12/6/2015
Session A11
These presenters have
nothing to disclose
You Want Me
to Manage My
Ward AND Do
Quality?
David M. Williams, Ph.D.
Executive Director
Institute for Healthcare Improvement
December 8th, 2015
IHI National Forum
David Munch M.D.
Faculty IHI
Chief Clinical Officer
Healthcare Performance Partners
Who
Dave Munch, MD
Faculty IHI
Chief Clinical Officer, Healthcare Performance Partners
David M. Williams, Ph.D.
Executive Director
Institute for Healthcare Improvement
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12/6/2015
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What
• Managing Improvement at the Frontline
–Understanding and managing time
–Coaching for Development
–Improvement Methods
–Rapid learning through doing
–Measurement Approaches
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Managing
People at
the
Frontline
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Why
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How
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What’s your aim?
• What are you trying to accomplish?
• How would you know if you achieved
this today?
Big Rocks
Stephen Covey – First Things First
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First Things First
Stephen Covey – First Things First
Operational Definitions
• Planned vs. Unplanned: Planned activities are reasonably clear and
are activities you planned to do as part of your daily work at a
scheduled time or during the course of your workday. Unplanned
are activities that presented themselves to you during your
workday, but you did not predict or plan for them in advance.
• Work’s Value: Use the following operational definitions to
determine if the work activity is value-added, incidental, or
wasteful.
– Value-Added: Something the customer is willing to pay for. Transform
the product or service in some way. Done correctly the first time
– Incidental: No-value added, but necessary
– Waste: No-value added, but NOT necessary
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Subject 13
Subject 12
Subject 11
Subject 10
Subject 9
Subject 8
Subject 7
Subject 6
Subject 5
Subject 4
Subject 3
Subject 2
Subject 1
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Activity Tracking PreWork
60:00:00
Planned vs. Unplanned Time
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48:00:00
UP
P
36:00:00
24:00:00
12:00:00
0:00:00
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% Planned vs Unplanned
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100%
90%
80%
70%
60%
50%
UP %
P%
40%
30%
20%
10%
Subject 13
Subject 12
Subject 11
Subject 10
Subject 9
Subject 8
Subject 7
Subject 6
Subject 5
Subject 4
Subject 3
Subject 2
Subject 1
0%
Average Time per Type of Task
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1:26:24
1:12:00
0:57:36
0:43:12
0:28:48
0:14:24
0:00:00
VA
I
W
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% Value-Added, Incedental, Waste
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100%
90%
80%
70%
60%
%W
%I
% VA
50%
40%
30%
20%
10%
Subject 13
Subject 12
Subject 11
Subject 10
Subject 9
Subject 8
Subject 7
Subject 6
Subject 5
Subject 4
Subject 3
Subject 2
Subject 1
0%
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Tools
• Inbox Zero
• Daily/Weekly Review
• Monkey Management – Managing
the “next move”
• Meeting Management
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Inbox Zero
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Capture To Do
Items
• Electronic
• Paper-based
• Sticky Notes
The Bullet Journal
http://bulletjournal.com
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Weekly/Daily Review
• Get Clear
• Get Current
• Get Creative
• Source: The Weekly Review Booklet by
Augusto Pinaud
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Other Resources
• Markovitz, D. (2011). A factory of
one: Applying lean principles to
banish waste and improve your
personal performance.
• Thomas, M. (2012). Personal
Productivity Secrets
Root Cause Problem Solving
• How do you get to the root cause of a problem?
– You must first deeply understand the problem that you
actually have, not the one you think you have.
• What do you need to do to deeply understand the
problem that you have?
– Direct Observation, interviews, baseline measurements,
mapping.
• Once I understand the problem, how do I determine
the cause of the problem?
– RCA, 5 Whys, Fishbone diagram
• Now, I’m ready to determine the solution that will
work!
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A3 Thinking
A3 Process
Follows
Scientific
Method
Problem
Cause
Solution
Action
Measurement
Similar To
Healthcare
Familiar PDCA
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Final Comments
• There is no “perfect” A3. The goal is
communicate, solve problems, get results
• Each time you do one, you will find ways to
improve your content and format
• Be open to feedback
• Reflect and learn
• Use A3 as an opportunity to share successes
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Round 2 - Some Questions to Discuss
• What’s our current method for executing on
improvement work?
• What are the common challenges and barriers
you encounter?
• How many of your improvement efforts
produce measureable and sustainable results
you can share and spread?
The PDSA Cycle for Learning and Improvement
Act
What’s
next?
