1. Role of the Executive Sponsor Reflections from Winchester Hospital Richard M. Iseke, MD Vice President for Medical Affairs and CMO

2. Background on Winchester Hospital Financially strong, highly regarded 229-bed community hospital (13K discharges and 9K surgeries) Extensive outpatient services including home care 2,600 employees, 700 medical staff, 700 volunteers Strategic goals focus on our success factors Quality and Safety Employee Engagement Physician Alignment Patient Experience Growth and Finance 2

3. Background Winchester Hospital First community hospital in Massachusetts to earn Magnet award Premier/Care Science National Quality Award (top 1% of inpatient hospitals) IPA and hospital, HPHC Honor Roll Top Employer: Boston Business Journal, The Boston Globe, Fortune High satisfaction: physician, employee, patient Centers for Excellence in certain areas 3

4. Background Physician, VP for Medical Affairs at Winchester Executive sponsor for a team Serve on Senior Leadership Team Infection Prevention reports to Director of Surgical Services Senior Team recognized growing strategic importance of infection prevention Reviewed with Team: CEO assessment of in- patient activities 4

5. The Beginning Followed tips from Jim Conway’s presentation Initial meeting at the Collaborative very helpful in allowing me to meet team (WHO checklist) and help them reframe the scope and timelines Regular updates very helpful to keep focus and provide “project management” – something other groups have asked for 5

6. Summary of Jim Conway’s Tips System-level aims Regular review of progress Removal of barriers to success Regular celebration of achievement 6

7. So then what happened Leader adapted the tools to take advantage of our culture. Every team is different My job became promoting the team via presentations at Quality, Board, Leadership Loops How to Spread 7

8. Spread Start a weekly huddle for PI team leaders CNO co-led the huddles, No agenda, Peer support HAI team had enthusiastic leader who was able to point out barriers, make you laugh and actually think your were complimented Compare stuck teams to the HAI team 8

9. What we found Lack of collaborative Lack of regular updates and learning initiatives Lack of sponsors Lack of recognition Lack of advice “Money is not a deterrent” 9

10. Look for collaboratives Form our own: WinCollaborative with Sue Gullo to launch it as guest speaker Motivational and connected history of leaders in nursing and medicine, and their carrying of the torch Have to have an exec sponsor Have to attend the kick-off session Have to attend regular updates Encourage external collaboratives Train our leaders became institutional goal What should we do? 10

11. Leadership Training Participate in Performance Improvement projects Leadership Loops on Tools including: Positive Deviance Lean Just Culture Safety Behaviors 11