Respond ‘The currency of leadership is attention.’ J. Reinertsen, MD Formal & Informal resources focus on the aims Inside: calendars, meeting agendas, project reviews, performance feedback and compensation systems External: Transparency

2 – Executable Strategy: Monitor and Respond

STOPSTART Focus on benchmarks Relying on technology Thinking “tools” & “best practices” Delegating leadership Focus on “Ideal” & rate of improvement Rely on people/Process Technology serves P&P Running the organization on “principles” Leading from the front, constant reinforcement

STOPSTART Dozens of metrics Internal focus (specialty, unit, role…) Managing by Control Improving what we know …greater complexity Few, visual, focused metrics that matter Patient centered, Value Steam focus Lead through Principles, Standard work. Lead transformation …start with simple

STOPSTART Experts collect data, Design/manage projects Incremental improvement Top down execution Rigid command & Control The “fix” mentality Access knowledge & Creativity of workforce Double digit gains in vital areas Bottom up execution Agile and adaptive The “fitness” mentality