IHI Framework for Leadership Improvement

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Seven Leadership Leverage Points

Innovation Series 2008

For Organization-Level Improvement in Health Care

Second Edition

All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, pro- vided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement.

How to cite this paper:

Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. (Available on www.ihi.org)

Acknowledgements:

IHI thanks staff members Jane Roessner, PhD, and Val Weber for their editorial review and assistance with this paper.

For print requests, please contact: Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138 Telephone (617) 301-4800, or visit our website at www.ihi.org

The Institute for Healthcare Improvement (IHI) is a not-for-profit organization leading the improvement of health care throughout the world. IHI helps accelerate change by cultivating promising concepts for improving patient care and turning those ideas into action. Thousands of health care providers participate in IHI’s groundbreaking work.

We have developed IHI's Innovation Series white papers as one means for advancing our mission. The ideas and findings in these white papers represent innovative work by IHI and organizations with whom we collaborate. Our white papers are designed to share the problems IHI is working to address, the ideas we are developing and testing to help organizations make breakthrough improve- ments, and early results where they exist.

Innovation Series 2008

Authors: James L. Reinertsen, MD: Senior Fellow, IHI; President, The Reinertsen Group Maureen Bisognano: Executive Vice President and Chief Operating Officer, IHI Michael D. Pugh: President and CEO, Verisma Systems, Inc.

Seven Leadership Leverage Points For Organization-Level Improvement in Health Care

Second Edition

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)1

Foreword to Second Edition

It is almost three years since we published the First Edition of our white paper, Seven Leadership Leverage Points for Organization-Level Improvement in Health Care, and in that time we have learned a great deal about what it takes to achieve results in quality and safety at the level of entire organizations and care systems. A primary source of our learning has been the application by committed leaders of one or more of these leverage points in the 100,000 Lives and 5 Million Lives Campaigns, in the course of which hundreds of organizations have achieved major improvements in system-level measures such as mortality rates and prevalence of harm. The Campaigns continue to be an extraordinarily rich source of learning to improve and extend our theory—and it is a theory—of “leverage” for leaders.

In addition to the Campaigns, the Institute for Healthcare Improvement (IHI) has also learned a great deal about what works (and, importantly, what doesn’t) from a diverse set of sources ranging from our involvement in national initiatives such as the The Health Foundation’s Safer Patients Initiative in the UK, large-scale collaborative programs such as the 200+ organizations in IHI’s IMPACT network that are participating in Learning and Innovation Communities, in-depth work with IHI’s Strategic Partners, and direct fieldwork and interviews with health care clients as well as industry leaders outside health care. We have noticed, for example, that many of the leverage points work well in the field without much modification, whereas others seem to need some reframing, or a special emphasis on particular elements within the leverage point, or even substantial revision.

Much of this ongoing learning about the role of leaders in quality has been distilled into three IHI white papers that deal either directly or indirectly with one or more of the original Seven Leadership Leverage Points. The 5 Million Lives Campaign’s “Get Boards on Board” intervention, for example, expands Leverage Point One, on the adoption and oversight of aims at the highest levels of governance, into the exceptionally detailed Governance Leadership “Boards on Board” How-to Guide.1 Leverage Point Six, on engaging physicians, has been the subject of intense interest, which in turn has led to the publication of IHI’s white paper, Engaging Physicians in a Shared Quality Agenda.2 And the work of Tom Nolan and the IHI Innovation Team has resulted in a very thoughtful new framework and white paper on the critically important issue of Execution of Strategic Improvement Initiatives to Produce System-Level Results,3 which has relevance to several of the original leverage points, particularly Leverage Points One (adopting aims), Two (developing and overseeing the execution of a strategy to achieve breakthrough aims), and Seven (building improvement capability).

Finally, as with any organically growing set of interconnected leadership theories, there is a constant need for “sensemaking.” In particular, many leaders have expressed the need for a “cross-walk” between frameworks, so that they can place their understanding of elements of various frameworks into some sort of meaningful context. For example, how does the IHI framework for strategic improvement (Will, Ideas, and Execution) relate to the Seven Leadership Leverage Points? What is the fit between the Framework for Execution and the leverage points?

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Because we have gained a lot of new knowledge and field examples, and are also faced with questions about relationships among various IHI frameworks, we thought this would be a good time to write a Second Edition of the Seven Leadership Leverage Points white paper. In doing so, we aim to:

• Propose “Version 2” of the Seven Leadership Leverage Points, incorporating our learning since the original white paper was published in 2005, particularly the learning on the subject of execution.

• Provide a number of specific examples of the field application of each leverage point (rather than the extended “for example” of the 100,000 Lives Campaign that we employed in the First Edition).

• Describe the relationship between the Seven Leadership Leverage Points and other IHI leadership frameworks.

Finally, it is important to point out that this new and improved set of leverage points is still a theory, and a theory at the “descriptive” stage of development, at that.4 By “descriptive” we mean that we are able to describe associations between each leverage point and results, but we are NOT able to ascribe specific cause and effect. In other words, the leverage points theory is not yet a “normative” theory, in that we cannot make the following statement: “If you as a leader do these seven things, you will get dramatic system-level results.” But we can say, with perhaps greater confidence than three years ago, “Where organizations are getting significant results, several of these leverage points appear to be strongly in place.”

We hope you find the Second Edition of the Seven Leadership Leverage Points white paper useful in your own leadership work, and we invite all readers to give us feedback from their own field observations, so that this management theory can continue to grow and improve.

James L. Reinertsen, MD February 2008

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)3

Context and Background

Leaders of health care delivery systems are under pressure to achieve better performance. Through mechanisms such as mandatory public reporting, pay for performance, and “non-payment for defects,” regulators, payers, communities, and informed patients are pressuring leaders to produce measured performance results. These results are often framed for specific circumstances (e.g., “reduce rates of wound infections after cardiac surgery”) and sometimes specified at the system level (e.g., “reduce rates of all forms of harm during hospitalization”).

Many hospital and health system leaders have themselves become personally and painfully aware of defects in their own organizations and office practices—needless deaths, harm, suffering, delays, feelings of helplessness, waste, and inequities—and with a lot of hard work, some have become quite skilled at achieving project-level reductions in these defects (e.g., lower rates of central line infections in a particular ICU). But it is much harder to achieve organization-level results—for example, reduced rates of all hospital-acquired infections, across all units and services. Increasingly, it appears that while health care CEOs and other leaders want to make these changes happen, they don’t have a tried-and-true method by which to bring about system-level, raise-the-bar change. Specifically, health system leaders often say that they are pretty clear about what they should be working on, but far less clear about how they should go about that work.

Leadership models and frameworks can provide a roadmap for leaders to think about how to do their work, improve their organizations, learn from improvement projects, and design leadership development programs.5 The core of the comprehensive IHI strategic improvement framework is Will, Ideas, and Execution3: in order to get organization-level results, leaders must develop the organizational will to achieve them, generate or find strong enough ideas for improvement, and then execute those ideas—make real improvements, spread those improvements across all areas that would benefit, and sustain the improvement over time. And when this Will-Ideas-Execution framework is fully fleshed out with the addition of two other core components, “Set Direction” and “Establish the Foundation,” 24 specific elements emerge into an overall leadership system for improvement called the IHI Framework for Leadership for Improvement (see Figure 1).

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Figure 1. IHI Framework for Leadership for Improvement

Leaders can be daunted by the breadth and depth of this sort of comprehensive model. Even though the 24 individual elements are quite clear, many of them are still fairly broad in scope (e.g., “Plan for Improvement” or “Review and Guide Key Initiatives”). So leaders often look at comprehensive models such as this and ask questions such as “But how exactly do I ‘Plan for Improvement’ or ‘Review and Guide Key Initiatives’?”

The Framework for Execution3 is a superb example of an answer to the “But how…?” question. This framework expands and explains a system for execution of large-scale change, and provides concrete and specific examples of what leaders do and how they do it, in organizations that are highly capable of execution (see Figure 2).

1. Set Direction: Mission, Vision, and Strategy

PUSH PULLMake the status quo uncomfortable Make the future attractive

3. Build Will • Plan for Improvement

• Set Aims/Allocate Resources

• Measure System Performance

• Provide Encouragement

• Make Financial Linkages

• Learn Subject Matter

• Work on the Larger System

4. Generate Ideas • Read and Scan Widely, Learn from Other Industries and Disciplines

• Benchmark to Find Ideas

• Listen to Customers

• Invest in Research and Development

• Manage Knowledge

• Understand Organization as a System

5. Execute Change • Use Model for Improvement for Design and Redesign

• Review and Guide Key Initiatives

• Spread Ideas

• Communicate Results

• Sustain Improved Levels of Performance

2. Establish the Foundation

• Reframe Operating Values

• Build Improvement Capability

• Prepare Personally

• Choose and Align the Senior Team

• Build Relationships

• Develop Future Leaders

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Figure 2. A Framework for Execution

The Seven Leadership Leverage Points framework, on the other hand, was developed in large part to answer a second type of question that leaders were asking:

• “This is a very broad framework; are there one or two places where I could get started, where my actions might have the greatest effect?”

• “We can’t work on 24 things at once. If we had to place our bets on a few specific leadership actions within this framework that would be highly likely to bring about system-level results, what would they be?”

Executives appeared to be asking about “leverage”: specific activities for leaders, and specific changes in leadership systems, in which a small change might bring about large, positive, system-level results. This white paper is an attempt to answer that question—that is, where leaders might place their bets to achieve system-level results.

Build Capability

ENVIRONMENT INFRASTRUCTURE

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The foundation for our answer about leverage comes from at least four different sources:

1. Complex Systems Theory: Complex adaptive systems such as health care organizations and communities cannot be specified and managed in detail. It is highly likely that small changes in certain critical aspects of these systems might bring about surprising and unpredictable amounts of improvement or deterioration in overall system performance. If leaders could choose the right system attributes (“leverage points”) and make small, perhaps difficult, but important changes, very large performance change might result.

2. Observed Performance of Leaders and Health Systems: We have been able to watch the actions of leaders in organizations participating in IHI’s Pursuing Perfection and IMPACT initiatives, as well as in the 100,000 Lives and 5 Million Lives Campaigns, and simultaneously to observe the performance of those systems. Where system-level change has occurred, we have attempted to infer from these sources what some of the leadership leverage points for improvement might have been. For example, we have observed that system-level improvement does not occur without a declared aim to achieve it, and that how the aim is declared and adopted by leaders appears to be very important. These leverage points are based largely on qualitative data—more anecdotes and stories about the work of leaders than a solid research base. Nevertheless, these stories are powerful, and serve to support and refine the theory.