• Ready to
implement?
• Try something
else?
• Next cycle
Plan
What will
• Objective
happen if we
• Questions &
try something
predictions
different?
• Plan to carry out:
Who?When?
How? Where?
Study Do
Did it
work?
• Complete data • Carry out plan
analysis • Document
• Compare to
problems
predictions • Begin data
• Summarize
analysis
Let’s try it!
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Think About Scope & Size
Resistant
Indifferent
Ready
Cost of
failure
large
Very Small
Scale Test
Very Small
Scale Test
Very Small
Scale Test
Cost of
failure
small
Very Small
Scale Test
Very Small
Scale Test
Cost of
failure
large
Very Small
Scale Test
Current Situation
Low Confidence
that current
change idea will
lead to
Improvement
High
Confidence that
current change
idea will lead to
Improvement
Cost of
failure
small
Small Scale
Test
Small Scale
Test
Small Scale
Test
Large Scale
Test
Large Scale
Test
Implement
Langley, G.J., Nolan, K.M., Nolan, T.W, Norman, C.L., & Provost, L.P. (2009). The improvement guide: A practical approach to enhancing
organizational performance (2nd Ed.). San Francisco: Jossey-Bass. P.146.
© 2009 R C Lloyd and IHI
Repeated Use of the PDSA Cycle
Changes That Result in
Improvement
50.0
UCL=44.855
45.0
A
40.0
Number of Complaints
B
35.0
C
30.0
CL=29.250
C
25.0
A P
B
20.0
A
15.0
LCL=13.645
S D
10.0
5.0
Jan01
Mar01
May01
July01
Sept01
Nov01
Jan02
Mar02
May02
July02
Sept02
Nov02
Month
Implementation of
Change
Hunches
Theories Ideas
Wide-Scale Tests of
Change
A P
S D
Very Small
Scale Test
Follow-up
Tests
Sequential building of
knowledge under a wide
range of conditions
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How will you See your problems
• “At a Glance” Status (Huddle) Boards
– What is my performance: historically and currently?
• Data over Time
– What does it tell me about the opportunities for
improvement?
• Gaps to Target, defects, events, etc.
– What are the most important problems to work on?
• Use the Pareto Principle: What 20% of activity can give me 80% of
my improvement?
– What am I doing about it?
• MFI & PDSA’s
– What do I need to know and do today to improve patient
safety?
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Performance Board
History
Performance Over Time
“How will we know that a
change is an improvement”?
Quality/ Safety
Patient
Experience
Cost of Care
People and
Partners
Financial
Sustainability
Example:
Run Chart
Example:
Run Chart
Example:
Run Chart
Example:
Run Chart
Example:
Run Chart
Pareto
Key Drivers of Performance
“What changes can we make
that will result in
improvement?”
Example:
Pareto Chart
Issue
Background
PDSA & Problem Solving
Example
A3
Current
Condition
Root Cause
Analysis
Daily Management
Process Metric
Example:
Daily data
x x x x
Future
State/Target
Countermeasur
es
Action Plan
Test/Cost/Bene
fit
Follow-up
Example:
Pareto Chart
Issue
Background
Example
A3
Current
Condition
Root Cause
Analysis
Example:
Daily data
x x x x
Future
State/Target
Countermeasur
es
Action Plan
Test/Cost/Bene
fit
Follow-up
Example:
Pareto Chart
Issue
Background
Example
A3
Current
Condition
Root Cause
Analysis
Future
State/Target
Countermeasur
es
Action Plan
Test/Cost/Bene
fit
Follow-up
Example:
Daily data
x x x x
Example:
Pareto Chart
Issue
Background
Example
A3
Current
Condition
Root Cause
Analysis
Future
State/Target
Countermeasur
es
Action Plan
Test/Cost/Bene
fit
Follow-up
Example:
Daily data
x x x x
Example:
Pareto Chart
Issue
Background
Example
A3
Current
Condition
Root Cause
Analysis
Future
State/Target
Countermeasur
es
Action Plan
Test/Cost/Bene
fit
Follow-up
Example:
Daily data
x x x x
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Department VMB
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Coaching
• “Coaching in its truest
sense is giving the
responsibility to the
learner to help them
come up with their
own answers.”
