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!

Lack of National Reporting Mandate for Hospital Infections Hurts Consumers

This article from Forbes brings together some compelling reasons for why we need more reporting of patient safety related data: Transparency & Accountability.

These principles seem to be on everyone's mind these days (see excellent recent blog by Dr. Kent Bottles in Hospital Impact on the topic). Transparency and accountability are like motherhood and apple pie - how can anyone disagree with these values? Yet we continue to struggle with achieving both as the industry grapples with just how much transparency there should be - should we report on complications related to four procedures or two? or should we not report at all.

Unfortunately, it takes regulatory mandates to get most providers to report, which has a dual edge to it. Regulatory mandates have a way of making people pay attention and try to comply; but at the same time, these mandates tend to invoke ferocious criticism - why should the government be involved in regulating quality? are the measures appropriate? why penalize instead of incentivize?

The article mentions a great potential solution - reward providers for reporting. This should be a sufficient incentive to get initial participants who can start learning from the comparative data, and hopefully start thinking about opportunities for improvement. The challenge will still be those providers who will forgo the additional payment incentive because of their philosophical disagreements with the data, methodology for collection, fear of how they will rank, and lack of commitment to performance improvement systems. The worry from a consumer or public health perspective is that the incentive winds up further dividing those providers who are motivated and therefore more likely to improve from those who have decided not to engage and therefore may become host to poor quality and patient safety processes. Will transparency and consumerism be enough at that point to get those providers to comply? or will competitive forces conspire to take some of those providers out of the market?

Patient Safety Data from Medicare Creates a Stir

This article from the Chicago Tribune lays out nicely some of the diverse viewpoints on some of the latest quality data to be posted publicly by Medicare - complication rates. At the heart of the matter is that the data being reported is derived from claims (bills) submitted to Medicare, and therefore it was never intended by the hospital to be a reflection of quality. Given that academic medical centers are more likely to find themselves on the list of "high complication rates", they are creating a stir in Chicago, Boston, and other medical meccas about the unreliability of the data. Not only is the data being publicly posted in order to drive consumer awareness and transparency, but CMS has announced that it will penalize hospitals who are in the highest tier of complication rates. There's clearly a lot at stake for all parties.

At the same time its refreshing to hear about the perspective of an institution such as Geisinger Medical Center - "We're perfectly fine with the way CMS does public reporting data," said Dr. John Bulger, chief quality officer at the Geisinger Medical Center in Danville, Pa., which is among the hospitals listed by CMS with substantially more complications than the average hospital. "At Geisinger, we would never shy away from the number and say, 'We don't need to get better than this.'"

This needs to be the key point for posting quality data publicly - how can we improve? what does this teach us about our patient care? how do we compare to other hospitals like us? do we really believe we are as safe as we think we are? Insight can often be painful, and it is tempting to rush to judgment both from the government side for thinking that the data is reliable enough to base payments on; and also on the part of hospitals who feel that they need to attack the data in order to defend their reputation or superiority.

Performance improvement starts first and foremost with a sense of humility, a desire to improve, and realization that improvement can and must be made. Much like the commendable approach taken by Geisinger,  it would serve all parties much better if the focus were placed on the improvement rather than on the strengths or weaknesses of data. 

Performance Improvement Tip of the Day: Better Listening

Here's a nice piece from the McKinsey Quarterly about how an executive can become a better listener:
(1) show respect
(2) keep quiet, and
(3) challenge assumptions. 

These traits are not very different from what it takes to lead performance improvement projects, and as such are worth underscoring here.

I'm linking it to a couple of other blogs on a similar topic that I have recently posted about the importance of "dialog" as well as "influencing people by connecting to their core desires", all of which help to strengthen the foundation for improvement.

Performance Improvement Tip of the Day: SMART Mentoring

We hear a lot about "mentoring" in the context of management, networking, and career development. The idea of mentoring is to establish a close relationship, usually one-to-one, between someone with wisdom or expertise in a particular area and another seeking insight and professional development in that area.

This construct is particularly useful in the performance improvement arena. Through the one-on-one, relationship oriented approach, performance improvement experts can effectively guide those who are at more incipient stages of expertise. True to the mentoring construct, the experts don't take on the task of performance improvement themselves, rather they help their mentees to become familiar with performance improvement concepts and tools, understand how all of the components support each other, and assemble the "performance improvement engine" for themselves. When done within the setting of an "active project", with the mentor's gentle guidance and support in the background, the learning is made more poignant and effective.