3. Hunches, Intuition, and Collective Experience: The authors come from a variety of backgrounds in health care and have tapped into our collective experience to postulate some of these leverage points—particularly those that surface as recurrent “difficult moments” for leaders. For example, it is our sense that the business case for quality is still fragile in many health care organizations, and therefore that if the chief financial officer (CFO) were somehow to become a champion for system-level improvement in quality, dramatic improvement would become much more likely.

4. Ongoing Research and Development of Management Theories and Methods: In the three years since the First Edition of the Seven Leadership Leverage Points white paper was published, we have learned a lot about topics such as execution, governing boards, transparency, and physician engagement, to mention just a few. We have attempted to weave this learning into the Second Edition of the Seven Leadership Leverage Points white paper, with a particular focus on the several areas of synergy between the IHI Framework for Execution and the Seven Leadership Leverage Points.

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It might be helpful to note what these leverage points are not:

• The leverage points are not intended to be a comprehensive framework for the leadership of organizational transformation. That is a much broader subject, addressed by approaches such as The Baldrige National Quality Program.

• The leverage points are not a substitute for a coherent quality method such as the Toyota Production System or the Model for Improvement. In fact, the organizations in which the leverage points would be applied are assumed to have adopted a coherent quality framework.

Finally, we would emphasize that we have framed these as leadership leverage points. In other words, we believe that these activities are the particular responsibility of the senior leaders of organizations.

This paper has three sections:

1. A detailed explanation of the Seven Leadership Leverage Points and specific examples of their application in health care, where available

2. A brief overview of the changes to the Seven Leadership Leverage Points from the First Edition (2005) to the Second Edition (2008)

3. A self-assessment tool (Appendix A) to help administrative, physician, and nursing leaders of health care organizations design and plan their work using the Seven Leadership Leverage Points

Leverage Point One: Establish and Oversee Specific System-Level Aims at the Highest Governance Level

A broad quality aim is part of the mission statement of most health care organizations. But if leaders are to achieve new levels of performance at the system level, we believe that governing boards must:

• Establish solid measures of system-level performance—for example, hospital mortality rate, cost per adjusted admission, adverse drug events per 1,000 doses—that can be tracked monthly, if not more frequently;

• Adopt specific aims for breakthrough improvement of those measures;

• Establish effective oversight of those aims at the highest levels of governance and leadership; and

• Commit personally to these aims and communicate them to all stakeholders in a way that engenders heartfelt commitment to achieving them.

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Establishing system-level performance measures helps to answer the questions, “What are we trying to achieve, and how are we doing at it?” Sometimes referred to as the “big dots” (a reference to the visual display of critical data points for important measures that reflect the quality of care delivered), well-chosen system-level measures collectively define what is ultimately important to the stakeholders of the organization. Collectively, they provide an answer to the question, “How good are we?”

To help measure the overall quality of a health system and to align improvement work across a hospital, group practice, or large health care system, IHI and colleagues developed the Whole System Measures.6

For each measure, IHI set an ambitious goal that would represent breakthrough performance—performance that exceeds previous believed “limits”—referred to as the “Toyota Specification.” The Whole System Measures provide an excellent example of a balanced set of world-class, system-level (“big dot”) quality performance measures from which an organization’s leaders might choose a few dimensions in which to seek breakthrough performance. The measures are intended to complement an organization’s existing balanced scorecard, measurement dashboard, or other performance measurement system.

The tables below list the Whole System Measures, the relevant Institute of Medicine (IOM) Dimension of Quality, and the Toyota Specifications. Table 1 shows the performance (“Toyota”) specifications for system- level measures, while Table 2 shows the performance specifications for specific components of the care system.

Table 1. Whole System Measures and Toyota Specifications: System Level

† Due to the lack of nationally available data using the Functional Health Survey-6+, IHI used self-reported health status data from the Centers for Disease Control and Prevention Health-Related Quality of Life Surveillance report.

‡ Due to difficulty with calculating Health Care Cost per Capita, a surrogate measure of Medicare Reimbursement per Enrollee may be used for ease of collection.

IOM Dimension of Quality

Patient-Centered

Whole System Measure

Patient Experience Score [Response to the question in the How’s Your Health database, “They give me exactly the help I want (and need) exactly when I want (and need) it.”]

Toyota Specification

72% of Patients Report, “They give me exactly the help I want (and need) exactly when I want (and need) it.”

Effective and Equitable

Functional Health Outcomes Score 5% of Adults Self-Rate Their Health Status as Fair or Poor [Self-rating will not differ by income]†

Efficient Health Care Cost per Capita

[Surrogate measure: Medicare Reimbursement per Enrollee per Year]‡

$3,150 per Capita per Year

$5,026 per Enrollee per Year

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)9

Table 2. Whole System Measures and Toyota Specifications: Component Level

Several aspects of Leverage Point One deserve emphasis, based on what has been learned over the last three years:

• The responsibility for adopting aims and overseeing measures cannot be delegated by the board. What the governance board pays attention to gets the attention of management, physician leaders, and, ultimately, the entire organization.

• Aims must be focused. It is unrealistic to set breakthrough aims across the entire spectrum of performance. In fact, it is highly unusual for any organization, in or out of health care, to achieve breakthrough levels of performance in more than one or two dimensions during any one year.

• It is impossible to overemphasize the importance of the data feedback loop that boards use to oversee the achievement of system-level aims. For strategic breakthrough aims, the primary question that the data must answer for boards is “Are we improving? Are we on track to achieve our aim(s)?” To allow boards to answer this question, measurement of performance must:

o Use consistent operational definitions so that the board can track the trajectory of performance over time;

IOM Dimension Whole System Measure Toyota Specification of Quality

Safe Rate of Adverse Events 5 Adverse Events per 1,000

Patient Days

Safe Incidence of Nonfatal Occupational 0.2 Cases with Lost Work Days per

Injuries and Illnesses 100 FTEs per Year

Effective Hospital Standardized Mortality HSMR = 25 Points Below the

Ratio (HSMR) National Average

Effective Hospital Readmission Percentage 30-Day Hospital Readmission =

4.49%

Effective Reliability of Core Measures 10-2 Reliability Levels

Patient-Centered Patient Satisfaction with Care Score 60% of Patients Selected the Best

Possible Score

Timely Days to Third Next Available Primary Care: Same-Day Access

Appointment Specialty Care: Access Within 7 Days

Efficient Hospital Days per Decedent During 7.24 Hospital Days per Decedent

the Last Six Months of Life During the Last Six Months of Life

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o Be timely (no more than a month’s lag between data and review); and

o Not necessarily be risk-adjusted or use “rates of events per number of interactions.” (These sorts of measurements tend to be more complex, can delay feedback loops, and are primarily used to answer a different question, “How do we compare to other organizations?”)

• It is not enough for boards to review performance measures. When they hear stories of the patients and families whose lives have been affected by quality and safety events, boards will drive for improvement with a much greater sense of urgency and commitment.

• Boards must develop the capability to oversee quality and safety. The best boards are bringing in members who are experts in quality methods in manufacturing and other industries, and are investing in education of all the trustees.

• It is often helpful to develop specific scorecards of measures to track progress on efforts such as a hospital’s work on the 5 Million Lives Campaign, or its major strategic goal to reduce hospital-acquired infections, rather than have key data elements related to these initiatives simply reported out and mixed together with all other quality and reporting metrics. Initiative- specific scorecards create context, which facilitates both understanding and monitoring of progress.

• When boards start holding management accountable for achievement of breakthrough aims, the trustees start asking tough questions. This sends signals throughout the organization that can be a powerful force for culture change.

Ascension Health’s board provides us with an excellent example of the practices described above. In 2003, the board of this 70-hospital system adopted a specific, focused breakthrough aim: zero preventable deaths and injuries by the end of 2008. The boards in each region have incorporated review of patient stories about preventable deaths into their meeting agendas, and the boards must approve the action plan to prevent similar events in the future. Furthermore, the regional boards do not simply accept every action plan passively, but often send the management team back to develop more robust solutions to serious safety risks. The Ascension system tracks the risk-adjusted mortality rate on a monthly basis, and has built the achievement of their aim—zero preventable deaths and injuries—into the management performance expectations. The results at the system level are shown in Figure 3.

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Figure 3. Example of Board Oversight of Performance Measurement for System-Level Aims at Ascension Health

Leverage Point Two: Develop an Executable Strategy to Achieve the System-Level Aims and Oversee Their Execution at the Highest Governance Level

Execution tends to be the weakest link in the Will-Ideas-Execution triad. As depicted in the Framework for Execution in Figure 2 above, and as described in detail in IHI’s Execution of Strategic Improvement Initiatives white paper,3 there are four critical steps for leaders who wish to achieve breakthrough results:

1. The senior team and board must adopt a few focused breakthrough quality and safety aims (as described in Leverage Point One, above).

2. The senior executive team must develop a plan—a “rational portfolio of projects”—with the scale and pace needed to achieve their aims.

3. Key projects must be resourced with capable leaders, both at the large project level and at the day-to-day microsystem level.

-0 .9 0 0 0

-0 .8 0 0 0

-0 .7 0 0 0

-0 .6 0 0 0

-0 .5 0 0 0

-0 .4 0 0 0

-0 .3 0 0 0

Ac tual Monthly D ifferenc e p-bar (Center L ine for D ifferenc e) LC L UC L

CareScience Observed minus Expected Mortality Rate per 100 Discharges Ascension Health

Baseline

1,038 Mortalities Avoided (Year 2)

374 Mortalities Avoided (9 mos. of Year 3)

1,412 Mortalities Avoided Since Baseline Period

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4. The management team must monitor and respond to data from the field at multiple levels in order to steer the execution of the strategy. Leaders must get answers to the questions, “Are we executing our strategy?” (data about the progress of the portfolio of projects) and “If we’re executing the strategy, is it working?” (data about the system-level measures that the organization is trying to move to a new level).

From field observations over the past three years of how senior executives go about building executable strategies and getting results, we emphasize the lessons that follow about the four critical steps to successful execution.

• Just as the board cannot delegate the adoption and oversight of system-level quality aims, the executive team cannot delegate the building and execution of a plan to achieve the aims. The era when quality aims could be delegated to “quality staff,” while the executive team works on finances, facility plans, and growth, is over. System-level breakthrough aims are by their very nature strategic, and require the energy and attention of the entire organization, led by the CEO and the entire executive team.

