beyond traditional bundlesmedia01.commpartners.com/apic_eo2_docs/100309_presentation_handout.pdf•...

Beyond Traditional Bundles:Beyond Traditional Bundles:

THE ART OF GETTING THINGS DONETHE ART OF GETTING THINGS DONE

Denise Murphy, RN, BSN, MPH, CIC

Vice President, Quality and Pt. Safety

Main Line Health System

Philadelphia, PA

ObjectivesObjectives

• Review the evidence and best practices for reducing healthcare associated infections (HAI)

• Discuss strategies for initiating change in an organized

manner

• Outline roles, responsibilities and power of data in driving

change

• Discuss three critical success factors in engaging others: influence, persuasion and concise communication

• Understand unique issues in engaging physicians in quality and patient safety efforts

• Review tools/methods effective in improving outcomes

The State of the Science in The State of the Science in Improving Clinical OutcomesImproving Clinical OutcomesAvoiding Preventable HarmAvoiding Preventable Harm

BUNDLES of Prevention Measures, BUNDLES of Prevention Measures, Best Practices Best Practices

or Evidenceor Evidence--based Medicine Standardsbased Medicine Standards

Infection Prevention

– CLABSI

– CAUTI

– VAP

– SSI

• Pressure Ulcers

• Patient Falls

• Culture of Safety

MLHS Central LineMLHS Central Line--Associated Bloodstream Infection Associated Bloodstream Infection (CLABSI) Prevention(CLABSI) Prevention

• Appropriate criteria-based utilization of central lines

• Hand hygiene

• Central line kits/carts

• Use of checklist for every insertion

• Line site choice (femoral site<internal jugular<subclavian<PICC)

• Chlorhexidine gluconate to cleanse skin before insertion

• Full barrier precautions for insertion

• Stabilization of cannula

• Transparent dressing and routine site check

• Daily assessment of need for central line

• Scrub the hub

• Drill down on use of PICC lines and using central line for blood draw

• Timely feedback about outcomes (rates) and process (bundles)

• Real time review of each infection by BSI prevention PI teams

MLHS CatheterMLHS Catheter--associated Urinary Tract Infection associated Urinary Tract Infection (UTI) Prevention(UTI) Prevention

• Appropriate criteria-based Foley catheter insertion

• Hand Hygiene

• Nurse-driven urinary catheter removal protocol

• Evaluation of silver-coated catheters

• Daily assessment of need for catheter

• Point prevalence survey on documentation

• Education for residents and nurses on insertion technique

• Review of each case by UTI prevention PI team

• CMS Surgical Care Improvement Project requirement to remove on first or second post-op day (or document why catheter is necessary)

MLHS VentilatorMLHS Ventilator--associated Pneumonia associated Pneumonia (VAP) Prevention(VAP) Prevention

• Hand Hygiene

• Daily weaning assessments, “sedation vacation” in standing orders

• Elevate head of bed (HOB) at least 30 degrees

• High-low evacuation endotracheal tubes for subglottic suction

• Oral care every 2 hours by nursing or respiratory therapy

• Chlorhexidine gluconate oral rinse twice/day

• Mandatory documentation fields for HOB and mouth care in electronic

documentation

• Feedback to caregivers when opportunity for mouth care is missed

• No routine vent circuit changes

• Emphasis on minimal opening of vent circuits

• Ambulate as early as possible or investigate mobility options

• Review of each infection by VAP prevention PI teams

• NO RAZORS; if hair must be removed, use clippers

• CHG wipe (skin antiseptic) for hip/knee surgery patients

• Use of CHG/alcohol skin prep

• Pre-operative prophylactic antibiotic choice and timing

• Post-operative discontinuation of prophylactic antibiotic

• Meeting with surgical specialty group when cluster identified

• Normothermia (normal body temperature)

• Infection prevention rounds in surgical suites

• Review of each infection by SSI prevention PI teams

MLSH Surgical Site Infection MLSH Surgical Site Infection (SSI) Prevention(SSI) Prevention

