Transcript Tight - WHA Quality Center

WHA Improvement Forum
For August

“Establishing the
Accountable Culture”
 
Jill Hanson & Stephanie Sobczak
Courtesy Reminders:
•Please place your phones on MUTE unless you are speaking (or use *6 on your keypad)
•Please do not take calls and place the phone on HOLD during the presentation. 1
Today’s Webinar
 The “two jobs” in healthcare
 Discovering root causes for the
lack of accountability
Agenda
 Strategies to “move” toward a
culture of accountability.
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We all have two jobs
1.The job we are hired to do
2.Improving the job we are hired to do
Because it just doesn’t
work to have others
change the work we do.
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Institutionalize Accountability
Question: Can the QI department be totally
accountable for clinical and patient outcomes?
Answer is: Yes.
IF your QI department places central lines,
administers medications, performs surgical
procedures, removes caths, hangs IVs, applies
falls/pressure ulcer/VTE interventions, etc.
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Clinical Areas & Accountability
• Clinical areas that
“do the process” are
naturally the only
people who can
effect the outcome.
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Unintended consequences
If the roles become “murky”….
• Quality is tasked with reporting and doing
• Clinical areas are too far removed from their
measureable outcomes
• Everything is a priority
• Eyes are taken “off the ball” – something is missed
• Capacity to be agile and adapt to change (i.e. new
evidence, rules and regs) is limited.
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“If you do it; you own it”
1. Are the clinical areas looking at their outcome data?
2. Are both management and front-line care giving
staff invested in the outcomes?
3. Are there ‘in process’ measures that help front-line
staff see how their daily actions impact outcomes?
4. Are physicians invested in the outcomes and
involved in the improvement?
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Identifying Root Causes
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Identifying When Improvement Stalls
You know it might be stalling when….
1. Failure to launch – never gets off the ground.
2. Gets “re-prioritized” soon after starting.
3. No complaining, questioning or discussion about the
topic – it’s too quiet .
4. Begin to notice “regression” - back to the old way.
5. Your measures don’t move or decline.
6. Team members run the other way when they see you!
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What You Might Hear
We already tried these things
This is another ‘flavor of the month’
We’re doing fine, why do we need to work on it?
I don’t know what my role is
I don’t have time to do this.
I thought (____) was going to do that
I can’t get anyone to help me
Its not my job to work on improvement
My dog ate my PDSA form
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Are these the true issues, or is
there an underlying reason?
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Typical Reasons
1. Lack of clear accountability or lack of a process to
hold people accountable.
2. Leaders don’t clearly emphasize the importance of the
improvement work during the day to day.
3. Process to move forward isn’t followed (such as PDSA).
4. No one looks at the data, or measurement isn’t even
happening  no way to see if the work makes sense.
5. Missed opportunities for coaching or getting feedback
on how it’s going.
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Key Root Cause Questions
• What?
– Determine the issue: missing data, not meeting, no progress
• Who?
– The person ultimately accountable for the project outcome
– The leader to whom the team reports
• How?
– Ask to see documentation (such as examples of small tests of
change) or data regularly
• When?
– Regularly scheduled opportunity to share data/results AND
– Just-in-time opportunities to ask
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Addressing Accountability
Taking a Tight-Loose-Tight approach to managing can
help with issue of accountability
The origin is from management guru Tom Peters. He
coined the term “Tight/Loose”
Later the other “Tight” was added which refers to
accountability for the deliverables and/or outcome.
(credited to Baldrige consultant Doug Sears)
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T-L-T Defined
Tight – What has to be done? Who is accountable
for doing it? What the parameters and
expectations are? When it should be
completed?
Loose – How it is done and who gets to participate.
Tight – Timelines and deliverables are met;
Progress is made and, if not, there are
consequences.
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T-L-T Actions
• Tight – Model the importance of improving
quality and safety; make clear who is
accountable for leading improvement and
actively participating in improvement
initiatives. Make clear your expectations for
knowing about the progress of the work. Be
transparent about limitation – financial or
otherwise.