• One good way to build a rational portfolio of projects is to develop a cascaded series of goals and drivers (see Figure 4). In this method, the senior executive team adopts one or two breakthrough goals and for each goal posits up to three “drivers”—structures, processes, or cultural patterns that would need to be put in place, or changed, in order to achieve the goals. Each of the chosen drivers is assigned to an individual member of the senior executive team as a goal to be achieved, and that executive then brings a group together at the next level to address a new driver question, “What would have to be changed or put in place in order to achieve this goal?” The conversations about goals and drivers then cascade in a similar fashion through additional levels of the organization, until the answer to the driver question looks like a project—i.e., something that could be executed by a specific team in a focused manner over, say, 90 days. The result of this cascaded series of goals and drivers is not only a good project plan, but also a highly visible, well-communicated logic of the plan wherein each person, at every level, knows their part and how those parts fit into the whole.

• IHI’s experience in the field keeps reinforcing the old truth: “Culture eats strategy for lunch.” When thinking through drivers of major system-level quality and safety aims, cultural drivers should be near the top of any leader’s list. Patterns of behavior that are driven by underlying values, habits, and beliefs—the organization’s culture—will dominate every other possible driver and may jeopardize changes to processes and structures unless they are explicitly addressed. Some examples of such patterns of behavior around safety practices might be the following:

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o “We follow the safety rules…unless we’re really busy.”

o “Those are good rules for infection prevention, but they really don’t apply to me.”

• The Framework for Execution describes other methods by which an executable project portfolio can be developed, but all effective methods seem to share the two features described below.

1. A good method for execution ensures that the system-level aims have a powerful influence on choices of projects throughout the organization. Managers are not being asked, “How does what you’re already working on in your department support the system-level aim?” Instead, the primary question is, “What do we need to do in order to accomplish the aim?” The first question results in what one frustrated manager reported: “We do all this strategic planning, and set these grand goals, and then the plan to accomplish the goals looks pretty much like every department simply rationalized its pet projects.” The second question results in a portfolio of projects with the scale and pace needed to accomplish the stated aim.

2. A good method forces focus. The example in Figure 4 depicts the logic chain for only one driver at each organization level. In reality, a cascaded set of conversations, with two or three drivers at each level, will branch many times, resulting in a fairly large number of projects once the process has played out to the project level. If leaders do not focus on one or two aims, supported by three or fewer drivers, then the cumulative burden of projects that results is overwhelming for front-line staff (especially when added on top of their daily work!).

• Large, complex projects must be led by capable leaders who are given the time to do the projects or the projects will not be successfully executed. Outside of health care, in companies capable of execution, the individuals chosen to lead a project of strategic importance are carefully chosen, and given time (for example, 50 percent to 100 percent of their time for six months) to complete a major strategic project. In contrast, health care organizations often ask leaders to take on major projects as “add-ons” to already daunting workloads.

• Even with careful attention to developing a logical portfolio of projects, creating focused aims, and enabling well-resourced and supported project leadership, a plan to achieve system-level breakthrough aims requires guidance and oversight from the senior executive team. A successful leadership system for execution has two critical components: 1) obtain data and feedback regularly on whether a) the strategic project portfolio is being executed, and b) the strategy is working; and 2) have senior executives regularly review and respond to timely, useful data on these two questions. This type of system ensures that leaders take timely action to resolve issues that may be prohibiting execution (e.g., break down barriers, provide resources for project leaders, or replace project leadership). If projects seem to be executed well, but little progress on system-level measures is seen, the senior team then takes action to revise the strategic project portfolio or ramp up the scale and pace of implementation.

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Figure 4. Example Cascading Series of Goals and Drivers

Leverage Point Three: Channel Leadership Attention to System-Level Improvement: Personal Leadership, Leadership Systems, and Transparency

The currency of leadership is attention. What leaders pay attention to tends to get the attention of the entire organization, and all potential resources for channeling leadership attention, whether formal or informal, should be connected to the aim: personal calendars, methods of data display, meeting agendas, project team reviews, executive performance feedback and compensation systems, hiring and promotion practices, to name a few. We have begun to notice three key ways in which effective senior leaders channel attention to system-level improvement: personal leadership, leadership systems, and transparency. In concert, these three methods form a powerful leverage point for achieving system-level results.

Personal Leadership

The staff pay attention to the organization’s senior executives and, in particular, to what they do with their time. If an organization establishes a new breakthrough safety aim (e.g., “eliminate

Leader Responsible

CEO

Key Drivers to Achieve Goal

• Physician/nurse teamwork • End-of-life care • Hospital-acquired infections

• Handwashing • Lean processes: Flow management, reduce wasted time and effort of staff to give time to barrier precautions, handwashing, etc. • Bundles: Ventilator, Central Line

• Adopt common pre-operative order sets for the same conditions • Learn and use “Level 2” reliability principles in all critical care areas and surgery suites

Execute the Project

Chief Medical Officer, Chief Nursing Officer

Department Chairs, Nursing VPs

ICU Unit Manager, Medical Director

Leader’s Goal

Reduce mortality rate by 20% in 2 years

Reduce hospital-acquired infections by 50% in 12 months

Fully deploy Ventilator Bundle and Central Line Bundle to all units within six months

Project: Achieve 10-2 reliability in the Ventilator Bundle and Central Line Bundle within three months

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hospital-acquired infections”) as part of its strategic planning process and the CEO and other senior executives continue to do exactly what they did the year before—attend the same meetings, visit the same project teams, read and ask questions about the same reports, ask for data about the same performance measures—then the staff ’s interpretation of this new goal is, “Well, it’s a nice thing to aim for, but they don’t really take it seriously, so why should we?”

Executives are constantly sending signals about what they believe to be important. Some signals are negative (e.g., arriving late to the meeting, not asking questions, taking a phone call during the meeting, and leaving early). Other signals tell the staff that executives really care about achieving the stated quality aim. Examples of positive signals might include the following:

• Prioritize Calendars: Leaders can change their personal schedules to make time for data review, meetings with project leaders, and other activities that support the work.

• Conduct Project Reviews: Senior executives can send powerful signals by personally performing reviews with project teams—asking about their project aims, connecting the work of the team to the overall organization aims, focusing on results, helping the team to overcome barriers, and providing encouragement.

• Tell Stories: Positive organizational “buzz” can be created by the stories that executives tell in their formal and informal communications. If the stories reinforce the cultural changes and practices needed to achieve breakthrough aims (e.g., a story about a manager’s willingness to do multiple rapid tests of change and the great results achieved), they will encourage more rapid adoption of the needed patterns and practices.

Leadership Systems

Personal leadership is a powerful way to channel attention, but even the best personal leadership needs to be supported by good leadership systems—the interrelated set of structures and processes by which leaders work. It’s a great beginning for a senior executive to remake her calendar to include project meetings, conduct project team reviews, and tell great stories that reinforce the desired culture changes and behaviors. However, if senior executive meeting agendas, data reviews, messages communicated at quarterly staff meetings, and featured items in the weekly newsletter do not all support the quality and safety aims, these defects in the “leadership system” will lessen the effect of that executive’s individual efforts.

A simple way to test the effectiveness of leadership systems is to find out what performance data are “top of mind” for senior executives and other managers. In most health care organizations, the vast majority of executives will know the last month’s operating margin and service satisfaction scores. But very few will know the last month’s mortality rate, or number of hospital-acquired infections, or number of decubitus ulcers. This is because the leadership systems are different for finance than

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they are for quality and safety—the reliability and timeliness of measurement and reporting, the frequency and depth of management reviews, and so forth.

In organizations that achieve system-level results, the key data related to quality and safety tend to be “top of mind” for executives, not just for the quality staff. The COO of an extremely high-performing community hospital—when asked about the most recent data for several key performance measures, which he quickly rattled off without reference to documents or other support—said the following about the basic elements of a good system for channeling leadership attention to system-level improvement:

“We get the key measures updated monthly. At each weekly management meeting we go over one of the categories—safety, for example—in depth, and take actions to make sure we’re on track. We post the numbers each month on every bulletin board in the hospital, so I get a lot of questions about them as I walk around. Besides, I just finished up our quarterly staff communication meetings where the main priority is to explain these numbers to all the staff. After all, a portion of my paycheck, and of all the staff ’s paychecks, depends on how we do against these numbers!”

Transparency

Perhaps the most powerful method of channeling leadership attention is to harness the power of transparency. (In fact, this is such a potent tactic that we debated whether “Harness the Power of Transparency” might stand alone as a new Leverage Point Eight.) The fundamental force behind this method is simple: if the public (regulators, media, community, patients) are paying attention to all of your quality and safety performance data (and not just the numbers that you’re proud of ), then those people inside the organization will tend to work with greater urgency to improve performance (especially the numbers they aren’t proud of ). Or, put more memorably: “If you’re going to be naked, it’s good to be buff.”7

The Wisconsin Collaborative for Healthcare Quality provides an excellent example of the power of transparency. A group of health care systems worked with employers to design and publicize a 40-item quality and safety report. The systems agreed to report all the data they had, good or bad, and also agreed that they would not use any of the data for marketing. When the first reports went to the public, each organization was the best in the state in at least one of the 40 measures, and each was also the worst in the state in another of the 40 measures. John Toussaint, CEO of ThedaCare, a participant in the Collaborative, describes the internal reaction at ThedaCare to having publicly displayed data they were not proud of:

“Within hours, the doctors in that department were in my office angrily asking me, ‘How dare you send out those numbers to the public? We look bad!’ After I calmed them down a bit, I said, ‘Well, maybe the numbers are bad because we are bad.’ It took about a week to solve the problem and make dramatic improvements in the numbers. We had been working on that

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issue for a couple of years, without getting anywhere. And once it went to the public, we solved it in a week.”

Health system leaders often express reservations about transparency because they fear that patients will choose other hospitals or medical groups if they see unflattering data. The past few years of experience, along with the limited data from formal studies of public transparency,8 should reassure hospital marketing departments that, in general, public reporting does not lead to shifts in market share and volumes, even when the reports show the hospital in a bad light.9

Other hindrances to transparency include fear of malpractice suits and worry that philanthropy will dry up if donors hear about poor performance measures. Neither of these fears appears to be valid. The vast majority of malpractice suits have nothing to do with errors or actual performance data, but rather are the result of broken trust relationships. And our experience with donors suggests that they recognize that no hospital is perfect, and they feel valued and respected when they are treated with honesty about hospital performance.

Leverage Point Four: Put Patients and Families on the Improvement Team

The most commonly cited reason for failure of organizations to reach breakthrough aims is the failure of the senior leadership group to function as an effective team, with the appropriate balance of skills, healthy relationships, and deep personal commitments to achievement of the goals. CEOs who want to achieve quality and safety goals must constantly ask themselves, “Do I have the right senior team in place to get the job done?” Getting this difficult judgment correct, and acting on it, is a critical task for the CEO, and is therefore a key leverage point for system-level performance improvement.

