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Leadership for Performance Excellence

© Copyrighted Ontario Community Support Association 2014. All rights reserved.

© 2014 All rights reserved

The Quality Advantage: Agenda

Time Agenda Item

9:00 – 9:10 am Welcome and Introductions

9:10 – 9:30 am Objectives and Expectations

9:30 – 10:10 am Making the Case for Board/Senior Leader Focus on Quality

10:00 – 10:30 am Drivers for Effective Leadership: Knowledge, Roles, Skills:

Reflective Exercise

10:30 – 10:45 am BREAK

10:45 – 11:50 am Drivers for Effective Leadership: Culture:

Reflective Exercise

Drivers for Effective Leadership: Partnerships with Key Stakeholders

11:50am – 12:00 pm Questions?



Workshop Objectives and Expectations

Objectives:

• Develop a shared understanding of the role of Boards & Senior Leaders in leading and overseeing the quality agenda;

• Discuss the key drivers for effective organizational governance and leadership of quality and safety;

• Reflect on current organizational practices relative to leading practices, and develop a plan of action for addressing gaps.

Expectations:

• What do you HOPE we discuss? What CONCERNS do you have about leading your organization’s quality agenda?



Making the Case for Board/Senior Leader Focus on Quality: What is the evidence?



There are significantly increased expectations AND scrutiny of Boards, particularly in relation to the quality agenda

The work you have undertaken on your governance journey to date will not be sufficient to take you to where

you need to be tomorrow - what will your tomorrow look like?

ECFAA

MSAA

Accreditation

Public Expectation

Funding Reform

Research/ Evidence



Where are we on the journey to excellence?

OECD Annual Comparison on Quality (Organization for Economic Cooperation and Development)

Ranked 10/11 Overall

Expended considerable effort on Access and ranked

11th

Ranked 7th for cost per capita


2004: Canadian Hospital Adverse Events Study: • 7.5% of admissions

• 37% considered preventable

2013: 5 year Pan-Canadian Safety at Home Study:

• 10-13% dependent on data source

• 56% deemed preventable (falls, med errors, infections)

Where are we on the journey to excellence?



The need to ‘bend the cost curve’ through new approaches



OCSA Quality Advantage Baseline Survey Results, 2014

0

5

10

15

20

25

30

35

40

45

50

Very Familiar SomewhatFamiliar

Not Very Familiar Unsure

Familiarity with ECFAA

Per

cen

t



Reasons: • Not enough time • Not the right staff • Waiting for mandate • Unaware of the Act


Accreditation • 40% accredited & 12% in the process

• Of these, 4 most common agencies: • Accreditation Canada (40%) • Commission on Accreditation of Rehabilitation

Facilities (CARF) (22%) • Hospice Palliative Care Ontario (15%) • Canadian Centre for Accreditation (CCA) (9%)

Metrics • Only 38% report on quality metrics

QIP • 45% have a Quality Improvement Plan

(QIP) • 2/3 of those accredited have a QIP


Are there studies that associate Board engagement with better clinical outcomes?

• Board establishes a Quality Committee

• Board sets the board agenda for quality

• Board sets strategic goals for quality improvement

• CEO and senior executives held accountable for quality and safety goals, frequently also tied to compensation

(Vaughn, Koepke, Kroch et al, 2006; Lockee, Kroom, Zablocki, Bader – Governance Institute/Solucient Top 100, 2006; Jiang et al, 2009 )



• Board receives a formal quality performance measurement report

• Board uses indicators of quality and safety [in decision-making]

• CEO is identified as the person with the greatest impact on QI, especially when identified so by the QI Executive

(Vaughn, Koepke, Kroch et al, 2006; Lockee, Kroom, Zablocki, Bader – Governance Institute/Solucient Top 100, 2006; Jiang et al, 2009 )



Are there any Canadian studies providing the same or different information?

• Ross Baker et al, Healthcare Quarterly 2010

(3 Canadian and 1 US case study, 15 pan-Canadian

interviews):

• Efforts are in early stages

• Concerned mostly with financial and access questions

• Board composition doesn’t always include individuals

with knowledge of quality and safety; few using a skills

matrix

• Most Boards receive voluminous indicators; no

information

• Organizations tend to struggle over compliance with

adherence to the Carver model



The Excellent Care for All Act:

What are the requirements?