MLHS Falls PreventionMLHS Falls Prevention

• Critical Assessment and re-assessment, include input from Pharmacy & Physical Therapy

• Falls risk communicated at handoffs• Evaluate unit equipment: alarms, low bed use, mats • High Falls Units

� Redesign unit care model (rounding, staffing, shift time) based on time of falls

� Re-institute Fall Huddle and post fall debriefing

• Consider � Bedside reporting, collaborate on risk, assess environment

• Hospital/Unit Falls Champions• Post “# days since (date of) last fall”

MLHS Pressure Ulcer PreventionMLHS Pressure Ulcer Prevention

• Pressure ulcer risk assessment for every patient on admission

• Reassess risk for all patients daily

• Inspect skin of at-risk patients daily

• Manage moisture

• Optimize nutrition/hydration

• Minimize pressure

• Experienced wound nurses to lead/educate

• Actively engage medical staff - documentation of ulcer ‘present on admission’ is critical

What Are Top Performers Doing?What Are Top Performers Doing?Evidence-based measures (bundles) Reliability engineered into processes

(cues, forcing functions, etc.)

Zero tolerance for PSAE

(preventable serious adverse events)

Standardized processes

(e.g., order sets)

Just Culture of Safety Technology enabled best practice

Medical staff fully engaged Real time analysis of events

Front line empowered Certification for risky procedures

Clear expectations set for safe behaviors Strong measurement/analysis

Reciprocal accountability Organized spread of learning

Commitment to teamwork Effective PI framework and tools

Formal, standard communication system Dedicated, skilled facilitators

Transparency and rapid feedback system PI oversight function

Systems approach to problem solving Simulation

We know WHAT to do, We know WHAT to do, itit’’s HOW to do it thats HOW to do it that’’s so s so

challenging!challenging!

• Identify the need for change using data

• State the problem concisely with a relevant description of problem / desired outcome

• Get the right people involved

– Identify a sponsor, multidisciplinary champions, expert facilitator, and leaders (possibly one from each discipline)

– Get management’s buy-in for project then commitment for their staff to

participate

• Back your request for change with data: pertinent studies, statistical rigor, their own patients’ information

� Femoral line utilization point prevalence

� ANOVA for SCIP (antibiotic timing)

� No Razor Campaign

Driving ChangeDriving Change……where to beginwhere to begin

• Find out what physician and team member priorities are…then align your requests with their needs

� Best outcomes for their patients

� SPEED, efficiency

� Research support

� Financial re-numeration

• Explain process (what, how, why?)

• Explain roles and responsibilities clearly

Where to beginWhere to begin……

• Sanction change and hold others accountable

• Align key leaders

• Create environment that enables change

• Devote time, energy and resources to change

• Publicly demonstrate resolve that change will happen

• Track and analyze progress, provide feedback to others

• Ensure a communication strategy exists

• Make rounds and acknowledge those implementing the change

• Link change to benefits for individuals and the organization

• Talk with those who express concerns or resistance

Roles: SPONSORSRoles: SPONSORS

• Demonstrate public and private support for an idea

• Act as role model by trying new ideas first

• Try to influence colleagues who don’t support change

• Contribute expertise or direct experience with a change

• Become knowledgeable and be able to answer ? about change

Roles: CHAMPIONSRoles: CHAMPIONS

• Support sponsor (s) to be successful^

• Supports the leader (usually content expert/process owner)*

• Help to plan, execute implementation of change*

• Teach new knowledge and skills*^

• Provide technical support and expertise*

– Select tools and methods to design and implement change

• Through relationship skills, influence those who will be implementing the change^

• Listen to concerns of those implementing change and obtain/support removal of barriers^

Roles: Roles: *FACILITATORS/LEADERS^*FACILITATORS/LEADERS^

83ICU (MICU)

Primary Bloodstream Infection Rates

Femoral Line Utilization % and (2004-2005)