We recognize that while getting the senior leadership team right is extremely important, this chal- lenge is fairly broad and universal (i.e., every CEO faces this question, for every kind of strategic aim). We therefore reframed Leverage Point Four to make it less “generic” and much more focused. Instead of “Get the Right Team on the Bus,” we have zeroed in on team members who usually aren’t even considered candidates to be on the bus—patients—and have restated Leverage Point Four as “Put Patients and Families on the Improvement Team.”

Our rationale for this change is straightforward. Quite simply, we have observed that in a growing number of instances where truly stunning levels of improvement have been achieved, organizations have asked patients and families to be directly involved in the process. And those organizations’ leaders often cite this change—putting patients in a position of real power and influence, using their wisdom and experience to redesign and improve care systems—as being the single most powerful transformational change in their history. Clearly, this is a leverage point where a small change can make a huge difference.

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What does Leverage Point Four look like in action? The following are four examples.

Daily Patient Conversations with Senior Executives

The entire senior management team at McLeod Regional Medical Center in Florence, South Carolina, starts each day by gathering outside the CEO’s office and then going to a patient care unit. Each member of the senior team visits three or four patient rooms, talks with the patients and nursing staff, asks patients about their experiences, and gives patients the daily newspaper. The whole process takes about 30 minutes, including a standing debrief with the entire team. Patients and staff see the senior team as personally engaged in making the care system better, and the senior executives hear ideas and concerns directly from patients in ways they have never done before. One powerful consequence is the effect these conversations have on the executives themselves, who typically feel energized and inspired to improve the care system with much greater urgency and commitment than they would without the patients’ words ringing in their ears every morning. The results at McLeod’s 550-bed hospital are spectacular: a 40 percent drop in mortality rate, some of the very best CMS Core Measure scores in the nation, and a dramatic drop in adverse drug events—including a seven-month run with zero harm from medications.10

Family-Centered Rounds

At Cincinnati Children’s Hospital in Ohio, it has become routine to give parents the choice to be full participants in the daily “work rounds” as nurses, house staff, and teaching faculty give progress reports, do examinations, discuss differential diagnoses, and make treatment plans. The process provides parents with direct, unfiltered communication about everything that is happening with their child, and also invites parents to provide information and participate in decisions in an unprecedented fashion. Parents are involved in ensuring that medication orders are correct and helping to create discharge goals. Families routinely say they now feel they are truly part of the care team. In the words of Steve Muething, a pediatrician and Assistant Vice President of Patient Safety: “Family-centered rounds began as a flow initiative and there was much resistance. Five years later it is a core value of our organization. Nurses and physicians believe care is better and safer and the teaching improves when parents are active participants in rounds. Teams are now uncomfortable when parents aren’t involved in rounds.”

Structural Integration of Patients and Families

Stimulated in part by a well-publicized patient death from an overdose of chemotherapy, Dana- Farber Cancer Center in Boston, Massachusetts, began asking patients and families to participate in the design of safer care processes. This institution now has over ten years of experience inviting patients and families to become full members of virtually every committee, task force, and improvement team in the organization. Over 400 patients and families are now actively involved as volunteers in these roles at any one time, as full participants in decisions about care design, safety improvements,

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facility planning, operations management, and strategic issues—essentially everything important about the organization. Although many internal staff members were skeptical about this change at the beginning, they now wonder how they ever ran Dana-Farber without having patients and families deeply involved. Two “results” stand out among many performance highlights: There have been no more fatal medication safety events in the 11 years since they began this structural and cultural change, and philanthropic support (by many of the same volunteers who help to run the organization) reached the astounding level of $160 million in 2006—without a major capital campaign.11

Patient Stories at Board Meetings

Every meeting of the Board Quality Committee at Delnor-Community Health System in Geneva, Illinois, features a patient story about a harm event, helping the organization “put a face on the problem” rather than just seeing abstract reports of measurements. Typically, a patient (or family member) is invited to tell what it was like for them to experience a surgical site infection, or some other quality defect. Board members then ask questions to clarify their understanding of the experience. Although these conversations take only 20 to 30 minutes during the actual meeting, there is a lot of preparation involved—to invite a patient or family member (not all want to participate), prepare the patient and family for the meeting, discipline the board not to get into ad hoc problem-solving during the meeting, and so forth. The effect on the board members has been powerful. They now ask questions of the medical staff and administration with greater passion and urgency, and they expect results. It might be a coincidence, but it is over a year since Delnor has had a ventilator- acquired pneumonia or a central line infection, and the mortality rate at Delnor has dropped some 40 percent in two years.12 There are other ways in which boards and senior leaders can hear patient stories,13 but none are as powerful as having the patient in the room.

The principles behind Leverage Point Four are nicely articulated in the “Patient- and Family- Centered Care” approach of the American Hospital Association,14 as follows:

• All people (patients, families, and staff ) will be treated with dignity and respect.

• Health care providers will communicate and share complete and unbiased information with patients and families in ways that are affirming and useful.

• Patients and families participate in experiences that enhance control and independence.

• Collaboration among patients, family members, and providers occurs in policy and program development and professional education, as well as in the delivery of care.

The most important learning from the last three years of experience is that these principles must be translated into specific structural and process changes if they are to have an effect on the organization’s culture. The most powerful of these structural and process changes—the one with the most

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leverage—is to “Put the Patient in the Room.”15 At least four things happen when patients and families work alongside health care professionals to improve quality and safety:

• Self-Serving Conversations Cease: Many complaints (e.g., “We can’t do it that way because that would require us to cooperate with that other cardiology group with which we compete”) sound unseemly when patients and families are in the room.

• The Whole System of Care Comes into Play: Patients experience care across multiple departments, medical groups, and organizations. They want solutions that work for them, not just for one part of the system.

• Better, More Innovative Ideas Come Forward: Patients and families are a tremendous wellspring of ideas for improvement and redesign, if we listen to their voices.

• Physicians and Nurses Feel Supported and Inspired: When patients are on committees and task forces, they become a source of energy and positive reinforcement for care professionals.

For all these reasons, we believe that Leverage Point Four—Put Patients and Families on the Improvement Team—is not only an important force in driving the achievement of measured results, it is also the leverage point with the greatest potential to drive the long-term transformation of the entire care system.

Leverage Point Five: Make the Chief Financial Officer a Quality Champion

One particular member of the senior executive team stands out, in our view, as a critical leverage point for large system change: the CFO. The connection between quality improvement and business performance is still weakly made in most health care organizations, but that is changing. The combination of pay-for-performance programs, major changes to the Medicare payment system, and the elimination of increased payment for eight “never events” has put quality and payment on the radar screens of many health care CFOs. Additionally, a number of organizations have begun to try to understand the true financial impact of harm events such as falls, medication errors, and delayed care. Others are examining the comparative cost of care when evidence-based care protocols are utilized.16 CFOs are finding significant opportunities to improve patient care margins by reducing and eliminating error and clinical waste.

Traditionally, the successful health care CFO is a master of the revenue stream, able to maximize contracts and payment systems. Cost-reduction efforts have generally been in reaction to external changes in the market or payment systems and are mostly one-time events focused on reducing the cost of labor, supplies, and vendor contracts (i.e., the inputs to the processes of care). But when compared to CFOs in other industries, health care CFOs have typically not focused on improving the processes themselves—taking out wasted time and effort, eliminating defects that require rework,

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and so forth. To a large extent, the core processes of health care—diagnosing, treating, communicat- ing with patients, etc.—have been something of a “black box” and off limits to health care CFOs.

Figure 5. CFO Cost Reduction Efforts: Health Care vs. Other Industries

Leverage Point Five reflects our belief that health care organizations would be far more likely to achieve dramatic improvement in system-level measures of both financial and quality performance if health care CFOs were to become strong drivers of quality-based elimination of waste, and if their commitment were translated deeply into the budgeting, capital investment, and innovation and learning systems of an organization.17

The strongest examples of Leverage Point Five in action tend to come from organizations such as Virginia Mason Medical Center in Washington, Park Nicollet Health Services in Minnesota, ThedaCare in Wisconsin, and McLeod Regional Medical Center in South Carolina that have adopted lean management principles (in particular, the Toyota Production System).18 In these health care systems, efforts to both reduce costs and to improve quality are primarily focused on the processes of care. Any reduction in input costs (supplies, personnel, etc.) comes about as a result of having removed waste from the process, not as a new constraint on an unimproved process. Examples of what these organizations are achieving by engag- ing the CFO in improvement of core care delivery processes include the following:

• Improving time available for care delivery: McLeod has eliminated 112 minutes of wasted nursing documentation time per cardiac patient, freeing up nurses to provide higher levels of quality and safety.19

Where Health Care CFOs Go

to Reduce Costs

Where Other Industries’ CFOs Go

to Reduce Costs

Inputs to Core Processes

• Supplies • Staff • Equipment • …

Core Processes

• Evaluating • Diagnosing • Treating • Communicating • …

Outputs

• Quality Results • Safety Results • Costs • …

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• Improving throughput and avoiding capital costs: By using lean techniques to manage flow, Park Nicollet now routinely processes 64 patients per day through the same endoscopy facility that once struggled to care for 30 to 32 patients per day, with less strain and effort on the part of nurses and physicians. Patients and staff are delighted, and $3 million in capital expenditures were avoided.20

• Making more secure long-term financial plans: ThedaCare has seen so much reduction in waste from their first couple of years of widespread application of the lean methodology that the CFO has built a long-range financial plan that does not require any price increases.21

Some patterns are emerging from these examples and others like them:

• Organizations with CFOs who are engaged in improvement efforts have adopted quality as the

strategy, not one of many strategies. The key marker of this strategy is seen when times get tough: these organizations invest more, not less, in quality when they are under financial pressure.

• These CFOs take a personal role in process improvement and waste removal. It isn’t enough to cheer on the sidelines; CFOs must be teachers and practitioners of quality methods, and actively seek out process improvement opportunities. A good example at Park Nicollet has been the huge reduction in administrative waste that resulted from the elimination of the entire budgeting process—three months of management time and energy expended every year in what the CFO realized was pure waste.22

• These CFOs encourage serious investment in development of improvement capability. When quality is the strategy, organizations recognize the significant investment that must be made to develop capable leaders of improvement at all levels and they make the commitment to build this capability (see Leverage Point Seven).

• CFOs are beginning to shift their focus to cost per unit as opposed to revenue per unit. Because most hospital payment systems involve a fixed form of payment (e.g., DRGs, case rates, bundled outpatient rate, Ambulatory Surgical Center rate, per diem rate), many CFOs are making the connection that eliminating infections, medication errors, falls, and delays in care are strategies for reducing their average per unit cost of production and increasing the margin on care delivery. Taking it one step further, some CFOs are beginning to ask what it should cost to treat pneumonia, replace a hip, or deliver a baby, for example, establishing a per-unit cost standard for various high-volume reasons for admission. Rather than asking managers to cut dollars from a budget, these organizations are asking managers to decrease the cost per unit of production by eliminating clinical and administrative waste.