ECFAA Requirements

• Quality committee of the Board

• Annual quality improvement plan, made publicly available

• Executive compensation linked to achievement of QIP performance targets

• Patient/client and caregiver surveys

• Employee/ care provider surveys

• Patient/client relations process, with information about the process publicly available

• Patient/client declaration of values, developed through public consultation



Excellent Care for All Act and Associated Directives

Hospitals, 2010:

Bill 46: Excellent Care for All Act, 2010

Primary Care (CHCs, FHTs), 2013

Policy Directive, QIP only

Community Care Access Centres, 2014


Long Term Care Homes, issued 2014, but not mandatory until 2015


From Q&A: “all health care organizations should be striving to uphold the principles of ECFAA, putting their patients, clients, and residents first. “



Proposed amendments to ECFAA re: patient engagement

March 24, 2014, draft Regulation under the Excellent Care for All Act (ECFAA), Patient Relations Process:

Processes for receiving, reviewing and attempting to resolve complaints expeditiously

Engage patients /caregivers in designing, reviewing & maintaining these processes

Appoint a patient relations delegate

Oversight with aggregate results to Quality Committee

• April 17, 2014 draft regulation under the Excellent Care for All Act

(ECFAA), QIPs:

• Patient engagement in development of Quality Improvement Plans (QIP)

• In QIP, describe patient engagement and how these activities inform development of the QIP)



Reflect on your own organizations in relation to ECFAA readiness

Assuming that the MOHLTC implements the same requirements to CSS agencies as to other non-hospital sectors, would you say your organization:

1. Has some understanding of the ECFAA requirements, but will need a lot of support

2. Has the knowledge but will likely need some support

3. Has the knowledge and will not likely require any support

If OCSA was able to provide you with support, what kind of assistance would you be looking for?



Quality Frameworks for Boards/

Senior Leaders



Governance Skills and Roles

Knowledge of Quality and [Client] Safety

Assess and Implement a Quality & [Client] Safety Culture

Relationship Between Board, Senior Leadership & [Key Stakeholders]

Measurement of Quality and [Client] Safety

Information on Quality and [Client] Safety

Create and Execute a Quality and [Client] Safety Plan

Drivers of Effective Governance High Impact Leadership

High Impact Behaviours: • Person-centred • Front line engagement • Relentless focus • Transparency • Boundarilessness

http://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=ddXvPwxCdvDhWM&tbnid=AK1TMqxWKwnVwM:&ved=0CAUQjRw&url=http://www.simul8.com/healthcare/reducing_variation_with_simulation.htm&ei=4w_YU5S4NM2OyATRm4DoCQ&bvm=bv.71778758,d.aWw&psig=AFQjCNEdqRzGZ4Ha554ASPfPsV4hOhAMvg&ust=1406755145988965


Drivers for Effective Leadership for Quality:

Drivers 1 & 2: Knowledge/Roles/Skills



The Board has the ultimate responsibility for quality and safety

The Board leads by, working with senior management, to:

Define quality/develop a framework for quality and safety

Ensure that the quality plan flows from the strategic plan

Identify board quality indicators to monitor

Develop its monitoring mechanisms and processes

Be actively involved in committee and board agenda design around quality

Embrace quality and become quality literate

Effective Governance for Quality and Patient Safety Education Program

http://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=UJmthhbhhapvVM&tbnid=6g9bKGxxJ5b7wM:&ved=0CAUQjRw&url=http://www.valuebasedmanagement.net/methods_strategy_maps_strategic_communication.html&ei=-rLzU7TNJoX-yQTir4L4Cw&bvm=bv.73231344,d.cGE&psig=AFQjCNGi5BINvSSA7-f3_3fPBFdV6X1fSA&ust=1408566317702443


Considerations in establishing a Quality Committee

• Directors who are passionate about the agenda – preferably 1-2 members with quality improvement knowledge/experience

• Systems thinkers who will not be intimidated by the complexity of your service issues, who can frame probing, constructive questions & understand the answers – willing to be the minority in the room and challenge management

• Staff who can educate & support directors

• Consider making it mandatory practice for every new member of the board to rotate through the quality committee

“Credentials might get you on the Board, but your performance is what keeps you there.”

Leonard Berry, Texas A&M University



Do you need a separate Board Quality Committee?

Options:

Separate (new) Quality Committee of the Board

Modify the mandate of an existing committee of the Board

Incorporate the terms of reference for a Board Quality Committee into the role of your full Board



Current & desirable organizational performance

Resources (investments of time and money)

Risks and challenges that could impede achievement of targets

Timeline for results

Asking good questions!

Two important questions for Board members to ask is “Why?”

and to continuously question

“How will we know?”

Boards need the following knowledge to oversee progress on an improvement agenda:



• How good are our services? • How do we compare to others like us? • How much of a gap is there

between our current and desired performance?

• Why does the gap exist and what is our plan to close the gap?

• How much variation is there

among our providers?

Key questions for Board members to ask…

AIM MEASURE CHANGE

Quality Dimension

Objective

Indicator

Current Performance

Target Target Justification

Change Idea

Method

Process Measure

Target Comment



Key questions for Board members to ask…

Are our services getting better?