0

5

10

15

20

25

30

35

40

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

2004 2005

BSI Rate (per 1000 line days)

BSI Rate (per 1000 line days)

0

2

4

6

8

10

12

14

16

18

20

Femoral Line Utilization Percent

Femoral Line Utilization Percent

BSI Mean Fem Line % Mean

Femoral Line Tracking

Back request for change with pertinent data, relevant information…

SOURCE: Barnes-Jewish Hospital, St. Louis

SCIP: PreSCIP: Pre--intervention state: intervention state: colorectalcolorectal serviceservice

250200150100500-50-100-150

USLLSL

Antibiotic Timing in Minutes

Process Capability Analysis for

Prophylactic antibiotic received within one hour prior to surgical incision

BJH SIP Colorectal Procedures vs. BJH Overall SIP Procedures

40

50

60

70

80

90

100

JULY AUG SEPT OCT NOV DEC JAN FEB

2004 2005

Month

% of compliance

OVERALL COLON

COLORECTALSERVICE

Six Sigma: reducing variationSix Sigma: reducing variationSix Sigma: reducing variationSix Sigma: reducing variation


Minutes

Frequency

250200150100500-50-100-150

7

6

5

4

3

2

1

0

Normal

Colorectal Surgical ServiceAntibiotic Timing August -Oct 2005

SCIP: PostSCIP: Post--intervention state intervention state

Interventions:•Colorectal pre-op and post-op standing orders were revised to reflect SCIP

guidelines

•Roles were clarified

� Surgeons are responsible for writing pre-op antibiotic orders

� Anesthesia staff are responsible for administration of pre-op antibiotics•An antibiotic question was added to the surgical “time out”

•A method was developed for rapid electronic feedback of individual service

compliance rates to surgeons/anesthesiology

Next steps:• Roll out to all surgical services

• Develop control plans to sustain gain for colorectal services

• Electronic method to monitor post-op glucose in cardiac pts.

• Electronic method to monitor core temp in colorectal surg. pts.

SIP 1 Prophylactic antibiotic received within one hour prior to surgical incision

40

50

60

70

80

90

100

JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT

2004 2005Month

% of compliance

OVERALL COLON

COLORECTALSERVICE


Summary of Hair Removal Studies with Infection Rates Summary of Hair Removal Studies with Infection Rates

Associated with Different Hair Removal MethodsAssociated with Different Hair Removal MethodsAuthor, Year Published Infection Rate per Hair Removal Method

Razor Clipper Depilator

y

NONE

Seropoian & Reynolds, 1971 5.6 0.6 0.6

Alexander & Morris,

1983

Time of

day

P.M. 5.2 4.0

A.M. 6.4 1.8

Cruse & Ford, 1980 2.5 1.4 0.9

Ko & Krieger, 1992 1.3 0.6

Mishriki, 1990 Wound class

Clean 7.1 5.8

Clean-contam 5.1 10.4

Contam 22.0 0

Dirty 28.6 12.5

Best Change AgentsBest Change Agents• Influential clinical and administrative leaders

• How to find them

– Chiefs/division chairs

– Directors and managers

– Effective committee chairs

– Formal and informal staff leaders

• ID physicians, ICU Medical Directors, Hospitalists, leaders of the service you are trying to influence

• Patient Care/Dept Directors and Managers; Unit Council leaders; Experienced, influential supervisors, Clinical Nurse Specialists, Educators

Team EngagementTeam Engagement

• Describe what is needed, underscore what everyone brings to the table

• Be as honest about the time commitment as possible

• Apply rules of influence and persuasion

• People like those who like them

• Reciprocity

• Social proof

• Consistency

• Authority

• Scarcity

Fundamental Principles of PersuasionFundamental Principles of Persuasion

The Process of Persuasion: 4 StepsThe Process of Persuasion: 4 Steps

1. Establish credibility through expertise and relationships

2. Frame goals on common ground - describe benefits of your position; if you can’t find shared advantages, adjust your position: compromise

3. Vividly reinforce your position, don’t use ordinary evidence; make numerical evidence more compelling with stories, examples and metaphors that have emotional impact.

