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Engaging Leadership and Governance in Quality and Patient Safety Initiatives

April 15, 2015 1:00 – 2:00 p.m. CT Kimberly McNally, MN, RN, BCC Trustee, University of Washington Medicine Kenneth P. Anderson, DO, MS, CPE COO, Health Research & Educational Trust

Engaging Leadership and Governance in Quality and Patient Safety Initiatives

HPOE Live! 2015 Webinar Series Kenneth P. Anderson, DO, MS, CPE

Business Case for Improving Care

• Describe the “Reasons to Participate”

–Payer rewards tie to explicit quality measures –Regulators publish specifics on performance (using the Web as an “ external driver”) –Patients are demanding greater transparency –Defining and deploying “best practice” will define our future

The Impact of NOT Focusing

• When Quality and Patient Safety systems fail:

–Patients lose trust –Reputational impact: patients tell friends and neighbors –Patients “vote with their feet” – growth impact –Risk management impact: it’s costly –Most important: patients may be hurt!

Themes for Quality Efforts

• Consistency – Commit to a culture of excellence for

every encounter (“Flawless Execution”)

• Standardization

– Automate whenever and wherever reasonable – Link operations (work flows) and physician preferences for care (best practice use)

• Teamwork

– Interdisciplinary teams (including IT) promote greater efficiency and effectiveness

Questions: Roles and Responsibilities

• Who is responsible for quality and patient

safety in our health care environment?

• How do we promote the critical thinking

needed to improve?

• How does your personal mission align with

the privilege of “caring” for our community?

Roles of Leadership

• Empower front‐line staff
• Provide resources
• Clearly state the vision
• Stimulate and guide
• Model behaviors
• Reward and recognize

Setting a Culture of Quality

• Effective Systems Are:

– Transparent – Intentionally designed – Continuously improving – Participant‐based – Holistic

• Systems Based Approach

– Team‐based Solutions – Data driven – Measure‐rich – “Systematized” – Well‐communicated

Start With Key Quality Principles

• High Value Care Principles (IOM):

–Safe –Timely –Effective –Efficient –Equitable –Patient Centered

Structure: Four Corners of Quality

• Quality Control

– Accreditation, compliance, safety, risk

• Performance Excellence (Process)

– Operations‐focused, standardization of care

• Quality Development (People)

– Tools acquisition and leadership training

• Quality Innovation (Technology)

– Delicate interface with technology as an enabler

Quality Control – The Regulatory Base

• Accredited by the Joint Commission (TJC)
• Licensed by the State (Dept. of Health)
• Certified for payment by the Feds (CMS)
• Regulated by numerous State and Federal

agencies

Performance Excellence – Better Each Day

• Role of incremental improvement: P‐D‐C‐A

cycles of improvement engine

• Advanced project planning using D‐M‐A‐I‐C
• Process‐focused with impact on outcomes

(Economic, Clinical, and Humanistic Outcomes)

• CORE measures as the initial point of entry

(measures tied to payment updates)

• Show progress visually and simply

Outpatient Cardiac Care Plans

MI & CAD (Antiplatelet/Beta Blocker) Composite Scores

81.3% 81.2% 84.6% 85.1% 85.8% 86.2% 88.8% 90.9% 93.5% 93.3% 93.1% 92.1% 88.0% 82.8% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10

Score Goal

Quality Through People Development

• Train leaders and the Board – give them the

“Keys to the Car”

• Train and equip Medical Staff leaders, provide

a sustaining framework

• Focus on future leaders ‐ residency quality

programs for young physicians; develop nursing quality leaders

• Use reinforcing resources such as IHI Open

School Chapter establishment

Quality Innovation and Redesign

• Answers simple question: “What works?”
• Hardwire effective care patterns into daily work
• Mine the EMR to create “Wisdom”
• Put the tools of change in the hands of the end

users, and make tools easy to use

• Engage “Activated Patients” to create patient‐

centered value

First week in September

ILI percentage by week

2 4 6 8 10 12

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

ILI % of outpatient visits

2007/8 % ILI 2008/9 % ILI 2009/10 %ILI

February

100 200 300 400 500 600 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Week # of Cases (all ZIPs)

5 10 15 20 25 30 35 40 45 50

# of Cases (specific ZIPs) All ZIPs 60091‐Wilmette 60061‐Vernon Hills 60626‐Rogers Park

Jan 8 June 3 Seasonal Flu

Outpatient Influenza Like Illness

Scorecards and Dashboards

• “Measuring” is the start of “Managing”
• Cascading dashboards allow direct “line of

sight” communication and alignment

• “A picture is worth a thousand words” –

promote effective and efficient communication

• Consider “whole system measures” to

demonstrate broad themes of improvement

At A Glance Project Reporting

20

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Cutting Harm Across the Board in Half

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0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Total Harm/1,000 Discharges

Total Harm per 1,000 Discharges

EMR Go Live Reduction of EED’s starts

Increased Transparency of Patient Harm Data

75% Reduction!