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T-L-T Actions
• Loose –
Give advice to teams; Model
effective project management; Provide access
to resources; Assist in addressing barriers to
the work. Give the team the space to try new
things.
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T-L-T Actions
• Tight – Informally, and frequently, ask for
updates on progress; Solicit formal reports;
Arrange presentations; Ensure access to key
committees for formal reporting, sharing
proposals and updates; Insist on seeing data
• Ensure there are consequences for not
following-through
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What & Who?
How?
By When?
What you will get:
Loose
Loose
Loose
Chaos; the ‘tail wagging the dog’;
ineffective, “loose-y goose-y” workplace.
Tight
Tight
Tight
“Micro-managed” staff that seem like
they won’t work independently; can’t get
along with others; describe work as
“walking on eggshells”.
Tight
Tight
Loose
Staff work on projects and seem busy, but
no real beneficial outcome occurs (i.e.
projects that go on forever….)
Tight
Loose
Loose
Poorly executed delegation, empowering
staff handle the why, but forgetting the
outcome
Tight
Loose
Tight
Staff that know what is important, and
what is expected – and get the job done.
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The Secret Formula
Tight LooseTight
Results!
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What Is Different In This Approach?
•
•
•
•
•
Makes improvement work more real-time & real
Less “management” led and more front-line led
Greater emphasis on measuring process
Quicker decision making about changes
Emphasis on spreading change and adopting
change in weeks (not months)
• Focus on tracking improvement for sustaining
success
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The Tight-Loose-Tight Worksheet
for Managers
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Tight – Loose – Tight Worksheet
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Using the Tool - Example
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Using the Tool - Example
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Using the Tool - Example
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Using the T-L-T Tool
• Review prior to meeting with the accountable
person/s
• Use for self-coaching about T-L-T
• Not meant to be a permanent tool to use, just
to help ‘hardwire’ your management practices
around accountability.
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Institutionalizing
Accountability
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Governance & Accountability
Quality and/or Practice councils:
• Review the outcomes
• Make decisions on what are the priorities
• Communicate the priorities house wide
• Marshall the resources to do the work
Refrain from “doing the work”
• Hold clinical areas accountable for their outcomes.
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Managers Role in Accountability
• Ensure the department priorities align with
those of the hospital
• Communicate the priorities to staff & discuss
• Clearly define expectations ( ex: Is participating
in improvement a requirement of the job?)
• Support with needed resources
• Apply Tight – Loose – Tight management
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QI’s Role in Accountability
• Provide a structured approach for improvement.
• Provide access to the outcome results for the
clinical areas.
• Provide assistance interpreting those results.
• Advocate for the clinical areas needing
assistance.
• Assist with strategizing plans to take action.
• Facilitate the process of improvement.
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Next Month: September 26
Managing the Improvement
“Portfolio”
 Methods for Sustaining great
September outcomes
 Monitoring Multiple Projects
Noon
 Taking Action when Action is Needed
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References
• Quality Improvement Workbook Sections 1 and 5
• The Improvement Guide: A Practical Approach
to Enhancing Organizational Performance,
Langley, Moen, & Nolan
• WHA Quality Center Tools and Templates
http://www.whaqualitycenter.org/PartnersforPati
ents/PfPTools.aspx
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Announcements
Partners for Patients – Improvement Leader Fellowship (ILF):
• Helps staff boost their QI knowledge to better execute their HEN projects
as well as future improvement work your organization may take on.
• Beginning August 21st, two-hour webinar Fellowship sessions every two
weeks through the end of the year. These sessions will blend QI
knowledge along with the content of the 10 HEN topics.
• Low-risk/low-investment to expose staff to this material without having to
arrange travel, staff coverage, etc.
• Each session will provide CEU credits.
Questions/More Information – Contact
Travis Dollak ([email protected]) or Tom Kaster ([email protected])
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Thank You!
Questions
Please complete 3 question survey when closing
webinar window.
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