Mentoring is also desirable from a structural sense - rather than consulting per se - because the mentee is always responsible for the project, and over time can function without the support of the mentor. In contrast to training, mentoring is generally more focused on the one-to-one relationship and, therefore, highly individualized to the mentee's needs. This further enhances the value of the process, and is more likely to result in successful activation, knowledge transfer, and performance improvement outcomes.

S - Support rather than lead
M - Make it individualized
A - Active project involvement
R - Relationship-based
T - Transfer of knowledge and wisdom

Performance Improvement Tip of the Day: SMART Dialogue

Referring again to Dale Carnegie's "How to Win Friends and Influence People in the Digital Age", the authors talk about the importance of dialogue (vs. monologue) as a means of connecting with "core desires".

The authors' concept of dialogue provides a great mechanism for improving "listening" skills as well, which we all agree are critical to leadership and change management. The authors define the following features of dialogue, which somehow align nicely with the "SMART" template:

• Secure
• Meets mutual needs
• Authentic
• Respectful (the authors use "considerate", but I exercised some poetic license here)
• Transparent/ Builds trust

How do these concepts connect? >>> If you engage in SMART dialogue, you will increase your influence with that individual, and thereby increase your capacity to lead change. 

Hospitals Decry Low Safety Rankings

This article in the Boston Globe lays out the concern emerging from the hospital community over the "safety" data that was recently released publicly by CMS (http://www.hospitalcompare.hhs.gov/), and is also planned to be included in the "value based purchasing" calculations that will penalize hospitals who have low "quality scores".

Even those who fared well on the rankings note that this metric was not intended for the purpose for which it is being used. One can certainly glean some insights from the AHRQ indicators that are used to calculate the patient safety scores. Having reviewed the respective data for a particular healthcare institution, I did find it to be helpful and a reasonably accurate reflection of our patient care. However, as the billing data from which these measures are derived are not generally constructed with the delivery of quality clinical care in mind, the data cannot be presented as a highly reliable picture of the quality of care being delivered at an institution. 

This isn't a question of using data, or comparing hospitals, or posting the data publicly - although each of these initiatives may independently inspire criticism as well. This isn't even about those institutions not faring well in a head-to-head competition crying foul. The central issue remains that one can't take major shortcuts in data gathering if one if trying to properly incentivize and motivate the system to improve. This doesn't work in an individual medical center or clinic - as one of the first tenets of performance improvement is to ensure that the data we share with our physicians and other clinicians is meaningful and reliable - nor does it work for the entire healthcare system.

The intention may be proper, but displaying such data publicly, expecting consumers to make healthcare decisions based upon it, and furthermore penalizing hospitals for not performing better on the same scale has the risk of coming across as a desperate maneuver to reduce costs in the guise of quality.

Reducing Readmissions through Guidelines (and other performance improvement techniques)

This article in Health Leaders Media provides a wonderful example of how to utilize performance improvement tools and principles in order to reduce readmissions. "UPMC Hamot, Lancaster (PA) General Hospital, and Muncie, IN–based Indiana University Health Ball Memorial Hospital have readmission rates that beat Medicare's HospitalCompare dataset national average in three key areas: 30-day readmission rates for heart attacks, 30-day readmission rates for heart failure, and 30-day readmission rates for pneumonia." The entities attribute their success in large part to the following interventions:

• Guidelines:
• "We researched best practices, and we standardized those practices."... "Then we put together teams of physicians and caregivers that care for the population of patients we were focusing on and developed standardized treatment guidelines that were then put into use."
• "The organization now has more than 200 guidelines in place, each created by an interdisciplinary team with a physician champion."
• Checklists: 
• Heart failure (HF) patients receive a home health referral upon discharge.
• Telehealth whenever possible.
• Scale with the blood pressure monitors hooked up to the phone line.
• Review weight every day.
• Standardization:
• Standardizing paperwork that is exchanged between hospital and after-care facilities.
• Multidisciplinary (in this case, cross-institutional) Teams: 
• "We took it a step further when we worked on heart failure. We created a heart failure skilled care order set and met with the administrator and director of nursing to make sure what we were putting on the order set could be used anywhere."
• Redesigning Care Processes:
• Inpatient HF clinic staffed by nurse practitioners.
• Link the specialists in the hospital to patients' primary care physicians and SNFs.
• HF coach calls discharged HF patients three times within the first week to make sure they are following up with appointments and understand their medications.