Are we on track to achieve our key quality and safety

objectives?

If not, why not?

Is the strategy wrong?

Is the strategy insufficient?

Is it not being executed effectively?

Is it too early in the process?

How many clients is that?



Additional questions for Board members to ask…

What are the intended consequences?

What are risks? What are the unintended consequences?

Are there other options?

What if __________?

How will that impact our client outcomes?

How can we ensure continuity of performance excellence through succession planning?



Reflection - Action Planning:

Knowledge, Roles, Skills



BREAK




Driver 3: Organizational and Board Culture



Organizational Culture

Commit to a culture of continuous improvement where:

Staff feel safe to admit to error/failure: culture survey

It is recognized that failure is usually a system issue, and seized as a learning opportunity

There are processes for disclosure, apology, incident analysis to identify root cause

Organizational transparency of information:

Transparent internal measurement &

transparent systems for accountability



No industry can define quality without the voice of the customer…


Continuum of Engagement

Levels of Engagement

Consultation Involvement Partnership & Shared Leadership

Direct Care

Organizational Design &

Governance

Policy Making

Clients receive information

about diagnosis

Organization surveys patients about their care

experience

Public agency conducts patient focus groups to

ask opinions about an issue

Clients asked about treatment plan

preferences

Organization involves patients as advisors or

advisory council members

Client recommendations re: research priorities are used by public agency for funding decisions

Treatment decisions based on client

preferences, evidence, clinical judgment

Clients co-lead safety and quality

improvement committees

Clients have equal representation on

agency committees that make decisions

on funding for health programs

Adapted from Carman KL et al. (2013) Patient and Family Engagement: A framework for understanding the elements and developing

interventions and policies, Health Affairs, 32(2), 223-31

Nothing about me, without me….

Diane Pampling, Co-author, Healthcare in a Land Called

PeoplePower, 2001.

Changing norms/culture is difficult without

involving people from outside your system.

We can’t control what happens in healthcare

(clients’ diagnoses, condition), but we can

control the client experience!



Board Culture

• Board ownership of and commitment to a Quality Plan

• Seen to be leading on the quality agenda

• Commitment to transparency and accountability

• Public access to board materials, results • Integration of clients/families

• Culture of inquiry, trust and candor at the Board, with an ability to operate in different modes (fiduciary, strategic, generative)

• Governing the quality agenda requires that Directors

understand operations.



Board Culture will Trump Board Structure Every Time

Do you have concerns about getting too operational when discussing quality & safety? (Microgovernance)

At what point along the decision-making continuum should an issue be brought for generative discussion?

Is strategy only discussed at Board Retreats, or do strategic discussions occur at many of your regular Board meetings?


http://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=NeW892rniqNoVM&tbnid=6KaP9qiNvIJyXM:&ved=0CAUQjRw&url=http://www.excitant.co.uk/resources/books/video-strategy-vs-operational-management&ei=AoLFUtaACq_8yAHz_4DoDA&bvm=bv.58187178,d.aWc&psig=AFQjCNHDgv-uzzEYe5tHgW5euZRA-we3UQ&ust=1388761980902864


Board Culture will Trump Board Structure Every Time

Is there always consensus on decision items?

Do you experience pinball governance?

Does the relationship between the Board and Executive Director support Board members challenging management on particular issues?


http://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=NeW892rniqNoVM&tbnid=6KaP9qiNvIJyXM:&ved=0CAUQjRw&url=http://www.excitant.co.uk/resources/books/video-strategy-vs-operational-management&ei=AoLFUtaACq_8yAHz_4DoDA&bvm=bv.58187178,d.aWc&psig=AFQjCNHDgv-uzzEYe5tHgW5euZRA-we3UQ&ust=1388761980902864


Reflection – Case Study




Driver 4: Partnerships with Key Stakeholders



Consider new relationships given shared accountability for results & voluntary integration

MOU Contract

Shared staff resources

Are your relationships with service delivery partners sufficient to achieve your organizational goals?



If not, what mechanisms might you use to strengthen these relationships for the future?

Partnership Continuum

Steering Committee

with ToR

MOU Formal Contract

No Documentation



A Call to Action!!!

Engage in a relentless quest to make things better.

As long as improvement is seen as something outside

the core work of the organization, as long as it is viewed as “something else to do”,

operational excellence will remain elusive.


David Hughes

Director, Member Services T: 1-800-267-6272 ext. 246 [email protected]

Sue Davidson

Director of Training T: 1-800-267-6272 ext. 273 [email protected]

Contact Us!

Paula Blackstien-Hirsch Principal

T: 905-771-0981 [email protected]


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