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Leverage Point Six: Engage Physicians

Clearly, all members of the health care team need to be engaged if leaders are to succeed in making quality and safety improvements. So why single out physicians? This leverage point arises from the reality that whereas physicians by themselves cannot bring about system-level performance improvement, they are in a powerful position to stop it from moving forward, and therefore their engagement is critical. Simply stated, leaders are not likely to achieve system-level improvement without the

enthusiasm, knowledge, cultural clout, and personal leadership of physicians.

“Yes, but how do we engage physicians?” Since the First Edition of this white paper was published, this has been the most common question asked by hospital and health system executives. IHI’s answer to this question is structured around the framework depicted in Figure 6 and is described in detail in the Engaging Physicians in a Shared Quality Agenda white paper.2 That white paper builds on the principles articulated in the initial Seven Leadership Leverage Points and utilizes continued learning from organizations that have achieved breakthrough levels of performance with a high degree of physician engagement (e.g., McLeod Regional Medical Center and Immanuel St. Joseph’s–Mayo Health System in Minnesota).

Figure 6. IHI Framework for Engaging Physicians in Quality and Safety

1. Discover Common Purpose:

1.1 Improve patient outcomes 1.2 Reduce hassles and wasted time 1.3 Understand the organization’s culture 1.4 Understand the legal opportunities

and barriers

2. Reframe Values and Beliefs:

2.1 Make physicians partners, not customers

2.2 Promote both system and individual responsibility for quality

3. Segment the Engagement Plan:

3.1 Use the 20/80 rule 3.2 Identify and activate

champions 3.3 Educate and inform

structural leaders 3.4 Develop project

management skills 3.5 Identify and work

with “laggards”

4. Use “Engaging” Improvement Methods:

4.1 Standardize what is standardizable, no more

4.2 Generate light, not heat, with data (use data sensibly)

4.3 Make the right thing easy to try 4.4 Make the right thing easy to do

6. Adopt an Engaging Style:

6.1 Involve physicians from the beginning

6.2 Work with the real leaders, early adopters

6.3 Choose messages and messengers carefully

6.4 Make physician involvement visible

6.5 Build trust within each quality initiative

6.6 Communicate candidly, often

6.7 Value physicians’ time with your time

5. Show Courage:

5.1 Provide backup all the way to the board

Engaging Physicians in Quality and Safety

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Each of the six elements of this framework is important by itself, but physician engagement is more likely when leaders work across all the elements. Specific examples of how hospital and health care system leaders are using the framework to engage physicians are described below.

Discover Common Purpose

The key idea here is to learn what the physicians’ quality agenda is, and to harness your quality efforts to their agenda. “Physicians’ quality agenda” is not an oxymoron. Doctors care deeply about their patients’ outcomes, and they also care deeply about wasted time (especially their own). In contrast, doctors are less excited about improving the hospital’s publicly reported quality scores, reducing length of stay, or removing waste in the supply chain—all of which they tend to think of as “the hospital’s problem, not mine.”

Hospital leaders can address this gap by how they frame aims and measure results. Physicians care about mortality and harm—quality and safety outcomes—much more deeply than they care about process measures, and one way to engage them is to make sure that the organization’s aims focus on outcomes that are meaningful to doctors. For example, instead of aiming to “be in the top tenth percentile of CMS Core Measures,” a hospital might establish an aim to “reduce the risk of needless deaths in the hospital.” One strategy to accomplish this aim might be to improve the reliability of CMS Core Measures for acute myocardial infarction and pneumonia.

Reframe Values and Beliefs

Both administrators and doctors need to reexamine and reframe some of their core values and beliefs if true engagement in quality and safety is to occur. Administrators must begin to think of doctors as partners rather than as customers. Doctors must begin to see their responsibility for the system’s quality results, and not just for their own personal quality performance. These sorts of deep cultural changes do not happen overnight, and won’t happen just because we wish them to. One example of process that might be redesigned to help drive changes in values and beliefs is the traditional “Morbidity and Mortality Conference.” Typically in these conferences it is the doctors who ask, “Did someone make an error of judgment or of technique in this case?” The redesigned process would focus on doctors and administrators asking a very different question: “What were the systems factors—culture, structure, processes—that contributed to this death, and what could we do together to change these factors?” Over time, as this question is repeatedly asked and addressed with real action, physicians will start to feel more like valued partners in the hospital’s operations, and they will also begin to work on the system of care, not just in the system of care.

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Segment the Engagement Plan

One of the most immediately practicable elements of the IHI Framework for Engaging Physicians in Quality and Safety uses the principle of segmentation. Not all physicians need to be engaged in any particular quality initiative, and those that must be engaged do not need to be engaged in exactly the same way. The idea is to develop a segmented plan for engaging physicians—one plan for a few physician champions, another plan for the physicians who might be members of the actual improvement team, yet another plan for the structural leaders of the medical staff who might need to adopt a new hospital policy based on the work of the team, and so forth. It is important when designing each of these segmented plans to include a plan to engage those physicians who are likely to block recommendations that emerge from the project team or policies recommended by the structural leaders.

Use “Engaging” Improvement Methods

Executives realize that doctors have often been cynical about quality improvement in the past because the methods—ways of involving physicians in improvement work, data reporting, etc.—are almost guaranteed to disengage them. For example, asking busy doctors to join an improvement team that meets every two weeks during the time doctors would otherwise be making rounds; using the vast majority of the meeting time for activities that don’t require physician input; gathering data month after month without testing any changes, then sending out flawed performance data on quality measures to individual doctors and asking them to improve.

The process for standardizing clinical processes is another example where redesign is needed to better engage physicians. Typically, when doctors are asked to standardize their approach to a clinical situation, they design a protocol, care pathway, or guideline—a specification of what should be done, using the best evidence. Visually, the process looks something like Figure 7—a series of conference room meetings, often stretched out over months, during which the evidence is debated and different doctors and specialties argue their favorite points—all about what should be done, in theory. There is little discussion about how, who, when, where—the practical aspects of actually executing a guideline in any given clinical setting—and no testing of any of the ideas in the real world to see whether any of this works. Is it any wonder that few doctors choose to use the final product, when it is eventually sent forth into the clinical world with the hopes that the doctors will “opt in”?

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Figure 7. The Typical Approach to Standardizing Clinical Processes

A much better way to standardize clinical processes, one that engages physicians, is to spend no more than one meeting on the what of a guideline and use small tests to refine the design for the local setting (see Figure 8). There is usually a good “starter kit” for a clinical protocol or guideline available from a national, reputable source—good enough for most clinical settings as an initial protocol. The main work of the standardization team is not to reinvent the science behind this protocol, within each hospital. Rather, their focus is on how to make the existing protocol work within the local context. The team tests various methods for how, who, when, where, initially on a very small scale, making frequent changes to improve implementability. Tests of change increase in scale, until most doctors find themselves able to use the protocol in their patient care. At that point, the guideline or protocol is adopted with the expectation that doctors opt out if they don’t wish to use it. After all, through its testing the team has demonstrated that the vast majority of doctors can use the protocol and it works well in daily practice.

Figure 8. Standardize Clinical Processes: Refine the Design for the Local Setting Using Small Tests of Change

Design

Test and Modify

Approve (if necessary)

Implement

CONFERENCE ROOMS

REAL WORLD

Design Design Design Design Approve

Implement

CONFERENCE ROOMS

REAL WORLD

CONFERENCE ROOMS

REAL WORLD

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Show Courage

Change is required to make improvements in quality and safety; this change is not easy, especially when one powerful voice speaks out against it. Physicians are among the most powerful voices in health care organizations and their collegial nature makes them reluctant to challenge other doctors. “Monovoxoplegia,” or “paralysis by one loud voice,” is a common phenomenon that occurs in doctors’ meetings, improvement teams, executive team meetings, and even in board rooms, where lay board members often sit silent when one doctor speaks up against a proposed change.

There is no simple answer to overcome “monovoxoplegia,” but the basis of an effective approach relies on building an organizational culture of courage—the courage to ask questions, to challenge the status quo, and to support the doctors and nurses who do wish to make improvements. Courage of this sort is beautifully illustrated by Donna Isgett at McLeod Regional Medical Center, and the question she now asks physicians when they balk at using evidence-based practices: “Are you saying that you value your individual autonomy more than you value your patients’ outcomes?” Knowing that they will be supported all the way to the board enables all clinicians, including doctors, to ask tough questions. Courage is infectious.

Adopt an Engaging Style

To achieve the best improvement results, leaders must keep in mind certain characteristics in the physician professional culture, including their focus on individual patients, a deep sense of individual responsibility for patient outcomes, the tendency to overestimate the risk of changes in practice, and valuing individual experience over data and formal studies. Below are some ideas, more fully described in the Engaging Physicians in a Shared Quality Agenda white paper, for developing a “style” that engages physicians in improvement.

• Involve Physicians from the Beginning: Don’t hand them a final or near-final version of proposed changes.

• Work with the Real Leaders: In most groups of physicians, there are typically one or two opinion leaders. They might not be the “titled” leaders within the organization, but they have earned the respect of their peers and can influence others. To facilitate change and improvement, these real leaders must be involved in the improvement work.

• Choose Messengers and Messages Carefully: Physicians often give credibility in part to who delivers the message, so it is important to plan how a proposed change is described and by whom (e.g., a specialist, a general practitioner, a physician with specific specialty qualifications, etc.). Furthermore, terms such as “accountability” and “performance reports” can have unintended meaning, and communication should be designed to be engaging rather than inflammatory.

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• Be Transparent, Especially with Data: Physicians generally don’t trust interpreted data, so give them access to the raw data. Even if they never look at the data, they will value knowing that you trust them to do so.

• Value Their Time with Your Time: If an executive leader asks physicians to take time to engage in a “critical strategic initiative” but can’t be bothered to attend meetings himself, then the doctors feel manipulated and undervalued, and physician engagement will suffer accordingly.

Leverage Point Seven: Build Improvement Capability

Three years of field experience have reinforced the critical importance of Leverage Point Seven. It would do little good for an organization to implement Leverage Points One through Six—adopt aims at the board level; develop brilliant plans to achieve the aims at the executive level; channel attention to the aims with transparency and executive time; engage patients in designing changes to achieve the aim; link financial and clinical improvements to the aim; and engage physicians in the aim—if no one in the organization were technically capable of making, sustaining, and spreading improvements (Leverage Point Seven).