4. Connect emotionally – adjust your emotional tone to match the audience’s ability to receive your message. Learn how people have interpreted past events and predict how they will probably interpret/react to your proposal.

Effective CommunicationEffective Communication

• Handoffs and transfers are most critical time to ensure effective communication to prevent harm

• Organize your thoughts in bullet points

• Be concise, accurate and relevant

– Consider SBAR communication

Situational Briefing ModelSituational Briefing Model

SS

BB

AA

RR

ituation

ackgroundackground

ssessment

ecommendation

Communication framework taken from Crew Resource Management traiCommunication framework taken from Crew Resource Management trainingning

Used with permission from Michael Leonard, MD, Kaiser Permanente

SituationSituation

•• SS

• Patient’s name and location

• The “one-liner”

“Nancy Drew room 11103A…

Her mental status has changed. When I

went to check on her just now she was

awake and talking to me but not making

any sense.”

BackgroundBackground• Pertinent medical history

• Important events to date

“She is an 83 yo with a hx of PVD and is POD #1 from a thromboembolectomy of a left leg artery.

I was in her room about 45 minutes ago to bring her meds to her – metoprolol and Zocor – and she seemed perfectly lucid then.

She has no hx of dementia. I haven’t heard anything about mental status changes from her previous nurse.”

•• BB

AssessmentAssessment

• What is going on now

• Vitals

• Pertinent labs

“I took her vitals and they look fine: Temp 37.1, P 72, R 12, BP 114/68, O2 sat 97% RA, Accu check is 102

I’m worried she might have had a stroke”

•• AA

RecommendationsRecommendations

• What you think needs to be done

“I’d like you to come see her right away.

Is there anything else I should do right

now?”

•• RR

Physician Engagement:Physician Engagement:THE COMPACTTHE COMPACT……

•• CompactCompact refers to the refers to the ““givegive”” and and ““getget”” that physicians that physicians

expect as members of their organizationexpect as members of their organization

•• The compact is often the unspoken The compact is often the unspoken ““psychologicalpsychological””

contract between an organization and its memberscontract between an organization and its members

•• Three aspects of a compact that physicians expect: Three aspects of a compact that physicians expect:

autonomy, protection and entitlementautonomy, protection and entitlement

Source: Argyis, C. Harvard Business School.

Personality and Organization, New York, NY: Harper and Row, 1957

……know when negotiatingknow when negotiating

• Autonomy: they want to take care of their patients without interference and retain control over daily

operations; often leads to resistance to standardization

• Protection: they want administration to be buffer between them and market forces and change.

Leads to resistance to participation.

• Entitlement: I “give” you my patients; I want to “get”

what I need to take care of them. “I bring patients so it’s your job to make everything else work.”

Leads to resistance to participate and standardize.

Tools to Facilitate ChangeTools to Facilitate Change

• Clinicians, especially physicians, are into outcome,

not process

• They must understand the tools being used

• Make it fun, but relevant

• Lean and Six Sigma are stimulating, hold interest

Six Sigma = 3/million defectsSix Sigma = 3/million defectsSix Sigma = 3/million defectsSix Sigma = 3/million defects

Performance ImprovementPerformance Improvement

Six Sigma and LeanSix Sigma and Lean

• Both methodologies attack complex problems with a team that follows a logical thought process, utilizes data and makes fact-based decisions to solve a problem

• Both are customer focused

• Hybrid between a Six Sigma project and Lean combines aspects of both methodologies

• Individually, both methodologies are effective for problem solving; together, they become much more powerful

Six Sigma DMAIC FrameworkSix Sigma DMAIC Framework

Define high-level project goals and the current process.

Measure key aspects of the current process and collect relevant data.

Analyze the data to verify cause-and-effect relationships. Determine what the relationships are, and attempt to ensure that all factors have been considered.

