Keys to Leading a Performance Improvement Team

This 30 Second MBA piece featuring Kaveh Naficy, Founding Partner, Philosophy IB nicely summarizes three keys to leading a diverse team:



(1) find common ground - help them understand why a team outperforms individuals
(2) get quick wins - perhaps something innovative
(3) transfer knowledge gained to other initiatives

All of these points apply just as well to leading a performance improvement team. PI teams are by their nature multidisciplinary and diverse - often including physicians, nurses, pharmacists, case managers, quality improvement specialists, managers, executives. Many of these individuals may not be used to the team dynamic, particularly the aspect that Kaveh highlights in his brief clip - why is the team more effective than the individual. This point is worth re-emphasizing, with the specific advice that team leaders use initial team meetings to establish for the members how much more effective they will be in championing the cause together.

Getting quick wins is key to gaining further buy-in, both from the team itself, as well as from external constituents. Helping the team identify this as a specific goal at the outset will be helpful to gaining necessary momentum.

Transferring knowledge to other initiatives is not something that we may normally think about as a key to leading a team, but it makes sense when you consider that the team's success will grow when it is placed within an institutional context and they see their efforts multiplying throughout the organization.

Three excellent points, incredibly well encapsulated by Kaveh!

Performance Improvement Tip of the Day: Influencing People

Dale Carnegie's "How to Win Friends and Influence People in the Digital Age", an updated version of the "time-tested" leadership primer, lays out many simple, ayet profound concepts that apply rather well to performance improvement.



Influence is often not discussed overtly as a performance improvement tool or principle - generally bundled within "leadership" or "developing a multidisciplinary team". However, influence is clearly the key to motivating people to change behavior or processes.

Everything else we discuss in performance improvement - data, feedback, profiling, multidisciplinary team, clinical redesign - may be moot if these elements don't help in "influencing" the staff, medical staff, and leadership to support the desired change.

One of the book's chapters on "connect with core desires" delivers a particularly powerful message for how to influence people: "True change is born of an interpersonal reach that takes hold of the deepest part of an individual".

This is something that is "known" to all of us, but still manages to evade us, particularly in the plethora of media, volume of connections, and numbers of projects that we are all trying to maintain. However, the advice couldn't be more pertinent.

In the course of working on a performance improvement project, think about how to "connect with the core desires" of the staff you are trying to influence. Here are a few simple tips:

• Understand the real needs of the people: Its not just a project you're managing; its change you're advocating; change affects people; and you need to understand what they're experiencing and desiring before you can try to change it. 
• Get out to the front lines. 
• Talk to the staff, and get their opinions. 
• Include staff opinions in the design, goals, initiatives of the project. 
• Capture the stories: Data is key for building a framework, but stories have the power to influence. 
• Be sincere about what you are trying to do: You can manipulate, threaten, or cajole, but no change is more lasting than that which comes from the "core".

Leadership & Business Model Failing to Support Patient Safety & Quality

In this post by Paul Levy, former CEO of BIDMC, and staunch patient safety advocate, points out the failings of healthcare leadership in creating a culture of safety.

Juxtapose his call-to-arms with this Letter to the Editor written by the Illinois Hospital Association stating that "hospitals .. firmly believe in providing the highest level of safe, quality care to every patient" (which comes on the heels of a fairly damning report recently in the Chicago Tribune about lack of investigation about patient safety concerns at Illinois hospitals).

I can't think of any healthcare entity or practitioner who would not stand behind a statement similar to that issued by the IHA - after all its what we all believe healthcare should be about (and it is the politically correct statement to make). Healthcare institutions and leaders are not deceiving us when they say they believe in quality and safety, and that they are working towards improving these outcomes. Yet the industry is still collectively failing to meet the needs of patient safety and quality. How then do we explain the gap between "what we all believe" and "why we are failing"? I would point first to a few logical disconnects:

• belief does not equate to action
• belief does not equate to the right action
• belief does not equate to primacy of belief
• belief may not equate to sufficient action

We can justify our belief in patient safety by committing some resources to the activity, and undertaking a few choice initiatives. However, this does not necessarily lead to the outcomes that ultimately everyone is concerned about - demonstrable improvements in quality and safety, and organizations driven by the same. The rate of improvement that these activities can sustain may not even keep pace with the increasing complexity of the healthcare delivery system, which continues to yield unfortunately visible, dramatic signs of failing the patient.