To effectively execute improvement projects throughout an organization, leaders must devote resources to establishing capable leaders of improvement in every microsystem. If successful projects are to scale up, spread, and change the performance of the entire system, then leaders must build a system of leaders capable of rapidly recognizing, translating, and locally implementing change concepts and improved designs. The list of capabilities required of senior leaders to drive system-level improvement is long, but includes at a minimum the ability to know, use, and teach the following:

• The Model for Improvement and small-scale rapid tests of change23

• A coherent improvement strategy such as the Toyota Production System24

• Concepts and practices of high-reliability organizations25

• Sophisticated practices in flow management26

• Concepts and practices of scale-up and spread of improvements27

• Concepts and practices of safety systems28

Park Nicollet Health Services provides an example of the level of investment in improvement capability that might be required if quality is to be the strategy for an organization, rather than just a strategy. In an organization of approximately 5,500 full-time equivalent employees, CEO David Wessner has taken 39 of his best managers “off the line” to become deeply trained process improvement leaders, with a full-time focus on facilitating rapid, sustained improvement in quality and safety. He plans to grow this

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group of leaders to at least 100 people, over and above the normal complement of staff in areas such as infection control, Joint Commission accreditation, and other typical quality and safety functions.

Over the past three years since the initial leverage points were developed, one of the most consistent findings has been that senior executives tend to overestimate the capability for improvement within their organizations. Simply sending a few staff to a couple of conferences and adding “quality and safety” to job descriptions will not begin to address the critical need for capable improvers at every level in health care organizations.

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Summary of Changes to the Seven Leadership Leverage Points

The table below provides a brief overview of the changes to the Seven Leadership Leverage Points, based on IHI’s learning between publishing the First Edition of the white paper in 2005 and this Second Edition in 2008.

Leverage Points Key Changes in the Second Edition (2008)

One Establish and Oversee Specific System-Level Aims at the Highest Governance Level

• Emphasis on the critical role of the board in quality • Learning about the power of stories and data at the board level

Two Develop an Executable Strategy to Achieve the System-Level Aims and Oversee Their Execution at the Highest Governance Level

Learning about what it takes to execute change on a large scale: • Focus on one or two major aims • Rigorous steering of the execution plan using good data

from the field • Resourcing strategic improvements with capable improvers and

change leaders as their primary job responsibility

Three Channel Leadership Attention to System-Level Improvement: Personal Leadership, Leadership Systems, and Transparency

• Confirmation and examples of the power of leadership attention to improvement aims

• A major new emphasis on the power of transparency to drive improvement and change

Four Put Patients and Families on the Improvement Team

• Original leverage point focused on establishing the most effective senior leadership team

• Revised leverage point focuses exclusively on the transformational role of patients and families on leadership and improvement teams

Five Make the Chief Financial Officer a Quality Champion

Six Engage Physicians

Seven Build Improvement Capability

• Learning about the potentially powerful role CFOs can play in improvement once they see “reduce waste in core processes” as the primary driver of cost reductions, rather than the traditional approach of “reduce inputs to (defective) core processes”

• Developed an entirely new framework for engaging physicians in a shared quality agenda, with extensive examples

• Continued reinforcement of the critical need to build capable improvers at every level as an important underpinning for the other six leverage points

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)31

Appendix A: Leadership Leverage Points Self-Assessment Tool for System-Level Results

The self-assessment is a discussion and action tool designed to help the administrative, physician, and nursing leaders of a health care organization design and plan their work in order to lead to a significant reduction in one or two system-level measures (e.g., mortality rate, harm rate, nosocomial infection rate, or chronic disease outcome measure). The self-assessment should be completed by the senior leadership team of the organization, first as individuals and then together as a group to review the results and plan actions that will address any leadership leverage points that need attention.

Leadership Leverage Points Action Needed / Action Planned By Whom By When

1. Establish and Oversee

Specific System-Level Aims

for Improvement at the

Highest Governance Level

Senior leadership team has developed specific “how much, by when” aims for system-level measures of quality and safety.

Board has adopted the aims and is overseeing their achievement using system-level measures of progress against the aim.

Patient stories about harm or quality issues (either in person, by videotape, or as told by front-line personnel) are part of every board meeting.

Accountability for achieving the aims is clearly established in the board’s executive performance feedback system.

32Institute for Healthcare Improvement Cambridge, Massachusetts

Leadership Leverage Points Action Needed / Action Planned By Whom By When

2. Develop an Executable

Strategy to Achieve the

System-Level Aims and

Oversee Their Execution at

the Highest Governance Level

Senior leadership team has developed a plan to achieve the aims that is focused on the right drivers, and has the necessary scale and pace.

Senior leadership team has resourced the projects that are necessary to achieve the aim with effective leaders.

Leadership team is steering and adjusting both the strategy to achieve the aim and its execution, based on weekly and monthly review of measures.

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)33

Leadership Leverage Points Action Needed / Action Planned By Whom By When

4. Put Patients and Families

on the Improvement Team

Patients and families are deeply involved in all improvement and redesign teams.

Each member of the senior executive team is engaged and committed to achieving the aim, and views this as part of his or her core work.

Leadership Leverage Points Action Needed / Action Planned By Whom By When

3. Channel Leadership

Attention to System-Level

Improvement

Senior executives personally do executive reviews with key project teams working on the aims.

Measures of progress on each project, and on the overall aims, are widely distributed throughout the organization and the community, even if you aren’t proud of the measures (transparency).

Leaders are given sufficient time to work on key projects (the work is not just added on to an already busy schedule).

34Institute for Healthcare Improvement Cambridge, Massachusetts

Leadership Leverage Points Action Needed / Action Planned By Whom By When

5. Make the CFO a Quality

Champion

CFO can articulate the business case for each improvement initiative and is a primary driver of quality improvement.

Finance representatives are integrated into improvement project teams to support the business case needs.

When times are tough, we invest more in quality since it is our primary strategy for removing waste and improving efficiency.

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)35

Leadership Leverage Points Action Needed / Action Planned By Whom By When

6. Engage Physicians

The executive team understands and shares the medical staff ’s intrinsic motivation for quality (outcomes, wasted time…).

The medical staff are regarded as partners in the delivery of care, not as customers of the hospital.

There is a clear plan for devel- oping physician engagement that recognizes the multiple “segments” of the physician staff (champions, structural leaders, others).

We use quality methods that encourage physician engagement in quality rather than drive them away (sensible use of data, make the right thing easy to do).

Executive, physician, and nurse managers are confident of support all the way to the board level, and have the courage to engage physicians in difficult conversations and avoid “monovoxoplegia” (paralysis by one loud voice).

Capable physician leaders have been appointed to each project, and are supported with good data and analytic resources.

36Institute for Healthcare Improvement Cambridge, Massachusetts

Leadership Leverage Points Action Needed / Action Planned By Whom By When

7. Build Improvement

Capability

The entire senior leadership team (including CEO and senior managers) knows and uses the technical and change leadership knowledge required to achieve the aims and execute the strategies:

• Content knowledge for each strategy

• Model for Improvement and rapid tests of change

• A coherent improvement strategy

• Scale and spread • Reliability science • Flow management • Safety systems

The senior leadership team can, and does, teach the technical and change leadership knowledge to others in the organization.

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)37

References

1 Institute for Healthcare Improvement 5 Million Lives Campaign. Getting Started Kit: Governance Leadership “Boards on Board” How-to Guide. Online information retrieved February 19, 2008. http://www.ihi.org/nr/rdonlyres/95eadb8f-3ad6-4e09-8734-fb7149cfdf14/0/boardhowtoguide.doc.

2 Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Results/WhitePapers/EngagingPhysiciansWhitePaper.htm.

3 Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Results/WhitePapers/ExecutionofStrategicImprovementInitiativesWhitePaper.htm.

4 Carlile PR, Christensen CM. Practice and Malpractice in Management Research. Working paper; January 2005. Online information retrieved February 19, 2008. http://deming.ces.clemson.edu/pub/den/files/theory_paper_final_jan_06.pdf.

5 Provost L, Miller D, Reinertsen J. A Framework for Leadership of Improvement. Cambridge, Massachusetts: Institute for Healthcare Improvement; February 2006. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/Leadership/EmergingContent/AFramew orkforLeadershipofImprovement.htm.

6 Martin LA, Nelson EC, Lloyd RC, Nolan TW. Whole System Measures. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Results/WhitePapers/WholeSystemMeasuresWhitePaper.htm.

7 Tapscott D, Ticoll D. The Naked Corporation: How the Age of Transparency Will Revolutionize Business. New York, New York: The Free Press; 2003.

8 Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic review: The evidence that publishing patient care performance data improves quality of care. Annals of Internal Medicine. 2008;148(2):111-123.

9 Jha AK, Li Z, Orav EJ, Epstein AM. Care in US hospitals—the Hospital Quality Alliance Program. New England Journal of Medicine. 2005;353(3):265-274.

10 Isgett D. Keynote presentation at The Queen’s Medical Center Conference on Quality and Patient Safety, Honolulu, Hawaii. February 24, 2007.

http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/Leadership/EmergingContent/AFrameworkforLeadershipofImprovement.htm

38Institute for Healthcare Improvement Cambridge, Massachusetts

11 Personal communication with James Conway, MS, Senior Vice President, IHI, and former Executive Vice President and COO, Dana-Farber Cancer Institute. October 10, 2007.

12 Personal communication with John Hubbe, PharmD, JD, Vice President Medical and Legal Services, Delnor-Community Hospital. January 25, 2008.

13 Reinertsen J. Idea 3: Put a Face on the Problem, Starting at the Board. Online information retrieved February 19, 2008. http://www.reinertsengroup.com/publications/Improvement-Ideas/idea-3-face-on-the-problem.html.

14 Strategies for Leadership: Advancing the Practice of Patient- and Family-Centered Care. American Hospital Association and the Institute for Family-Centered Care; September 2004. Online information retrieved February 19, 2008. http://www.aha.org/aha/content/2005/pdf/resourceguide.pdf.

15 Reinertsen J, Schellekens W. 10 Powerful Ideas for Improving Patient Care. Chicago, Illinois: Health Administrative Press with the Institute for Healthcare Improvement; 2005.

16 Norling R. Keynote presentation at the CEO Summit, Institute for Healthcare Improvement National Forum, Orlando, Florida. December 11, 2007.

17 Nolan T, Bisognano M. Finding the balance between quality and cost. Healthcare Financial Management. 2006 Apr;60(4):66-72.

18 Going Lean in Health Care. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2005. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm.

19 Personal communication with Donna Isgett, Vice President for Clinical Effectiveness, McLeod Health. December 2007.

20 Personal communication with David Wessner, CEO, Park Nicollet. June 2006.

21 Toussaint J. Presentation at the Institute for Healthcare Improvement Executive Quality Academy, Boston, Massachusetts. June 2006.