Patient Fall Strike Teams

Yuma, Arizona

To Change the Practice of Medicine

• Create higher “value” health care – engage

ALL participants, especially physicians

• Promote patient activation/engagement
• Satisfy the Triple Aim: better care for

individuals AND populations at lower cost

• Standardize evidence‐based management:

achieve scale, reduce cycle time, accelerate gains, deploy sustaining systems

HPOE LIVE! WEBINAR

Engaging Leadership and Governance in Quality and Patient Safety Initiatives

April 15, 2015

Kimberly McNally, MN, RN, BCC Trustee, UW Medicine Board

What is board engagement?

Board Work Board Work Relationships Relationships

Engagement Engagement

OUTCOMES

Board engagement leads to…

Trusting relationships Trusting relationships Relevant work Relevant work Attention to details Attention to details Improved governance Improved governance

Indicators of an engaged board

• Forward-thinking group whose work and meetings

are designed around critical issues

• Participate in well-designed opportunities for

meaningful deliberation in an environment characterized by trust, candor and respect

• Provide challenge and support to accelerate change
• Trustees feel their time, talent and energies are well

used; can articulate value produced

UW Medicine

Engagement Pyramid

Physician Leadership Physician Leadership Board Leadership Board Leadership

Aligned metrics Aligned metrics

Executive Leadership Executive Leadership

Collaborative Leadership through Partnership

between the Board, executive & physician leaders

• at entity and

system level

Why is Collaborative Leadership Important?

• Health care organizations are messy, complex

and interdependent

• Effective strategies require a systems approach

and inclusion of multiple perspectives

• Many sectors and constituents need to “own”

parts of the goals and solutions

• Leadership role is to build a community of leaders

Collaboration

Collaboration needs a different kind of leadership; it needs leaders who can safeguard the process, facilitate interaction and patiently deal with high levels of frustration.

Chrislip & Larson

Highlights of Our Evolution

• Getting started
• Transitioning forward
• Advancing to future

Evolution

• Creating culture of collaborative leadership
• Recognizing fiduciary responsibility extends beyond

finance; trustees see their role as quality champions

• Making sense of myriad performance metrics
• Recognizing strategic importance of quality data and

trends in public disclosure

• Developing quality literacy
• Benchmarking with UHC Quality Scorecard
• Challenging traditional assumptions; building will for

improvement

Evolution

• Setting directional focus with board self-assessment,

periodic retreats; reinforce with monthly meetings

• Learning to ask better questions to understand factors

underlying performance and what leaders are doing to address them

• Aligning quality metrics with executive recruitment,

selection and performance

• Designing roles for entity and system boards and

quality committees to ensure rigorous, proactive and effective oversight and to reduce redundancy

UW Medicine Quality Focus Areas

Triple Aim

• Execute on Patient are First framework
• Transform care; new delivery models
• System-level quality measures and dashboards
• Continue focus on reducing hospital-acquired

infections

• Ongoing attention and focus on safety culture
• Broaden ambulatory setting metrics
• Understand population health/ACN metrics
• Educate and engage next generation of clinicians

Some levers – increase engagement

• Build physician leadership capacity
• Conduct benchmarking – national, regional, internal
• Use dashboards – targeted for different audiences
• “Unpack” metrics – meaning, importance, factors

that impact results

• Embrace mistakes/errors

Some levers – increase engagement

• Attend educational programs together
• Invest in leadership development
• Integrate patient voice/story at every opportunity;

use board members to share their care experiences

• Build partnerships – board/executive/physician

leaders; unit level MD/Nurse Manager dyads; across continuum

Exerting Influence

• Know when to take a stand
• Intentional agenda

design and skilled facilitation; create the “right” conversations

• Balance inquiry and advocacy to

advance dialogue

• Reward authentic dialogue about

quality/safety gaps

• Create climate for innovation

Board as conversational agents

Envision the future - Advance the dialogue – Shape the agenda

• How is the Board currently

using conversations well?

• Which conversations are

missing or not effective?

• What are the conversational

practices?

How “good” is our hospital/health system?

Are we driving down/eliminating harm? Are we driving down/eliminating disparities? Are we providing patient/family-centered care? Are we taking cost out of our system? Is our workforce prepared? Are we improving the health of our population? How do we know? What’s the evidence?