As Paul Levy states, quality and safety have to be " internalized it into .. decision-making and process improvement efforts". However, this approach is also vulnerable to the following challenges:

• quality and patient safety are as yet not adequately measured
• institutional leadership is generally constrained by the rules of the industry
• societal leadership has to change the rules of the game 

If the primary objective for hospitals is revenues and volumes, healthcare executives will inevitably subjugate patient safety to these business drivers. Our healthcare institutions need to be rebuilt with the ideas of maximizing patient safety and quality first, and restructuring the business model around quality and safety. Pay-for-performance (P4P) programs, quality measurement, public reporting, value based purchasing are all initiatives that support the "quality and safety movement", however, are not sufficient to transform the industry and its leaders to "think quality first". They are seen by many within the industry at worst as "bureaucracy", "regulatory burden", "added costs", and at best as "nibbling around the edges". Attempts to measure additional dimensions of quality and to increase transparency are generally met with similar immediate reactions. The industry is not generally rushing forward to embrace and evolve into a quality-driven model. This is largely to be expected, as the current business model does not allow for the typical healthcare institution to be "built around quality".

The Accountable Care Organization (ACO) concept is generally a push in the right direction - at least it is an attempt to create more of a platform for quality while reducing the model's demand on volume for profitability. However, the dimensions of quality measurement as yet are significantly limited - is the patient's experience of safety truly measured by patient satisfaction surveys? are physicians' views about quality incorporated into the "core measures"? are nurses' concerns about safety incorporated into "hospital acquired complications"? And even though the ACO model changes the focus from "doing more for every patient" it subtly subverts the business incentive to "do as little as possible (within the limitations of measurable quality) for every patient" and "sign up more patients (through hiring more physicians) to join the ACO".

In order to drive real transformation of the industry - rather than just "payment reform" - a true "quality-driven" business model needs to be developed. As opposed to the "volume" or "frequency" turnstile, we have to develop a "quality and safety" turnstile. Quality and safety should be measured at the level of the individual patient, and drive the payment mechanism only if deemed adequate. Institutional leadership can only rise to the challenge if the rules of the game are changed at the societal level.

No Ego in Performance Improvement

This recent blog post by David Witt in Blanchard LeaderChat stimulated me to think about the role of ego in performance improvement. There are lots of authors writing about this topic recently - my favorites being Deepak Chopra's "The Soul of Leadership" - which coincidentally talks about the potential of soul-driven vs. ego-driven leadership; and Jim Collins' "Good to Great", which talks about "level 5 leaders having a unique combination of intense will combined with personal humility". 

Performance improvement is ultimately all about leadership, so one is compelled to think about the impact that ego-driven leadership can have on improvement efforts. I think the issue is the same as identified by David - ego can drive ambition and results (a la "the activated internal champion"). However, when it comes to creating sustainability, generating buy-in, and managing behavior - all critical aspects of performance improvement - its ultimately the "team-player" that wins out. 

The leader (or PI Specialist or Project Leader) who can "channel her ego" into building the following performance improvement components will not only achieve success in short-term goals, but also has a greater likelihood of sustaining the gains.

• Culture Aspects
• "No blame" 
• Feedback provided constructively
• Accountability provided fairly
• Systems Aspects
• Multidisciplinary team drives problem-solving
• Platforms for awareness 
• Forums for education 
• Channels of communication 

Let’s All Feel Superior: Individual Failures Require Leadership, Systems, and Culture to Bind

I read this op-ed piece from David Brooks in the New York Times with great interest. While talking about the Penn State scandal, Brooks identifies several fascinating psychological constructs that we use as individuals to avoid taking the "right action":