A few additional PI techniques come to mind that are not mentioned in this article, but would be a natural adjunct to the initiative, and could help to ensure excellent outcomes:

• Disseminate Data to Physicians, Nurses, and Other Staff to generate awareness.
• Provide Feedback in the event that there is a "failure" in a process in order to ensure that individual practitioners learn of any gaps in their behavior.
• Create Profiles of Providers in order to generate further awareness about team and individual performance.

Improving Surgical Quality: Tracking Emergent vs. Elective Surgery

This article in Health Leaders provides an important reminder about the need for performance improvement experts to understand our data in more detail. Many hospitals formally evaluate various surgical quality measures, including the Surgical Care Improvement Project (Core Measures), complications, infections, readmissions, mortality, returns to the OR, returns to the ICU. However, these hospitals may not be differentiating between Emergency Surgery vs. Elective Surgery, a variable that can change the likelihood of complications considerably.

This research being undertaken at Wake Forest University Medical Center underscores that unless we understand the variables behind the data that we are collecting, we will likely not understand how to truly improve outcomes.

Another danger in "aggregating data" - particularly in this day of mandated physician profiling, e.g., through the Ongoing Professional Practice Evaluation (OPPE) - is that we may project individual practitioners to have higher complication rates than their peers, when in reality they may have a selective patient population. For example, perhaps some practitioners take more emergency call than their peers, which would lead them to perform more emergent procedures. 

Other variables, such as delay in performing surgery, quality of OR team, communication within the OR/ preoperative timeframe, may also play a role in the outcome of the procedure. However, unless we are attuned to these variables, capturing them, and studying them, we will not be serving the cause of improvement nor will we be able to effectively engage and help our physician colleagues as actively as we would like.

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".

Performance Improvement Tip of the Day: Better Brainstorming

In the performance improvement world, we rely often on "brainstorming" as a proven strategy for generating ideas about how to overcome barriers, gaps in care, and general problem solving.  A thought-provoking piece in Fast Company Design about how the brainstorming process works - or doesn't work - made me think about  how we can improve our use of this technique.

The article points out the following principles which may help us brainstorm better:

• need some individual time, and some group time to generate ideas
• group dynamics tend to inhibit some creativity, but the prospect of criticism also improves the quality of ideas 
• good ideas usually come about as a solution to a readily identified problem
• the most productive groups were those with a baseline of familiarity but just enough fresh blood to make things interesting
• physical proximity of group members helps to encourage "serendipitous" conversations and discoveries

For performance improvement personnel, here are some thoughts on how to apply these principles:

• have the group brainstorm problems first, before identifying solutions
• encourage individuals to think independently about solutions before embarking on the "group discussion"
• plan ways for the performance improvement team to informally network with each other in order to stimulate the "accidental discovery of ideas", e.g., dinner, bagged lunch, social hour, etc.
• ensure that there is a healthy mix of experts and novices in the team 

The Regulator's Dilemma: Censure or Close a Nursing Home

This article points out a difficult dilemma, if you close a facility because its not performing well what do you do for patient access? Healthcare is a difficult business, with some barriers to entry, as well as limited supply of particular resources (including physicians, nurses, hospital beds, and/or nursing facilities). If you shut any of these resources down, you do so with the realization that this is not an entirely "renewable" resource, and also with the realization that the free market may not spring forth to supply an alternative - particularly for the poor, elderly, vulnerable members of society.

The article is part of the "Trust and Neglect" series by the Detroit Free Press which attempts to shed light on the challenges of the nursing home industry in Michigan. The first article in the series talks about the extent of the problem and adds names and stories to make the numbers real.



