HIGH-IMPACT LEADERSHIP: DEVELOPING CORE LEADERS
M12 Monday, December 5, 2016
Objectives:
1. Gain an in-depth understanding of four Core Leadership Competencies
2. Apply practical insights to developing their core leaders and teams
3. Can describe new behaviors critical to the practice of leadership “in the middle”
8:30-9:00
Introductions and Overview
9:00-10:15
Managing the Work
10:15-10:30
Break
10:30-12:00
Improving the Work
12:00-12:45
Lunch
12:45-2:00
Build Team Capability
2:00-2:45
Shape Team Culture Part 1
2:45-3:00
Break
3:00-3:45
Shaping Team Culture Part 2
3:45-4:00
Q&A and Building Your Plan
Case Study: Managing the Work at Orlando Health rev.11.14.16
Background: In the recent 18-24 months, Orlando Regional Medical Center (ORMC) began
implementation and organizational spread of unit/departmental based strategy and process
improvement boards called Gemba boards (“Gemba : A Japanese word meaning the ‘actual place’, used
for the place where the work is done, such as an exam room, the laboratory, an operating room, or the
cafeteria”( Imai, 2012, p. 62)). Each unit/department reflects the same strategic imperatives that the
administration’s board displays. Consequently, the administration board is a reflection of strategic
imperatives that have been established by the Board of Directors and senior leadership. The difference
lies in the depth of the process improvements that are reflected on each board. Any team member or
leader can complete an idea ticket and submit to the boards. This case reflects one such idea, where the
frontline sees the opportunity for a process improvement that could have a major impact on more than
one strategic imperative.
A Case for Innovation at the “Middle”: Chris is a Physical Therapist and the supervisor for acute care
therapy. Chris heard many discussions and brainstorming sessions by his own manager and the Chief
Operating Officer related to spending money to make money and how we can decrease length of stay.
As part of Chris’s development for further leadership roles, his manager never hesitated to encourage
her team to try new things that would improve care and save money.
Chris had observed multiple patient discharge delays that were due to durable medical equipment
(DME) arrival times. Patients often waited hours for discharge because the outside DME Company could
not deliver the required walkers, wheelchairs, or commodes until the next day. It was shown to have
extended patient stays for several hours and many times overnight.
Chris gathered data for two weeks, looking at the resources tied into obtaining the needed DME and the
cost of the bed being utilized by a patient who was ready for discharge but was only waiting on a piece
of equipment. The nurse manager for the Ortho unit worked with Chris to develop an idea ticket. It was
clear that their project would require buy-in from the administration team. Chris and the nurse
manager brought their ticket to the weekly administration strategy board huddle and presented their
idea when it was their turn. Administration was supportive and excited at the team time. They were
watching the first big process change idea come from the front line team.
Chris enlisted discharge planners, nurses, and care coordinators to work with him as a team to solve the
problem. Chris learned through his own research that we would not be able to obtain our own DME
supplies for patients and just give it away (it costs less to give away a $32 walker than to hold a bed) due
to certain laws.
Chris then ventured out by calling the Center for Medicare Services (CMS) on his own. Through his
discussions with CMS, he learned of a way that our organization could partner with a current vendor of
orthopedic supplies and maintains certain DME at the hospital. The order for that DME would then be
coordinated between the hospital and the orthopedic supply company on discharge. The outside
company would then make the appropriate contacts for approval of providing certain DME and the
permission to bill insurance.
Case Study: Managing the Work at Orlando Health rev.11.14.16
Chris created metrics that are being used to verify the success of this new process. He measures the
financial impact of the decrease in length of stay on the Ortho unit and patient experience scores
specific to discharge on Ortho.
While Chris and the team work toward slight modifications in the process and recording the “lessons
learned”, the ultimate end goal will be a sustainable process that can better serve other patient
populations within ORMC and other Orlando Health hospitals.
Activity:
-
List the 5 components of “Manage the Work” as described by Pugh and Munch (2016).
Now, identify examples of these components in practice within this case.
Case Study: Orlando Health Imaging Council-Improve the Work
Background: A problem was identified relative to the timeliness of approved report availability for imaging studies. This
had long been a challenge in our organization and was impeding our ability to excel in areas of length of stay,
throughput, patient experience and physician satisfaction. All of these impact components needed consideration as we
structured a process improvement activity that would provide sustainable results. Several disciplines including imaging,
transcription, nursing, IT, risk management, and physicians were identified as key stakeholders and each had a different
perspective as to what the real obstacles were and why they existed. In essence, we lacked an appreciation or
understanding of what each discipline was experiencing as a result of the problem and therefore, the culture was lacking
with respect to collaboration, support, patience and team mindedness. We needed a means of accountability through
standardization and clarity of responsibility. Ultimately, we were failing to meet the needs of our patients and our
physicians.