• Normalcy Bias - "shut down and pretend everything is normal" 
• Motivated Blindness - "don't see what is not in their interest to see" 
• Bystander Effect - "the more people are around to witness the crime, the less likely they are to intervene" 
• Self Deception - "we attend to the facts we like, and suppress the ones we don't" 
• Blind Spots - "when it comes time to make a decision, our thoughts are dominated by thoughts about how we want to behave; thoughts of how we should behave disappear" 

His key point is that we're in denial of "the underside of our own nature", which I would have to believe is likely true. However, as Brooks also points out "in centuries past people built moral systems that acknowledged this weakness .. they helped people make moral judgments and hold people responsible amidst our frailties." I would argue that this is the real weakness. Human nature has not changed, but society has evolved into such a complex organism such that the systems to keep "human nature in check" are not functional.

But this is ultimately what is means to be a leader - whether spiritual, political, or organizational - and to create an organizational culture: help to guide human nature - despite its many failings, blind spots, self deception, and biases - to achieve a purpose and pursue actions that no individual would undertake on his/ her own.

Many of us see these individual failings consistently in our healthcare organizations, which have largely been build around the notion that failure of behavior is an individual failing. Sometimes these individual failings are just as egregious as the examples used by Brooks when staff, managers, and executives "stand by" and allow for actions to be taken that lead to patient harm in the guise of "its just the way things work around here".

However, as many industry leaders have been pointing out - particularly the stalwarts for patient safety - individual behavior may contribute to a failing, but it is not the cause. The system (i.e., culture or society) that allows that behavior to be manifest is the cause. If we want better behavior, decisions, actions or ultimately the outcomes which result from these behaviors, then we have to work with greater diligence to build the leadership, systems, and culture that will allow individual failings to be overcome or at least held in check. The likelihood of harm is just as great, and not at all excused because the victims are sometimes unknown, or because it happens within a building and not on the street.

How to Address Cleanliness Violations at Hospital? New Building or Performance Improvement

The LA Times posted this article about UCLA Harbor Medical Center's safety violations stemming from "lack of cleanliness".

The plan for correction: "Los Angeles County is spending nearly $323 million to construct a 190,000-square-foot building at the hospital that will replace both the surgical facilities and the emergency room. "

As some of the comments to the story point out, its not all about the facility - its also about management and leadership. I've worked with organizations that have faced even older infrastructure, and yet we have improved their cleanliness with good old fashioned management and systems:

• Leadership recognized the difficult situation but resolved to address it.
• Management threw its shoulder "to the flywheel" and made it turn.
• A voluntary team of "cleanliness inspectors" toured the hospital on a regular basis and documented cleanliness of high risk areas - in a manner that could be measured, easily disseminated, and compared.
• Performance improvement systems were installed to ensure improvement:
• Pulled together a "performance improvement team" to oversee the issue.
• Measured the results.
• Made the measurement consistent and reliable.
• Disseminated the findings.
• Developed policies for cleanliness that could be adhered to by all.
• Ensured accountability by reporting on the team's findings to the governing body through the appropriate oversight committees.
• Made the "clicks of the fly wheel visible to all" by showing that some departments (that were just as resource-starved as the others) were able to make improvements.

Perhaps a new building is necessary at UCLA Harbor for many reasons, but in order to reform healthcare, we as a society have to start recognizing that adding costs (staffing, equipment, and buildings) to solve a problem are not sustainable interventions. Improving leadership, management, and systems are.


ADDENDUM 11/1/11: This story published subsequently in the Daily Breeze provides further details about a corrective action plan being put into place at UCLA Harbor. "Those fixes include a reorganization and restructuring of the hospital's infection prevention and control unit, identifying problems with the physical plant and enhancing efforts to assure staff members are washing their hands and practicing good hygiene." All of these actions appear to be appropriate, however, the key to real and sustained improvement from the "corrective action plan" is to ensure that the actions are monitored regularly, and that comprehensive performance improvement systems are implemented.

Performance Improvement Tip of the Day: Culture Drives Performance

The culture of an organization determines behavior, decision-making, and ultimately outcomes. It is "baked into the design" of every (clinical) process. Therefore, in order to improve outcomes, one must understand and shape culture. This requires intricate analysis, leadership support, and a broad enough span of time to accomplish the changes required.