Many of the cases should disturb all of us:

• Staff tied a residents hands hands together with a garbage bag
• Respiratory therapist forgot to connect a patient to a ventilator; and also forgot to check his vitals
• Nurse fell asleep on the job allowing a patient to wander out of the facility

The reasons behind these mistakes are theoretically remediable:

• Nursing homes try to cover up errors
• Staff are overwhelmed
• Homes don't follow their own procedures
• Staff are not competent for the roles they are assigned 

Some healthcare systems related issues that appear to be contributing:

• Bureaucratic rules that burden homes and their staff with too much paperwork
• Differences among inspectors about interpretation and application of rules
• Regulatory systems dependence on "fines, surveys, and lists" to censure chronically underperforming homes 

The common thread here appears to be lack of staffing, which results from low operating margins, which are only going to come under increasing pressure as the industry has recently gone through an 11% cut in reimbursement. Where will the solution to protect patient safety come from when the staff are already overwhelmed and the industry is going to face increased financial pressures?

We need more aggressive redesign of care processes, simplification of protocols, reduction of bureaucracy and paperwork. Perhaps this can lower costs of operations, and increase the amount of time that staff can spend on patient care. 

Different business models have to emerge that are able to provide adequate, safe, quality care. Perhaps the "accountable care organization" model now being promulgated for Medicare patients - which rewards practitioners and facilities for reducing cost and improving quality - can provide a new financial model for facilities to improve their care processes.

A new regulatory framework also has to emerge to solve the "dilemma" posed by this report. In addition to fines, inspections, surveys, and lists, more aggressive action should be taken to ensure that staffing is appropriate to provide adequacy of care; or perhaps repeat offenders should be "mandated" to implement a structured, supervised "performance improvement system". 

Should Individual Performance Reviews Be Made Public?

This opinion piece posted on the USC Annenberg School for Communication & Journalism site made me think about a similar debate being carried out in healthcare

I think its become more "accepted" that physician and hospital ratings will be posted publicly, but what the content of those should be is still a matter of fierce debate. How much transparency is appropriate?

I think asking the question from the perspective of the average citizen makes it more poignant - "would you want your work performance to be publicly posted?" Advocates of privacy decry any advertent or inadvertent posting of personal data, however, what could be more personal than job performance?

Perhaps the issue here is that these are government employees? But most physicians are not government employees - should only the profiles of the ones hired by the VA be posted publicly? And then, as the article states, why shouldn't we have publicly posted profiles of highway engineers, postal workers, politicians?

Is the issue that medical (and education) professionals require more oversight and transparency? Its hard to argue that posting profiles for other professionals - politicians, bankers, lawyers, etc. - would not lead to greater accountability in those fields as well. The true power of the market could really be exerted then as the public could "vote with their feet" and support those professionals whose work was positively reviewed.

In this age of technology, social media, and consumerism, the demand for public reporting in general seems to only be increasing. And its hard to argue that it overall hasn't had a beneficial effect for the consumer along the lines of: more information = consumer empowerment = better decision-making = better outcomes. However rating an organization such as a restaurant or hotel, or rating a commodity such as a car, book, or technology, are fundamentally different functions than rating an individual - even if he be a professional. The public posting of the same has a level of invasiveness that would make many of us likely to recoil.

I'm generally a staunch advocate for public reporting of data, but public reporting of ratings for individuals seems to be crossing some ethical and intellectual lines. What is the rationale that makes it appropriate? 

Dangerous Assumptions & Lack of Systems: Breakdown in Communication of Test Results

This article in the Washington Post points out a disturbing, yet unfortunately widespread, cause of medical errors: breakdown in communication of test results.

The Joint Commission addresses the issue as one of its National Patient Safety Goals for hospitals. However, systems at many hospitals and physician offices are not "airtight" enough to assure the reliable transmission of information and the delivery of safe care.

The "root cause" for this error generally comes down to one of a few common factors:

• Staff too busy with their "day-to-day" routine. 
• If the result reporting process is not well-integrated into their clinical workflow, there is a high likelihood of system failure.
• No clear process identified for handling of critical lab results.
• This is probably the "over-arching" root cause for the issue at hand. If the process for communication is not robust, not well disseminated, and not monitored, it will inevitably lead to errors. 
• Miscommunication about who in the hospital/ office is handling the communication.
• Results may get reported to a non-clinical staff member (such as a Unit Clerk or Office Manager) who is not the right individual to interpret the significance of the findings.
• Physician was not reachable despite numerous attempts.
• Sorry to say that this is probably one of the most common reasons for failure to relay critical test information, particularly in a busy hospital setting. 
• Lab techs, nurses, and other staff try to follow an "established process", but the process is doomed to repetitive failure because one of the key steps is not reliable.
• Results get communicated, but subsequent "changes to reports" are lost. 
• Unfortunately, this happens often for tests that have to be "incubated" (such as microbiology reports) or "reviewed" (such as radiology reports).
• Test results that cross clinical settings (such as hospital to provider office) are prone to getting lost. 
• Every provider and every hospital may have a different mechanism and process for communicating critical test results. This increases the complexity of the process exponentially, and makes it more prone to break down.
• When there is not "one standardized process for communication" across the local healthcare system, how do we expect individual physicians, staff, and even organizations to ensure reliability?