Shifting the conversation

• What patterns of data are

we seeing over time?

• How is this connected to…?
• What assumptions are we

making?

• How else can we think about

this?

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Sample questions

• How will we translate the community health needs

assessment data into specific strategies? What health care disparities will we focus on reducing?

• How do we know we have the right patient and family

engagement strategies for the people we serve?

• What is the front-line users experience with ____?
• After we hardwire safety practices, what’s next?
• How have we changed medical and nursing practice

based on evidence-based research?

Sample questions

• What are we learning…and how are we spreading

effective practices for fall prevention across the system?

• With MD credentialing, how do we incorporate

feedback from other clinical team members? How do we know the MD professionalism policy is making a difference?

• What evidence do we have that front-line staff feel

supported to speak up?

• How are we rewarding innovation?
• What’s missing from our approach to make us feel

confident about our commitment to quality?

Sample questions

• What have we learned from our discharge call

data….where are the gaps in effective transitions?

• How have we advanced our palliative care since last

year?

• If we truly aspire towards a patient/family centered

culture, what can the Board do to support this work? How can we be effective sponsors?

• How does our budget reflect our commitment to

employee and workplace wellness?

• How does our performance management system

align with the quality goals?

Executive Safety Rounds

• Observe culture and care

in action – listening and learning tours

• Understand challenges

faced by front-line staff and physicians

• Demonstrate commitment

to continuous improvement

• Set participation

expectations

• How do you learn about

quality goals?

• What aspects of the

clinical environment could lead to patient harm?

• What would make the

work you do safer for patients?

• What have you learned

from any near misses that may occurred recently?

• What challenges do you

have implementing safety protocols?

The board meeting is the center of communication & relationship success or failure.

Larry Walker

Committee Meeting Tips

• Develop annual work plans
• Jointly prepare agenda – committee chair,

executive and physician leaders

• Choose meaningful patient stories to set the tone
• Provide right amount of data
• Watch for jargon…ask for lay explanations
• Engage in dialogue re: two key dashboard

indicators that are trending red

Committee Meeting Tips

• Pose questions to catalyze discussion
• Encourage trustees to ask questions
• Recognize leadership actions that enhance the

culture of safety

• Ensure shared understanding of what was

heard at the meeting, what will happen as a result, and what’s next

• Seek regular feedback on committee’s

effectiveness

Lessons Learned

• Have clear agreements in place to support
• partnership. Provide timely feedback as needed.
• Consistency is key. Everyone needs to be

reporting the same data. Cascade structured communication.

• Trust, transparency and acknowledgment are

essential ingredients.

• Work to balance attention to metrics with time for

“blue sky” thinking.

• Focus and sophistication emerges over time.
• Awareness re: fatigue with growing pace of

change …still move forward in face of uncertainty.

To lead is to live dangerously because when leadership counts, when you lead people through difficult change, you challenge what people hold dear- their daily habits, tools, loyalties, and ways of thinking- with nothing more to offer perhaps than a possibility.

Ron Heifetz, Leadership on the Line

Kimberly McNally, MN, RN, BCC Trustee, UW Medicine Board 206.547.3133 kamcnally@me.com

Thank you!

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Questions?

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@HRETtweets #hope #equityofcare

For a listing of upcoming HPOE webinars check

• ut our website.

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For more information go to www.hpoe.org

Join Us!

www.aha‐ slhq.org/QualityRoadmap

2015 Quality Roadmap: Achieving Equitable Care for All Patients

Meeting Purpose

• Bring together a diverse audience from

membership groups across AHA

• Focus on the intersection of quality and equity

to advance patient‐centeredness, improve health outcomes and establish new paths towards success

• Hear from cutting‐edge leaders in quality and

equity of care

• Network during breakout sessions and a

storyboard reception

Meeting Details

• Date: Wednesday, July 22, 2015 | 9:00 a.m. –

6:00 p.m. PT

• Location: San Francisco, CA | San Francisco

Marriott Marquis

• Who: Members of one of the host
• rganizations to participate
• More details here!

Call for Storyboards!

• Share your organization’s story!

– Exhibit original content about your organization's work to address health care disparities, promote equity of care and improve quality of care for all patients – Highlight ongoing or recently concluded improvement projects, best practices or case studies – Include a performance measurement or data analysis component

• Submit your proposals electronically by Friday,

May 29 at 6:00 p.m. CT

• Click here for more info.

For More Information

Email Roadmap@aha.org and visit

http://www.aha‐slhq.org/events/Roadmap/qualityroadmap.shtml

Thank You!

Contact Us: www.aha‐slhq.org slhq@aha.org | (773) 270‐3127 @AHA_SLHQ

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