– Vince Lombardi
Coaching: The Development of People
Timely
Active
Inquiry
Aim
Presence
Coaching
Action &
Follow-up
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The Five Elements to Coaching (Slide 1)
1. Presence: Know yourself, know your people, be in the
work
1. Observe directly to know specifically what people are doing
2. Objective - Every coach has a playbook
1. Build your Playbook: Strategic to tactical including the basics
2. If there are too many: develop rotating weekly (or monthly) schedule
3. Be specific about the coachee’s role: GRRATE
1. Goals, Roles, Responsibilities, Accountabilities, Timeframe, Empowerment
3. Timeliness: Immediate intervention is the most effective
1. John Shook - “Know normal from abnormal, and know it right now.”
The Five Elements to Coaching (slide 2)
4. Interaction: Active Inquiry
1. It is not about the right answer, it is about The Right Question
1. To Understand where they are and why they are there
2. To listen for stuck points, blind spots and build other alternatives
3. To stimulate learning, create new insights and come to
agreement
5. The Action: Advancing Performance and Development
1. What is your role in supporting and empowering the coachee: address
barriers, etc.
2. Reflect & Discuss Follow up
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Coaching vs Commanding
Routine
Urgent
Emergent
Commanding
Coaching
Where We Are
Routine
Urgent
Emergent
Commanding
Coaching
Where we need to be
The Healthcare Sweet Spot
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(High) THE FOUR LEADERSHIP STYLES
S
U
P
P
O
R
T
I
V
E
High Supportive and
Low Directive
Behavior
High Directive and
High Supportive
Behavior
S3 S2
S4 S1
B
E
H
A
V
I
O
R
Low Supportive and
Low Directive
Behavior
(Low)
High Directive and
Low Supportive
Behavior
(High)
DIRECTIVE BEHAVIOR
HIGH
D4
DEVELOPED
MODERATE
D3
LOW
D1
D2
Blanchard et al.
Leadership &
the One Minute
Manager
DEVELOPING
DEVELOPMENT LEVEL OF FOLLOWER(S)
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Levels of Development
• D1 - Low Competence, High Commitment
“Enthusiastic Beginner”
• D2 - Some Competence, Low Commitment
“Disillusioned Learner”
• D3 - Moderate to High Competence, Variable
Commitment “Reluctant Contributor”
• D4 - High Competence, High Commitment “Peak
Performer”
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The 4 Disciplines of Execution
•
•
•
•
Focus on the Wildly Important
Act on the Lead Measures
Keep a Compelling Scorcard
Create a Cadence of Accountability
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Systems: processes and interactions at all levels
Drivers
Staff
Management
Leadership
Governance
The Patient
Mainstay
Evaluation
Entry
Therapies
Transition
Support
Revenue
Cycle
HR
I.T.
Facilities
Supply
Chain
The Art of Managing Up:
Wayne Turk
• Communicate
• No surprises
• Provide solutions, not
Problems
• Be honest, trustworthy,
loyal and committed
• Understand your bosses
perspectives and agenda
• Understand your bosses
preferences
• Use your bosses
strengths, compensate for
your bosses weaknesses
• Be aware of your bosses
hot buttons
• Request feedback
• Don’t go over your bosses
head
• Understand your own
management style and
take responsibility fore its
effect on others
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The System of Continuous Improvement
Interlocking Responsibilities
Executive Leadership
“True North”
Strategy Deployment
Developing Manager
Capability (Coaching)
Provide the Systems &
Structures
Middle & Front Line Management
Front Line Staff
Execute the work
Drive Improvement
Visual Management
Standard Work aligned to
Strategy
Continuous
Improvement
and Operational
Excellence
Developing Team Members
Surfacing & Solving Problems
Taking Away Barriers
(Coaching)
Participate in Improvement
Hardwire with Standard Work Hardwire with Standard Work
(Manager)
Core Work
Initiatives
Improve Process & Performance while Developing People: “Learn by Doing”
Turn to your neighbors
• List 3 things you will do
when you go back to
strengthen your ability to
drive improvement?
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12/6/2015
Practical Improvement Science in Healthcare:
A Roadmap for Getting Results
• IHI and HarvardX have created
a free, 6-week MOOC that
starts on January 20, 2016
• Expert faculty: Don Goldmann,
Dave Williams, Don Berwick,
Karen Baldoza, and Amy Reid
• Learners have the option to
earn 6 CEUs for $99 upon
course completion
Enroll today on HarvardX or at www.ihi.org/ph556x
Who
Dave Munch, MD
Faculty IHI
Chief Clinical Officer, Healthcare Performance Partners
[email protected]
David M. Williams, Ph.D.
Executive Director
Institute for Healthcare Improvement
[email protected]
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