The system described by Dr. Eric Poon at Brigham and Womens Hospital is a constructive approach to this problem:

However, this system is mostly reliant on an electronic interface, which may not be applicable to all providers in a diversity of clinical settings. In addition to using electronic systems wisely, healthcare providers should remember the key principles of performance improvement for systematically reducing the likelihood of error in this vital clinical process:

• Undertake a root cause analysis for any specific errors at the respective institution
• Undertake a FMEA (failure modes effect analysis) to formally assess the likelihood of systems breakdown for key processes
• Ensure that a specific process is laid out and communicated widely to all staff and physicians
• Build in redundancies to ensure that an "adequate safety net" is in place to catch errors before they affect a patient
• Monitor data both on outcomes (errors reaching the patient) as well as critical steps in the process (such as success in test result handoffs)
• Report data widely to staff, physicians, leadership
• Provide feedback to staff and physicians on individual errors
• Incorporate education about process into staff orientation and ongoing training forums

LED Displays in Hospitals Improve Compliance through Feedback

I recently blogged about "The Power of the Feedback Loop" and then came upon this article from The New York Times about an interesting application of this concept that I thought I should share.

ICUs in North Shore University Hospital in Manhasset, NY are using LED displays to provide instant reminders and feedback to staff:




The initiative is based on a system developed by a private company called Arrowsight. It employs video-surveillance of staff as they enter and exit patient rooms. Random snippets of video are monitored by employees in India who rate each event as pass or fail. Nurse managers receive close-to-realtime information about hand hygiene rates, and the LED displays provide positive reinforcement when the hand hygiene rate for the shift meets the target.

The results:

• Hand hygiene compliance has improved from 6.5% to over 80%. 
• Rates of hospital-acquired infection are reported to have dropped. 
• The culture of the institution with respect to hand hygiene appears to be changing. 

The concept of analyzing video tape for compliance with clinical processes and converting that into data and feedback is highly intriguing, although privacy advocates will be duly concerned about the monitoring implications. The cost of the technology may also prove to be limiting to widespread dissemination. However, I love the innovativeness of the solution, its incorporation into the clinical workflow, and its harnessing of the power of the feedback loop in changing behavior.

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 

Hospitals Reduce Bloodstream Infections: Performance Improvement in Action

This article from The Tennessean provides a nice overview of gains made by hospitals in the state to reduce bloodstream infections related to catheters - a hospital-acquired condition that can be deadly. The secret to their success? They applied principles of performance improvement:

• The State Department of Public Health started collecting data across institutions.
• US Department of Health and Human Services established a benchmark for all hospitals to aspire to.
• Hospitals started following a "safety checklist", including the following elements:
• thoroughly wash hands
• wear sterile protective garb
• avoid putting catheters in the garb
• cleanse the infection site 
• remove catheters as soon as they are no longer needed
• Centennial and Methodist University Hospital committed to transparency by posting their numbers on their own websites.
• Vanderbilt increased awareness about the initiative by posting signs counting "days since the last infection".
• Vanderbilt developed an "antibiotic stewardship program" to closely monitor use of antibiotics which has helped to reduce the incidence of multi-drug resistant pathogens.

It is gratifying to see initiatives like this taking hold as other states have also been reporting positive outcomes with their collaborative efforts. However, there is a lot of improvement work to be done! Federal and state officials should provide a greater impetus to such initiatives - lead more collaborative efforts, aim for higher targets, and try to achieve the gains faster. The hospitals that have not achieved gains at the same rate as others may need more assistance from the state or other agencies in setting up their performance improvement systems.