22 McVay G, Cooke DJ. Beyond budgeting in an IDS: The Park Nicollet experience. Healthcare Financial Management. 2006 Oct;60(10):100-102.

23 The Model for Improvement. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/.

24 Spear S, Bowen HK. Decoding the DNA of the Toyota Production System. Harvard Business Review. September 1, 1999.

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)39

25 Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston, Massachusetts: Institute for Healthcare Improvement; 2004. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliabilityofHealthCare.htm.

26 Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. IHI Innovation Series white paper. Boston, Massachusetts: Institute for Healthcare Improvement; 2003. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Results/WhitePapers/OptimizingPatientFlowMovingPatientsSmoothlyThroughA cuteCareSettings.htm.

27 Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C. A Framework for Spread: From Local Improvements to System-Wide Change. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Results/WhitePapers/AFrameworkforSpreadWhitePaper.htm.

28 Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006. Online information retrieved February 19, 2008. http://www.ihi.org/IHI/Results/WhitePapers/LeadershipGuidetoPatientSafetyWhitePaper.htm.

http://www.ihi.org/IHI/Results/WhitePapers/OptimizingPatientFlowMovingPatientsSmoothlyThroughAcuteCareSettings.htm

20 University Road, 7th Floor

Cambridge, MA 02138

(617) 301-4800

www.ihi.org

White Papers in IHI’s Innovation Series

1 Move Your Dot™: Measuring, Evaluating, and Reducing Hospital Mortality Rates (Part 1)

2 Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings

3 The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement

4 Improving the Reliability of Health Care

5 Transforming Care at the Bedside

6 Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)

7 Going Lean in Health Care

8 Reducing Hospital Mortality Rates (Part 2)

9 Idealized Design of Perinatal Care

10 Innovations in Planned Care

11 A Framework for Spread: From Local Improvements to System-Wide Change

12 Leadership Guide to Patient Safety

13 IHI Global Trigger Tool for Measuring Adverse Events

14 Engaging Physicians in a Shared Quality Agenda

15 Execution of Strategic Improvement Initiatives to Produce System-Level Results

16 Whole System Measures

All white papers in IHI's Innovation Series are available online at www.ihi.org and can be downloaded at no charge.

A Framework for Leadership of Improvement 1

A Framework for Leadership of Improvement

February 2006

In Crossing the Quality Chasm, the Institute of Medicine (IOM) has set forth a vision of a 21st century health care system that performs dramatically better than current benchmarks.1 The IOM envisions a care delivery system that delivers theoretically ideal care, across six dimensions of quality, for all conditions. The contrast between this vision and the present reality is stunning. Even the best of our current health care organizations approach the ideal in one or two quality dimensions, for one or two conditions, only some of the time. Such a dramatic change in health care delivery systems will not be brought about by a simple project-by-project approach, using the same organizational structures that have produced the current levels of performance. Rather, this transformation will require rebuilding our leadership systems to focus the organization on improvement. It is our purpose in this document to outline a framework for a system of leadership that could successfully accomplish the IOM challenge of delivering ideal care. This framework for leadership of improvement can be useful in several ways:

• As an organizing structure to understand how the various work activities of health care leaders contribute to the broad aim of transformation and improvement of the care system.

• As an ongoing learning tool, to be contributed to and modified by participants in Institute for Healthcare Improvement (IHI) networks, projects, and initiatives

• As an aid for health care leaders to assess and improve their organizations • As a guide for the design of leadership development programs in health care

organizations A Framework for Leadership of Improvement We propose the following basic framework for building a leadership system capable of meeting the IOM challenge (see Figure 1)… The primary function of leaders in health care is to influence their “followers” to develop behaviors, habits, processes, and technologies that result in dramatically improved performance. This influence can be thought of as a combination of “Push” (making the status quo uncomfortable) and “Pull” (making the future attractive). The influence comes about through a variety of five leadership activities, as described below.

A Framework for Leadership of Improvement 2

Figure 1. A Framework for Leadership of Improvement

1. Establish the Mission, Vision, and Strategy: Use the organization’s mission, vision, and strategy as a relentless drumbeat to communicate the direction of the organization to all stakeholders while maintaining constancy of purpose. It will be critical to obtain and maintain the long-term support of the governing board if constancy of purpose is to be achieved. 2. Build the Foundation for an Effective Leadership System: The extraordinary aims of the IOM vision will require extraordinary leaders, as well as an extraordinary level of alignment and teamwork among those leaders. The framework requires the care system to choose and align a leadership team capable of this transformational task. That team, in turn, must reframe operating values, develop a broad cadre of leaders throughout the organization, and establish exceptional levels of improvement capability. 3. Build Will: The challenges of the IOM Dimension described above will engender significant resistance, hesitance, and second-guessing. The leadership framework requires leaders to prepare the organization for change; generate discomfort with the status quo; make the vision of the future attractive; and create and sustain the commitment for improvement in all areas of the organization. 4. Generate Ideas: The IOM challenge of delivering ideal care will not occur using the same thinking that led to the present state. Knowledge management systems must be designed to listen to patients and other stakeholders and turn their communications into ideas for change. In addition to investing in internal research and development, leaders will also need to find new ideas by reading and scanning widely to learn from other industries and disciplines outside of health care. .

Making the status quo uncomfortable Making the future attractive

Leadership for Improvement

Will Ideas Execution

Foundation

Set Direction: Mission, Vision and Strategy

PULL PUSH

A Framework for Leadership of Improvement 3

5. Execute Change: Ultimately, nothing will occur without solid execution of needed changes. The organization undergoing transformation will need to have in place a solid model for testing, adapting, and implementing new ideas in the systems of care. This will require the organization to possess exceptional capacity for improvement, project management skills, and highly disciplined methods for design and redesign of the structures, processes and services needed to implement, sustain, and spread the good ideas. Building the System The leadership framework is presented in different ways and at different levels of detail in an effort to provide a variety of ways of understanding the leadership role in organizational transformation. Figure 2 adds more detail about the 26 specific components for each five key activities of the framework. Figure 2. A More Detailed View of a Framework for Leadership of Improvement

PULL

PUSH

1. Set Direction: Mission, Vision and Strategy

Make the status quo uncomfortable

Make the future attractive

3. Build Will • Plan for Improvement • Set Aims/Allocate Resources • Measure System

Performance • Provide Encouragement • Make Financial Linkages • Learn Subject Matter • Work on the Larger System

5. Execute Change • Use Model for Improvement

for Design and Redesign • Review and Guide Key

Initiatives • Spread Ideas • Communicate Results • Sustain Improved Levels of Performance

4. Generate Ideas • Read and Scan Widely, Learn from

Other Industries and Disciplines • Benchmark to Find Ideas • Listen to Customers • Invest in Research and Development • Manage Knowledge • Understand the Organization as a

System

A Framework for Leadership of Improvement

2. Establish the Foundation • Personal Preparation • Choose and Align the Senior

Team

• Build Relationships • Develop Future

Leaders

• Reframe Operating Values • Build Improvement Capability

A Framework for Leadership of Improvement 4

While the detailed view of the leadership framework lists the specific components that leaders of improvement must engage in, it fails to depict the critical linkages between these detailed activities. Ultimately it is the integration of these components to work together as a system that will accomplish the IOM challenge of delivering ideal care. . Figure 3 depicts the 26 leadership components as key processes that link together to form a system of improvement. This representation of the leadership framework as a system of interrelated processes more accurately reflects how the framework can be used within an organization. As leaders build this system of improvement it is critical to work on the linkages between processes, as well as the specific improvement processes themselves. Figure 3. The Leadership Framework as an Integrated System

Changing the old and communicating the direction

Building a System of Leadership for Improvement PULLPUSH

Planning for

Transformation Measuring

System Perform-

ance

Strategic Benchmarking

Setting Aims/ Allocating Resources

Making Financial Linkages

Learning Subject Matter

Listening to Customers

Understanding the Organization as a System

Set Direction: Mission, Vision and Strategy

Communicating Results

Reviewing and Guiding

Key Initiatives

Using a Model for

Improvement to

Design and Redesign

Spreading Ideas

Reframing Operating Values

Personal Preparation

Building Improvement Capability

Building Cooperative Relationships

Choosing and Aligning the Senior Team

Investing in Research & Development

Providing Encouragement

Sustaining Improved Levels of Performance

Wide Reading and scanning, learning from other industries and disciplines

Knowledge Management

Working on the Larger System

Developing Future Leaders

The Activities of Leaders of Improvement The purpose of the leadership framework is to produce a shared mission, vision, and values, along with the necessary will, ideas and organizational processes to accomplish the IOM challenge of delivering ideal care. The 26 specific component of the framework are organized

A Framework for Leadership of Improvement 5

into the categories of setting direction, building the foundation, creating will, generating ideas, and executing change. For simplicity, the component processes are described below at the organizational level, but can readily be translated to the other levels (divisions, departments, hospitals in a system, etc). Although it is useful to describe these activities one by one, they clearly form a system of leadership, and so it is somewhat artificial to parse them into separate individual items. It is how they are woven together in any particular organization by its leaders that make an effective system of leadership for improvement.

1. Set Direction: Establish Mission, Vision, and Strategy • Develop written statements of purpose of the organization, including consideration of

mission, values, vision, and strategic objectives that incorporate quality as a core strategy. • Communicate this purpose to all stakeholders. • Relate the work of different parts of the organization to the purpose. Use these purpose

statements to guide and focus business planning. • Use the vision to form strategies and align improvement activities • Align any organization incentives with the purpose. • Build education and employee development programs around the purpose. • Visibly use the purpose statements to make key organizational decisions.

2. Establish the Foundation for an Effective Leadership System

Reframe Operating Values • Define the desired culture through a set of principles, beliefs, values, tenets, or doctrine

that describes how the organization should conduct itself while accomplishing its mission.

• Incorporate quality as a strategy and the new health care environmental rules: o Use all the science we know as a profession. o Patients are the center of care and get all the control they want. o Think and act to optimize the system. o Cooperate and collaborate.

• Introduce and explain all change within the context of these operating values. • Address critical issues that may be related to the understanding and acceptance of the

stated values. • Change policies that are not consistent with the operating values. • Use the statement of operating values as the foundation for policy and statements about

safety, environment, ethics, quality, etc. • Model these operating values in all leadership and management activities. • Get feedback on the performance of the senior leadership team relative to the values.

A Framework for Leadership of Improvement 6

Develop Future Leaders • Create a process for identifying future leaders of the organization. • Create a formal development process that includes mentoring and rotation of

assignments. • Provide the opportunities for future leaders to participate in formal improvement

initiatives. • Schedule all leaders to participate in leadership development curriculum. • Consider support of the organization values as well as performance and results when

evaluating employees and medical staff for leadership positions.