Within the context of most performance improvement projects, we generally think about operating "within the cultural paradigm" of the institution, otherwise many targeted interventions may get rejected by the organization.

However, in order to achieve "breakthrough performance", the organization's culture has to be changed as it is in large part the culture that is constraining outcomes. Thus, performance improvement specialists have to be adept at gauging what "cultural change" they can successfully advocate for and implement within the course of their projects in order to lead the organization to higher-level performance.

"Culture" makes its presence felt in many subtle ways. Even in the "simple" case of implementing order sets, the following are variants of interventions that can be implemented based upon "what the organization's culture is ready to handle":

• use of order sets 
• mandating use of order sets 
• implementation of "opt out" orders 
• use of nurse or therapist-driven protocols 
• pharmacist or nurse "pulling the chain" to stop the process for any unclear orders

This blog from Ron Ashkenas on HBR Blog Network presents a nice, concise analysis of culture, its impact on performance, and a few tips on how to assess culture:

"Any management team can assess its culture by asking these kinds of simple questions across a range of organizational behaviors. For example: To what extent do we reward individual vs. team results? To what extent do we share information broadly or parcel it out narrowly? To what extent do we encourage or discourage risk?"

8 Common Sense Skills - for Recruiters, Managers, and PI Specialists

8 common sense skills - yet not so common to find ..

http://www.ere.net/2011/10/12/8-skills-recruiters-should-have/#more-21422

This article was written with recruiters in mind, but it applies to all managerial and leadership roles. It also applies quite well to performance improvement specialists, as they need to possess many of the same skills:

(1) Listening - Can't identify gaps/ barriers without being a good listener.

(2) Sales - Need to be able to convince others to participate in the initiative.

(3) Followup - Many performance improvement projects languish because of "action-item neverland".

(4) "Hunter mentality" - Not typically thought to be a "PI skill", but the best PI specialists will be incessantly searching for new ways to drive their projects to higher performance.

(5) Big picture thinking - In order to get the organization's resources and commitment behind the project, the capable PI specialist will be thinking about how the initiative impacts the organization at the "big picture" level; for example, this can improve outcomes, which improves patient satisfaction, which improves word-of-mouth, which increases the customer base.

(6) Consultative in nature - There are many roles on a PI team, but in general the PI specialist plays a facilitation role, rather than enforcement. The idea is to get staff and physicians engaged and involved rather than feeling that they are being dictated to. The PI specialist keeps the project organized and moving forward, but is not trying to insist upon a particular format or intervention.

(7) & (8) Personable, approachable, cultivates relationship - I haven't met a PI specialist who has succeeded if they don't have a core personality that is agreeable to work with. The work of the PI specialist is "teamwork" and these skills are essential to well-functioning teams.

Leadership by Crisis

Here is an interesting piece from the Health Care Leadership Blog, referencing a Harvard Business Review article by Ronald Heifetz about leadership in times of crisis .. keeping an organization at the "cutting edge" literally seems to require keeping it "on edge" with grim consequences on either side ..

http://www.healthcareleadershipblog.com/2009/07/post-recession-alerts-for-health-care-leaders.html

Embracing Disequilibrium

Heifetz cited Paul Levy's success as the "turnaround leader" at Beth Israel Deaconess (BID) Hospital in Boston as an example of leadership that carefully leveraged uncertainty and instability as a potent lever for engaging an organization to change its culture and sustainably pull itself out of crisis:

"...a successful turnaround was no guarantee of long term success in an environment clouded by uncertainty....Keeping an organization in a productive zone of disequilibrium is a delicate task...if [the heat] is consistently too low, people won't feel the need to ask uncomfortable questions or make difficult decisions. If it's consistently too high, the organization risks a meltdown..."

The authors go on to cite Levy's successful use of potentially unstable devices (publication of error rates) and public cultural confrontation (of unproductive cross professional squabbles) to expose the implications of an unacceptable status quo and drive the changes essential to BID's survival.