Initiative: It is relevant but not surprising that considerable change was occurring in tandem with the problem that had
been identified. However, the imaging managers and supervisors recognized the need to prioritize this particular
problem. To be candid, they were frustrated with the feedback that was being given regularly from other areas in terms
of not having timely critical information about their patients. At the root of the problem was the need for a technology
that would allow our physician to interpret studies using voice recognition and self-editing, however even with the
technology we had significant hurdles with respect to old processes and policies that did not align with what we
identified as our future state. We needed buy-in from all stakeholders to ensure a successful transition from the current
to future state which included our physicians, technologists, administration and others.
The managers recognized that the amount of change involved would require everyone on the team to understand the
end goal and to understand their role in helping to achieve it.
Throughout the process leadership recognized the need to evaluate processes that were impacted as a result of this
change and to develop subsequent plans of action to support the overarching goal of reducing time to a final approved
interpretation. The action plans were critical tools in ensuring progress. We established regular meetings with the key
change agents and reviewed our progress on a regular basis. Superusers were identified by the managers and were
provided the time and training necessary to be able to effectively support the in that role. The managers met with the
superusers regularly and provided guidance and support. Checklists and reports were crafted that provided a means for
the team to understand the progress being made ( see data provided). Physician ownership of the process was
paramount but so was compliance by the imaging team of the standardized work that had been redesigned as a result of
the new workflow. The reports were used to understand where and when fallouts were occurring and a weekly call was
established to discuss the orders that had been entered and completed and were missing approved reports. Physician
leaders were informed of compliance with the new process and were responsible for addressing individual physicians
who may have been identified as non-compliant.
Report out to senior leadership through the Allied Health Executive Council ensured a consistent focus on the priority
and to help remove barriers that were identified by the Imaging Council as they progressed through the initiative.
The team worked together to change a process that involved several disciplines, had endured significant workarounds
and was outdated. The results were remarkable in that they were consistent and sustainable. Consequently, the
managers identified the opportunity to further drill down to a specific area (see example slide#2). While improvement
had been made overall, there was opportunity for further collaboration and focus in the emergency department where
efficiency is essential. The managers continue to apply the skills they learned and refined as a result of this process and
are confident in their approach for the next opportunity.
Data:
Preliminary Radiology results available in PACS within
1 hour of order: Orlando Health Process Improvement
FY 2014 - 2015
45
40
AVERAGE MINUTES
35
30
25
20
15
10
5
0
Ma
Ma
Ma
Ma
Jun Jul Aug Sep Oct
Apr
Feb
Apr
Jun Jul Aug Sep Oct Nov Dec Jan Feb
y
r
y
r
15'
15' 15' 15' 15' -15
14'
14'
14' 14' 14' 14' 14' 14" 14' 15' 15'
15'
15'
14'
14'
Series1 42 32 29 12
9 7.2 12 14 11 8.4 10 9.6 7.1 8.5 7.4 10 8.3 10
8 8.1 9.4
Data:
Finalized Radiology Reports are available in PACS within 1 Hour of Order for ED
Lower is Better!
Plain Film (DX) Examinations CY 2016
60
MEDIAN MINUTES
50
40
30
20
10
0
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
APMC
38
32
31
38
32
32
37
34
34
DPH
41
36
36
37
37
35
35
36
37
ORMC
55
53
56
56
55
51
55
56
55
SS
46
40
37
36
35
36
33
37
35
Activity:
After reviewing the case and the above documents, the following is designed to challenge you in identifying key
components of the core leader skill sets and competencies:
1. Identify examples in this case for the following:
• Sharing vision and building will
• Modeling the way
• Promoting transparency
• Encouraging mindfulness
2. Give an example of how the imaging council could use what they learned from this case to further shape team
culture
Background: Orlando Health, established five audacious goals on its quality journey in 2011. At
the beginning of the quality journey, transparency with the board, leadership and team
members became a guiding principle. One system goal was to reduce overall harm by 80%
within five years. Medication errors was the largest category of harm events in the organization
and at each individual hospital. An interdisciplinary team was charged with studying the issues
associated with medication errors in the hospitals, reviewing the literature and data and make
recommendation to the Chief Quality and Transformation Officer and Vice President of Patient
Care. The organization has had for many years, a well-established shared leadership model in
the nursing and allied health. Engaging the team in patient safety and improvement activities
became a focus.