Improve or optimize the process based upon data analysis using techniques such as design of experiments, analysis of variance (ANOVA).

Control to ensure that any deviations from target are corrected before they result in defects. Set up pilot runs to establish process capability, move on to production, set up control mechanisms and continuously monitor the process to sustain the gains.

Basic Elements of Lean Basic Elements of Lean Flow: The continuous creation or delivery of value without

interruption

5S: A complete system for workplace organization, including the process for sustainment

Visual Management: Using visual signals for more effective communication

Pull: Working or producing to downstream demand only

Standard Work: Identifying the “best practice” and standardizing to it, stabilizing the process (predictability)

1 by 1: Reducing batch size to one whenever possible to support flow

Zero Defects: Not sending product or service to downstream customer (internal or external) without meeting all requirements

VSA*: Improve the Experience of a VSA*: Improve the Experience of a Patient with a Central Venous CatheterPatient with a Central Venous Catheter

High Level Current State

Decision to

Insert

Prep for

Procedure

Insertion of

Central

Line

Care &

Maint.

Line

Removal

Start IV

support/

line?

RN to page MDNo

Wait

MD

assessment of

periphrials

Wait Choose MD

Communicate

with person to

insert line

Walk and

SearchWait

Find and

communicate

with staff

Order for CL

Wait:

process

order

Patient

Education

Assess

LOC

Patient sign

paper consent

Wait: MD

arrival

Evaluate

patient

condition

Wait:

Labs

Transport

patient

Wait:

staff

arrival

Gather

supplies

Environmental

prepPatient prep

Wait:

ultrasnd

supplies

MD prepPatient Prep

and DrapeDry Time

MD prep: local

anesthesia

Wait for

Local

onset

Insertion

TIME OUT

Secure

catheter and

apply dressing

CXRayCXR

Verification

Use or

Not Use?

Documentation

Checklist

Chart

documentation

MD/RN

Monitor patient

and site

Initial Dressing

Applied (RN)

Documentation

(RN)Chest X-Ray

Wait:

radiolo

gy

Wait:

results

Wait for

orders

Use of Line

(lab draw,

flush, med

infusion)

Wait

Daily

observation

(dressing, cath)

Dressing

changes

Infusion

management

Decision

for central

line

removal

Wait for MD or

Transport to IRWait

Assemble

equipment

New line

placement if

necessary

(e.g. PICC)

Wait

Document

assessment,

placement, &

removal

Discontinue

existing line

*Value Stream Analysis

Current State to Future StateCurrent State to Future State

Decision to

Insert

Prep for

Procedure

Insertion of Central

Line

Care & Maint.

Line Removal

Start IV

support/

line?

RN to page MDNo

Wait

MD

assessment of

periphrials

Wait Choose MD

Communicate

with person to

insert line

Walk and

SearchWait

Find and

communicate

with staff

Order for CL

Wait:

process

order

Patient

EducationLOC

Patient sign

paper consent

Wait: MD

arrival

Evaluate

patient

condition

Wait:

Labs

Transport

patient

Wait:

staff

arrival

Gather

supplies

Environmental

prepPatient prep

Wait: ultrasnd

supplies

MD prepPatient Prep

and DrapeDry Time

MD prep:

anesthesia

Local

onset

Insertion TIME

OUT & local

Secure

dressingCXRay Verification

CXRay

Read

Use or

Not Use?

Documentation

Checklist

Documentation

MD/RN

Monitor patient and site

Initial Dressing Applied (RN)

Documentation (RN)

Chest X-RayWait: radiolo

gy

Wati: results

Wait for orders

Use of Line

(lab draw, flush, med

infusion)

Wait

Daily

observation

(dressing, cath)

Dressing

changes

Infustion

management

dec for

line removal

Transport to IVR

WaitAssemble equipment

New line placement

WaitRN Discontinue

Line

Document,

assess, placement,

removal

Current State

Future State

Decision to

Insert

Prep for

Procedure

Insertion of

Central

LIne

Care &

Maint

Line

Removal

Start Daily access Call MD CommunicateMD place

orders

MD get ready

(review labs,

get consent,

det. location)

Room Set-upPrepare pt &

meds

Drape & prep

patients(gown,

skin prep)

Time out &

Local Anes.