Performance Improvement Tip of the Day: A "SMART" PI Project Checklist

In this "list-obsessed" world of ours, its hardly a surprise that one would create a "Checklist for Checklists". In healthcare, the call has gone out from Drs. Peter Pronovost and Atul Gawande to introduce Checklists as "patient safety tools". They are particularly useful when dealing with complex systems, and for reminding personnel of "basic operations" that can't be forgotten. When used properly, Checklists can ensure that necessary aspects of care are delivered, and free up highly trained personnel to think about when to deviate from a Checklist, and focus on higher level decision-making.

As we make our performance improvement teams more results-oriented, the Checklist becomes a useful tool to help keep the projects themselves on track. This helps to remind our project leaders about the steps they need to take in order to ensure that project goals will be met.

The "SMART" PI Project Checklist below - in keeping with our "SMART" theme - helps to provide a relatively simple, easily implementable framework for delivering improvement. In this context, "SMART" reminds us of the following:

• When designing Goals, Feedback, and Profiles, keep them "SMART" in order to ensure efficiency and minimize the likelihood of resistance or conflict. See prior blogs on each of these topics for more details.
• The "SMART" PI Project ensures that we:
• "Specify" ownership of the project.
• "Monitor" results in an ongoing fashion, and ensure that others in the organization help us with the monitoring.
• "Analyze" the current system in order to properly develop Goals, identify Barriers, and identify the Critical Processes that need to be undertaken in order to deliver results.
• "Redesign" the system intelligently building in decision support to ensure reliable outcomes, and enhancing safety mechanisms to catch problems real-time.
• "Train" ourselves, our staff, and our leaders to deliver better results using proven "behavioral management" techniques of Feedback and Profiling.

While this list can be individualized for the needs of particular institutions, the elements included are generally those that I find essential in delivering results. As you work through the list, you are introducing greater reliability into the system and establishing an increasingly mature culture of improvement.

"No one wants to be an Outlier" - Spine Surgeons at BIDMC Use Performance Improvement Tactics to Reduce Waste

This initiative at BIDMC to reduce waste in spine surgery is a great example of a "performance improvement system" (in this case they used Lean) to improve outcomes (in this case clinical utilization). A similar "performance improvement" approach can work in improving quality, mitigating risk, and improving patient safety.

The article identifies the following "performance improvement tactics" that should be integral components of all improvement projects:

• Examined how much they used and spent (review and monitor data)
• Questioned why each device was being being used (ask why five times)
• Studied reasons for wastage (undertake root cause analysis)
• Asked surgeons, operating room personnel, industry representatives, and nurses to help them identify waste (seek multi-disciplinary input)
• Compiled lists of who had been wasting more instruments than others (create profiles)
• Shared lists [of waste generators] with each other (create report cards)
• Awareness campaign (educate)
• Physician leadership prompted change (get support from leadership)

The key behavioral drivers that project leader, Dr. Kevin McGuire, Chief of Orthopedic Surgery, identified are "physicians are competitive in nature" and "no one wants to be an outlier". Understanding these drivers is key to understanding some of the performance improvement tools and how to deploy them effectively.

Performance Improvement Tip of the Day: Hierarchy of Clinical Decision Support

As we construct checklists, order sets, and various other tools to help guide clinical activity, there is a hierarchy of decision support that patient safety and quality improvement experts need to be aware of.

HIERARCHY OF CLINICAL DECISION SUPPORT
Level	Description
1	No decision support provided
2	Education provided re. clinical decision,  but no decision support at point-of-care
3	Decision support provided at point-of-care, but not integrated into workflow
4	Decision support integrated into clinical workflow, but optional
5	Decision support mandatory to complete,  but "opt in" required to activate
6	Decision support is the default option,  with "opt out" required to de-activate
7	Decision support automatic, e.g., initiated by protocol, with parameters built in for safety

In general, as you implement higher levels of decision support, the likelihood of the "right" action being undertaken increases as the dependence on the clinician making an "active effort to choose the right action" decreases. However, at the same time, clinical autonomy in decision-making is also reduced, which is often perceived as  "administrative" or "heavy-handed" by physicians. As such, it is wise to embark upon the "hierarchical" journey with caution, full support of the medical leadership, and a clear sense of what the "medical culture" and "institutional culture" will be able to support.


Over the course of future blogs, I will provide some examples of these decision support levels in practice.