The nursing leadership council, nurse practice councils, pharmacy council were highly engaged
in helping the interdisciplinary team understanding the issues with support from the quality,
risk and data analytics team. Chief nursing officers from throughout the system have had, for
example, a weekly call discussing all harm events as do the allied health leaders.
Medication reconciliation, access to timely medications, independent double
verification and distractions were some of the identified drivers associated with the medication
errors. A variety of process changes occurred to make medication administration safer. The
system team recommended implementation of a barcoding system for medications as an
essential step to develop a safer accountable system for medication administration. The
success of the implementation was critical to reduce harm events.
A Case for Team Engagement
Dr. P. Phillips Hospital (DPH), one of the eight hospitals in the system was the third
hospital to implement the barcoding system. The goal was to achieve 90% medications barcoded. With each hospital implementation there were lessons learned and improvements
made. The chief nursing officer (CNO) of DPH knew the importance of a successful
implementation and created a hospital steering committee that included the nurse managers,
the hospital practice chair and co-chair, the pharmacy manager, learning specialist and nursing
administrators several months before the hospital was to go live. She charged the team with
oversight of the process, review of the policy, resources needed, communication and
engagement of the team. The steering committee was a forum for discussion, debate and
decision-making. The team visited the hospital that was implementing the barcoding system
observing the process and engaging with their peers. The CNO’s goal was to gain an
understanding the issues and challenges for the team and address safety and sustainability in
her hospital.
The team met weekly. Five weeks before the implementation at the hospital, the CNO asked
the managers and unit practice chairs to identify equipment needed including additional
computers and types of scanners based on the individual unit needs. Some units preferred
wireless scanners while other requested wired scanners. Meeting with the steering team, unit
practice council and allied health council, the CNO proposed a revision in the medication
administration policy. The proposed changes were developed to ensure that patient safety was
the focus. The policy revision addressed consequences if a team member deliberately chose to
not administer medications using the established barcoding system. There were two offenses
that would result in immediate termination including: using and carrying printed arms bands
versus using he patient’s armband and creating a work-around instead of following the
established process of scanning medications. All staff administering medication were required
to review and sign the new policy.
The unit practice council chair with the nurse manager were responsible for the
implementation and conducted shift huddles. The CNO and administrators in their weekly
rounding spent time with the listening to the staff on successes, issues and concerns. There was
weekly messaging from the CNO, reports from pharmacy and it was a regular agenda item on
the unit practice council agenda. Some staff struggled during the bar-coding system
implementation. Members of the practice council, learning specialist and nurse manager
coached and supported them as issues arose. After several months the percentages of
medication scanned met the goal and remained stable at 90-92%.
The CNO challenged the steering committee to identify ways to increase the medication
scanned to 95%. The pharmacy audit identified individuals who missed more than nine
medications scanned in a month. In some cases, it was issues with scanning labels on
prepacked medications and IV solutions and inconsistency in policy on heparin flush scanning.
Initially there was a two-page list of individuals who missed more than nine medications each.
Over the course of three months, the hospital reached 95% medications scanned and remains
there today.
Activity:
• List the 4 components of “Building Team Capability” as described by Pugh and Munch
(2016).
• Now, identify examples of these components in practice within this case.
Orlando Health: Shaping Team Culture
In 2012, the critical care team at Orlando Regional Medical Center was given a survey to
discover opportunities to unify the team. This included nurses, physicians, residents, respiratory
therapists, pharmacists, and other key clinicians. The outcomes were telling. They painted a
picture of distrust, disloyalty, leadership deficits, a lack of psychological safety, and feelings of
inadequacy and lack of appreciation.
Over the next 24 months, administration would team with physician leaders and departmental
leaders to create initiatives centered around the patient, but that would require team
cohesiveness. Team building sessions were held with team members from each area and a
shared vision was created. Promises were made in terms of proper communications and how
debriefings would take place after major incidents.
It was not without incident or minor bumps in the road, but the outcomes have been the
creation and implementation of the following patient care initiatives;
These initiatives would include;
• Evidence-based ventilator weaning guidelines
• Daily collaborative rounding and checklists
• Weekly critical care task force meetings
• Early mobility protocol
• From 8 ICU admissions order set to 1
The team has demonstrated a positive response by the most recent team member surveys. For
example, respiratory care scored the lowest at ORMC in 2013 for “teamwork across
departments”. They felt unappreciated for their expertise and a lack of trust for the physicians.
In the most recent survey, they are one of the highest scoring departments in that area.
Physician leaders have been given many leadership training opportunities and as the care team
leader, they are expected to set the best example for the other team members. The physicians
who once had adversarial relationships with the therapists, now hold successful medical
director positions. Physicians spend more time teaching and guiding the team on their
decisions, rather than directing orders without explanation and input. The goals are to have a
psychologically safe environment where honesty and integrity are paramount, for the sake of
the patient.