Insert CVC &

secure line

MD clean site

& apply

dressing

Chest X-ray

and read

Interprete &

order Use/No

Use

Move pt Clean up room

monitor pt &

site

Discuss

continued need

change

dressingDocument

Infusion

managment

Clinical

decision for line

removal

Assess need

for alternative

access & insert

Aquire supplies

for removalRemove Line

Apply dressing

& compress &

pt educ about

site

Document

6 fewer steps

11 fewer steps

7 fewer steps…

47% Decrease in Steps!47% Decrease in Steps!

RIE #3 Central Line RIE #3 Central Line Supplies/Equipment at Point of CareSupplies/Equipment at Point of Care

Needleless caps 3

Sterile Saline Flush 3

Filtered Needle or straw 1

Caps 2

Masks with Eye Protection 2

Sterile Gowns xl 2

Chloraprep 3 ml tinted 1

Lidocaine Label 1

Full Body Drape 1

Needle Driver 1

Sterile Towels 4

Sterile Pen 1

Op Site Dressing 1

Suture or Statlock 1

Safety Scalpel 1

Central Line Insertion Checklist 1

Benzoin 1


Standard CartStandard Cart


Procedure Cart ReProcedure Cart Re--StockingStockingStandard WorkStandard Work


Metric Baseline Post

Experiment

Target

Standardized CL

Kits

ICU 0%

Nursing Division 0%

100% 100%

POC CL Supplies

– Procedure Cart

ICU = 100%

Nursing Division =

4.5%

100% 100%

# Types of CL kits >3 1 1

Motion (ft) to

Gather Supplies

Nursing Division =

3810 ft (.72 mi)

283 Ft Decrease by 25%

Time to Gather

Supplies

Nursing Division =

30-45 min

(~.5 FTE/year)

2.2 min

(8 min to restock

cart)

5 min

# Items to Gather 17 2 Decrease by 50%

Metrics for CVC Rapid Improvement Event # 3Metrics for CVC Rapid Improvement Event # 3


ItemItem Current annual cost Current annual cost Estimated annual Estimated annual

future costfuture cost

CL catheter $14,938 $14,938*

CL Kit $15,732.64 + (single supplies $25.54 ea)

$21,560

CL Carts N/A $39,521.88

Ultrasound N/A $92,000

Cost of CA-

BSI

$2,088,000 (58 BSIs over 12 mos) $1,368,000

(38 BSIs, 1/3

reduction)

TOTAL $2,118,670 $1,536,019

Savings of $582,651Savings of $582,651


ResultsResults

Rewards for Team MembersRewards for Team Members

• Arrange for leadership briefings, led by team members

• Acknowledgement – Visible Recognition

• Make improvement work fun

• If possible, plan for publications/presentations

• Contract for services (Medical Staff)

• Education paid for, or texts, online modules, journal

subscriptions

• EFFICIENCY

• Improved outcomes for patients

Culture trumps strategy!Culture trumps strategy!

Culture Intersects All Other StrategiesCulture Intersects All Other Strategies

© 2006 Healthcare Performance Improvement, LLC.

ALL RIGHTS RESERVED.