Choose and Align the Senior Team • Strive to have the senior leaders of the organization work together as a high performance

team. • Modify the composition of the leadership team, if necessary, to embody the desired

operating values. • Develop a senior leadership team with the right balance of skills, healthy relationships,

and deep personal commitment to achievement of the organization’s purpose.

Build Relationships • Consciously build effective relationships among the employees and other key

stakeholders in the organization • Use the values statement and other components of the purpose to create commonality

among groups in the organization. • Integrate the medical staff with the leadership team. • Encourage the leadership team to participate in community activities. • Share information openly across all departments. • Support with key suppliers (staff, equipment, supplies, pharmaceuticals, payers, etc.) on

improvement initiatives.

Build Improvement Capability • Target development of improvement capability to all members of the senior team.

Consider: sponsorship of improvement initiatives, one, connecting to leaders outside the organization, external courses, new employee training, site visits, peer mentoring.

• Develop a strategy for the role of managers and supervisors in improvement initiatives. • Integrate development of improvement skills with the overall HR development plan. • Use participation on improvement teams as part of the development of all employees. • Develop internal capability in all aspects of the science of improvement.

Prepare Personally • Make a conscious decision whether or not to invest personal reputation and energy into

leading the effort to address the IOM challenge of delivering ideal care. • Master the core competencies of a leadership development program. • Ask for feedback and coaching to improve individual effectiveness. • Create a personal improvement plan and align personal goals with the organization’s

A Framework for Leadership of Improvement 7

vision. • Serve as a mentor for potential leaders.

3. Build Will Plan for Improvement

• Translate the organization’s purpose to action by developing a credible set of strategies, plans, and budgets that will drive organization success.

• Integrate planning for improvement into strategic and business planning processes to create an effective system for planning.

• Summarize inputs from research, feedback, benchmarking, marketing, the external environment, and new ideas.

• Based on these inputs, develop (or update) strategic objectives that could best accelerate the performance of the organization.

• Develop a priority list of the processes and services to design or redesign. • Establish improvement charters to address the high priority processes and services and

allocate resources. Set Aims and Allocate Resources

• Deploy the organization’s plan for improvement by chartering and staffing improvement initiatives.

• Establish aims to accomplish the improvements that can be resourced and managed. • Create charters to describe the scope of improvement initiatives based on the

improvement plan. • Include goals for initiatives that reflect the best performing systems in each are of care. • Expect all staff to participate in improvement activities. • Appoint members of the medical staff to support improvement initiatives and provide

release time. • Provide sponsors for the key improvement initiatives.

Measure System Performance • Guided by your mission and business strategies, establish the key measures of

performance of the system. • Balance the measures from the perspectives of customers, finance, operations, and

employees. • Display these measures as run charts in management reports and public documents. • Learn how the organization is executing its strategy and how it functions as a system

through study of these measures. • Align division and department measures with system performance measures. • Expect individuals and teams to use system performance measures in their improvement

work.

Provide Encouragement • Change negative statements into positive ones.

A Framework for Leadership of Improvement 8

• Routinely show appreciation for effort and results. • Accept people where they are and work with their strengths. • Treat people at all levels of the organization with respect. • Work to ensure that important interactions (e.g., board meetings) add rather than subtract

energy from the individual or the improvement team. • Use project designs that build in encouragement and reinforcement:

o Divide large projects into smaller ones (e.g. projects designed to cut the performance gap in half, rather than completely close the gap.).

o Assign tasks that are slightly beyond current capabilities and show confidence in the team or individual.

o Promote learning from Plan, Do, Study, Act testing on a small scale.

Make Financial Linkages The broad aim of improving value of any product or service can be divided into three sub aims suggested by Noriaki Kano:

1. Eliminate quality problems that arise because expectations of customers are not met 2. Reduce costs significantly while maintaining or improving quality 3. Expand customers’ expectations by providing products and services that they perceive as

unusually high in value In health care category 1 aims include decreasing adverse events, delays, and billing errors. Aims in category 1 are the ones that are frequently pursued in improvement efforts in health care. Many health care organizations are becoming skilled at acknowledging and finding quality problems, measuring their frequency, and engaging doctors, nurses, and other clinicians in reducing these defects. It is less clear how to determine whether the reduction of these defects provides a financial gain for the organization in the short run. What has been referred to as “the business case for quality” often is a search for a side effect of reduction of costs resulting from the reduction of defects. Category 2 aims seem to be less prevalent in health care. The prevailing culture among clinicians often results in conflict when executives propose category 2 aims. Even when the aims are pursued, improvement teams usually produce potential savings, for example less wasted time, rather than actual cost savings, less overtime wages. Converting potential cost savings into actual cost savings requires processes that executives and financial expects must operate. Deliberate intention to establish aims in category 2 will support our overall portfolio of work. An aim of reducing 1-3% of total organizational expenses is a level of performance which comes from benchmarking organizations inside and outside of health care which consistently reduce costs through redesign. Category 3 aims can be achieved by more convenient services such as email correspondence with doctors, shared internet health records, or very convenient access to care. Traditionally category three aims have been achieved by medical breakthroughs such as drugs for AIDS or laser eye surgery. In a system of health care that is not population based the gains in revenue

A Framework for Leadership of Improvement 9

associated with achieving category 3 aims are often associated with increased costs for some other part of the system or for society. Organizations Linking Financial improvement with their quality portfolio will:

• Adopt a balanced strategy using each of the Kano’s categories of improvement • Establish clear accountability within the leadership team for quality and the bottom line. • Assign financial specialists to partner with the improvement leader to plan and track

financial impact • Ensure that no major improvement is made without an analysis of the impact on the

patient and the business, and make sure that predictions are reviewed by clinical and financial staff

• Define a reinvestment strategy: clinical , ser vice and systems, great work environment, IT/HR, bottom line

• Communicate how financial performance is related to the fulfillment of improvement aims

Learn Subject Matter • Personally learn the subject matter that is driving key change initiatives, including

understanding of the principles and science of flow, safety, and reliability, and patient- centered care.

• Personally study, and in some cases master, new design principles for major organizational improvement initiatives.

Work on the Larger System

• Manage the connections between your organization and the broader health care system. • Focus system performance measures on the population of the entire community the

organization serves, and not just on the organization’s patients. • Become involved in setting health care policy through participation on committees in

government and professional organizations. • Bring payers, purchasers, and regulators into the organization to meet directly with the

board of directors and staff. • Share all of the organization’s performance data on cost and quality with staff, the board,

and the community. • Obtain board commitment to quality as the strategy, and maintain board attention on

overseeing the work of transformation. • Use the media to make visible, public statements of the organization’s intent to transform

to dramatically higher levels of performance. • Recruit board members who will challenge and push the organization on quality and

value performance. • Create external systems that enhance the business case for quality. • Use public measurements of performance to create internal pressure for improvement. • Work with payers and regulators to establish payment and regulatory models that drive

the transformation rather than inhibit it.

A Framework for Leadership of Improvement 10

4. Generate Ideas

Read and Scan Widely, Learning from Other Industries and Disciplines • Find great prototypes, either inside or outside of health care that can be adapted. • Send individuals to attend meetings and conferences and expect them to bring back ideas

for change. • Schedule group visits for leaders to other industries outside of health care at least once

per year. • Formalize organizational surveillance of scientific developments that can lead to ideas for

change.

Benchmark to Find Good Ideas • Identify best practice industries and organizations for issues similar to those your

organization is facing. • Study performance data to learn the best performing organizations in each are of health

care. • Encourage individuals to visit other organizations to look for great ideas for change. • Assign champions to new ideas to develop them into improvement initiatives within the

organization. • Assign the responsibility for “finding new ideas” to an individual or group.

Listen to Customers (patients) • Identify the current and future patients of the organization and group them into

appropriate segments (such as disease types, payers, geography, etc.). • Develop a system to gather information about patients’ needs, satisfaction, and loyalty in

each segment. • Develop systems to gather information connected to the organization’s purpose from

suppliers, employees, and the marketplace. • Communicate this information to all parts of the organization at appropriate times • Analyze information from patients to guide planning and improvement efforts.

Invest in Research and Development • Allocate resources for research and development. • Connect the research agenda to the organization’s strategic objectives. • Report on R&D results in the planning process each year.

Manage Knowledge • Maintain a system (i.e., knowledge warehouses) to organize the ideas for improvement

the organization possesses. • Emphasize knowledge sharing in the culture of the organization. • Develop systems to capture and disseminate tacit knowledge from individuals.

Understand the Organization as a System • Understand the major processes and services in the organization.

A Framework for Leadership of Improvement 11

• Prepare system maps to show how these processes link together to form a system. • Use these system maps and other aids to learn how the organization functions as a

system. • Develop a deep understanding of the system to guide planning and improvement

initiatives. • Use understanding of the system and its dynamics to organize information and

knowledge.

5. Execute Change

Use an Improvement Model for Design and Redesign • Select a standard approach (an “improvement model”) to execute change in the

organization. • Train all employees and other stakeholders in the model and basic methods for

improvement. • Encourage use of the model for everyday improvements as well as major design and

redesign efforts. • Redesign status reports to be consistent with the model for improvement.

Review and Guide Key Initiatives • Frequently review progress of major change initiatives and improvement projects in

senior operations meetings. • Maintain knowledge of all important projects and meet with improvement teams at

regular intervals. • Remove obstacles for improvement teams and provide recognition of their work. • Acknowledge that failures that occur as part of tests of new ideas are expected and

accepted, as long as learning results from them. • Study the activities of the team to learn about the key processes in the organization and

the key forces driving the system. • Redirect and redeploy resources as improvements are made.

Spread Ideas • Formalize processes to support the transfer of ideas for change throughout the

organization. • Understand the social networks in the organization and identify opinion leaders that can

help spread changes. • For targeted ideas, name a “spread champion” and provide him or her with resources and

authority to implement the ideas. • For key spread initiatives, create a matrix of the components of targeted changes to track

the rate and extent of spread throughout the organization.

Communicate Results • Hold meetings across departments to share improvement activities and exchange ideas.

A Framework for Leadership of Improvement 12

• Develop formal communication processes to gather and share information and results

from improvement initiatives. • Share performance data with all staff. • Create verbal descriptions on graphs of key system performance measures to describe the

impact of improvement initiatives. • Communicate openly to the larger community about your results and progress.

Sustain Improved Levels of Performance • When improvements are made, also make it difficult to revert to old processes. • Establish and document standard processes to accommodate the improvements and

support the spread of improvements throughout the organization. • Incorporate new measures of performance into the organization’s system performance

measures. • Update organization audits to include review of the new process standards. • Incorporate the changes into job descriptions and new employee training.

References: 1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

IHI Framework for Leadership Improvement

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