Activity:
Give an example from this case where each competency from Shaping Team Culture is
demonstrated.
Managing Time & Attention Exercise
How do you spend your day?
The following exercise is designed to collect data about how you currently spend your day. The
information will help you to identify what activities add value to your patients, staff, and role and
what activities do not.
Instructions: For one week, track all of the activities you do during your workday. Include the start
and stop time, a description of the activity, if the activity was planned or unplanned, and if the
activity was value added, Incidental, or waste. The following examples and operational definitions
will add you in the exercise.
Current State – How do you spend your time?
Please use the time tracking form to capture your activity data. Here is an example of how to
complete the form.
Start
Time
8:30
8:42
9:00
End
Time
8:42
9:00
9:15
Activity
Read and write email
Develop A3 for improvement project
Help staff to find medical equipment
needed for care
Source: A Factory of One, Fig. 1.3
Planned or
Unplanned
P
P
U
ValueAdded/Incidenta
l/Waste
Incidental
Value-added
Waste
Example Activities: Activities may include any of the following. The list is not all-inclusive, so add
activities as appropriate.
Meetings
Moving between
locations
Generating
reports/memos
Coaching
Phone Calls
Patient Care
Fixing problems
Customer
Communication
Emails
Dialogue with staff
Administrative Tasks
(scheduling, Payroll)
Responding to
requests
Instant Messaging
Reviewing
reports/memos
Quality Improvement
Other?
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 valueadded, incidental, or wasteful.
Value-Added:
Incidental:
Waste:
Something the customer is willing to pay for
Transform the product or service in some way
Done correctly the first time
No-value added, but necessary
No-value added, but NOT necessary
Resource: http://afactoryofone.com/wp-content/uploads/2011/11/Chapter-1.pdf
Managing Time & Attention Exercise
Type of Waste: Using one of the categories below, select the type of waste each activity is and
indicate it in the table above.
Defects (Rework)
Transporting Stuff
Over-Production
(Redundant work)
Inventory (Too Much)
Waiting
Motion (Movement of
People)
Not Clear (Confusion)
Excess Processing
Day of the week _______________________
Start End
Time Time
Activity
Planned or
Unplanned
ValueIf Waste,
Added/Incide
what
ntal/Waste
type?
Source: A Factory of One, Fig. 1.3
Resource: http://afactoryofone.com/wp-content/uploads/2011/11/Chapter-1.pdf
Managing Time & Attention Exercise
Summarizing Your Data
Add up all the hours and determine percentages of your total time for each category. Use this as a
Pareto to target opportunities improvement.
Total time
(hh:mm)
Activity Category
Top Three (3) Wastes
From the list above, what are your top three (3) wastes?
Waste Activity
Description of Waste
% of Total
Time
Type of Waste
(see
definitions
below)
Resource: http://afactoryofone.com/wp-content/uploads/2011/11/Chapter-1.pdf
Core Leader Skills and Competencies
Self-Assessment Tool
How well do I …?
Manage the Work
Low
High
Possible Follow-up Idea
1. Manage time and resources
1
2
3
4
5
_______________________________
2. Create standard work and process
1
2
3
4
5
_______________________________
3. Measure: financial, quality, customer & key processes
1
2
3
4
5
_______________________________
4. Surface and solve problems in real time
1
2
3
4
5
_______________________________
5. Engage across departmental/team boundaries
1
2
3
4
5
_______________________________
Improve the Work
Low
6. Prioritize and align to strategy and aims
1
High
2
3
4
5
_______________________________
7. Understand current state, cause and target condition
1
2
3
4
5
_______________________________
8. Learn and use improvement tools and methods
1
2
3
4
5
_______________________________
9. Reduce variation and waste
1
2
3
4
5
_______________________________
10. Get results and sustain them
1
2
3
4
5
_______________________________
Build Team Capability
Low
11. Develop competency through coaching
1
2
3
4
5
_______________________________
12. Use the whole team
1
2
3
4
5
_______________________________
13. Communicate effectively
1
2
3
4
5
_______________________________
14. Establish respect and accountability
1
2
3
4
5
_______________________________
Shape Team Culture
Low
15. Share vision and build will
1
2
3
4
5
_______________________________
16. Promote transparency
1
2
3
4
5
_______________________________
17. Model the way
1
2
3
4
5
_______________________________
18. Encourage mindfulness
1
2
3
4
5
_______________________________
19. Keep the person at the center
1
2
3
4
5
_______________________________
High
High
Page 2 of 2 Version 5.0 August 2016