FallsPressure UlcersPatient Satisfaction…and on, and on…

Central LineInfections

HandHygiene

Surgical SiteInfections

Codes Outsidethe ICU

Culture

��

��

1. Leaders make safety a visible and vocal priority

2. We have zero tolerance for reckless behavior

3. Management sets clear expectations around safe(ty) behaviors

4. Staff understand their accountability

5. Managers hold staff accountable 100% of the time

6. Staff speak up about risk without fear

7. Peers observe, coach and hold one another accountable for safety

8. Staff are equipped with critical thinking skills and apply them when safety is

at risk

9. Our patients and our workforce are surrounded by safe systems and

processes enabling them to prevent harm

10. Staff proactively engage patients and families in their healthcare

MLHS Culture of Safety GoalsMLHS Culture of Safety Goals

“Clinical Bundle”

Process DesignProcess Design Behavioral AccountabilityBehavioral Accountability

“People Bundle”

VAP Prevention

1. Elevation of the head of

the bed to between 30

and 45 degrees

2. Daily “sedation vacation”

and assessment of

readiness to extubate

3. Peptic ulcer disease

(PUD) prophylaxis

4. Deep venous thrombosis

(DVT) prophylaxis

(unless contraindicated) S O U R C E :S O U R C E : ©© 2 0 0 6 H e a l t h c a r e P e r f o r m a n c e2 0 0 6 H e a l t h c a r e P e r f o r m a n c eI m p r o v e m e n t , L L C . A L L R I G H T S R E S E R V E D .I m p r o v e m e n t , L L C . A L L R I G H T S R E S E R V E D .The Biggest Challenge: The Biggest Challenge:

EXECUTIONEXECUTION

“The most creative visionary strategic

planning is useless if it isn’t translated into

action. Think simplicity, clarity and focus –

and review your progress relentlessly.”Melissa Raffoni

Harvard Management Update

February 2003

Three Keys to Effective ExecutionThree Keys to Effective Execution1. Maintain your focus

– Realistic: align goals and resources; map actions out on time chart and make sure all is doable

– Simplicity: prioritize the “vital few”, communicate simply and often

– Clarity: everyone is clear about their role in driving goals; use stories/examples to clarify what needs to be done (or not!)

2. Develop tracking systems that facilitate problem solving– Metrics must be visible to everyone responsible for goals

– Keep asking “why?” to get to root cause of barriers to success

– Track process (Behavior) and outcomes

– Assign key success factors to only one accountable “owner”

3. Set up formal reviews– Review process/outcome metrics and discuss barriers routinely

– Personnel and resources should be at the top of the agenda

Source: Melissa Raffoni, Harvard Management Update 2/03

From Strategy to PerformanceFrom Strategy to Performance

1. Keep it simple.2. Challenge assumptions.3. Speak the same language

4. Discuss resource deployment early. 5. Identify priorities.6. Continuously monitor performance.

7. Develop execution ability.

Source: Turning Great Strategy Into Great PerformanceHarvard Business Review: The High Performance Organization

July-August 2005

Execution:Execution:LeaderLeader’’s Seven Essential Behaviorss Seven Essential Behaviors

1. Know your people and your business: the day-to-day realities.2. Insist on realism: make truth part of every dialogue.3. Set clear goals and priorities: 4-5 are plenty; they should be

on your calendar and in your check book!

4. Follow through: lack of it is major cause of failure to execute.5. Reward the “doers”.6. Expand people’s capabilities through coaching.7. Know yourself: be authentic, self-aware and humble.

Practice self-mastery by keeping ego in check, taking responsibility, adapting to change, embracing new ideas and adhering to your standards of honesty and integrity under all conditions. Source: Adapted from EXECUTION: the discipline of getting things done.

Larry Bossidy and Ram Charan; Crown Business, New York, 2002

SummarySummary

• To engage leadership: make clear the need for change, the data/supporting evidence

• Communicate clearly about what you need and why; set role expectations; be honest about time commitments

• Use principles of influence and persuasion

• Know what makes physicians “tick”…understand the compact they make with your organization

• Find strong champions and change agents

SummarySummary

• Use proven performance improvement tools and experts that can facilitate change

• Recognize and reward those who make change happen and make it stick!

• Educate senior leaders about clinical bundles and “people” bundles.

• Understand critical success factors related to EXECUTION…these also ensure sustained

improvement over time.

THANK YOU!!THANK YOU!!

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