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Utah Association of Local Health Departments Train-the-Trainer Workshop October 19 and 20, 2011.

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Presentation on theme: "Utah Association of Local Health Departments Train-the-Trainer Workshop October 19 and 20, 2011."— Presentation transcript:

1 Utah Association of Local Health Departments Train-the-Trainer Workshop October 19 and 20, 2011

2 Workshop Overview Welcome Remarks Introductions Why are we here? Expectations

3 … PHF Mission: We improve the public’s health by strengthening the quality and performance of public health practice Innovative Solutions. Measurable Results.

4 Brainstorming 5 minutes individually, write down: What issues have arisen around implementing or setting up a QI training session? Volunteer ideas as scribe writes Build on listed ideas Add new thoughts as they occur Debrief to whole group

5 Coaching QI Teams Teams don’t use tools in a vacuum Soft skills as well as hard skills © PHF 2009

6 Coaching QI Teams The purpose of coaching QI Teams is to: Build a partnership between the coach, team leader, and team members Help the team move to a higher level of achievement Help the team overcome obstacles Help the team navigate a politically sensitive situation Provide training or problem solving assistance

7 Coaching QI Teams Building a partnership between the coach, team leader, and team members is effective when there are: Agreed upon ground rules Clear expectations Specific time frames Established goals and measures of success

8 Some Issues That Could Arise: Coach groups into teams Clarify objectives and goals Dissolve hidden agendas Move to commitment & accountability Move from hoping to acting Generate efficiency Model success of other high performing teams Share values & vision of the organization Overcome frustration & failure Keep them going Give recognition

9 The Five Dysfunctions of a Team Fear of… Conflict Absence of… Trust Lack of… Commitment Avoidance of… Accountability Inattention to… Results The Role of the Coach Be Vulnerable Demand Debate Force Clarity and Closure Confront Difficult Issues Focus on Collective Outcomes © PHF 2009 P. Lencioni 2005

10 Coaching QI Teams The goal is to build a culture of commitment and accountability

11 What is Coaching? Establish trust Build rapport and open communication Clarify key roles and responsibilities Establish goals and an effective personal development plan Create and implement a mentoring agreement

12 Coaching Exercise, #1 Break into teams of five each List out the elements you would want in a coach Identify the top three elements you would consider most important for a successful coaching intervention. Debrief

13 First Rule of Coaching Start where your client “is” and not where you think he should be or where you are.

14 Second Rule of Coaching Confirm readiness: Is the client receptive to coaching? Do they want to be coached? Have they requested coaching or been told to get it? What do they expect to get from coaching?

15 Third Rule of Coaching Set Expectations: Establish goals Intent is to help, not run the team Build trust – who do you have to report your results to – make it clear Establish when and where coaching will take place

16 Fourth Rule of Coaching Observe The Team: Identify destructive behaviors Document specific incidences Document their strengths and weaknesses Understand what they think is blocking or hindering their progress

17 Fifth Rule of Coaching Develop an Improvement Plan: Describe observed team behaviors and the impacts; both good and bad Review causes that lead to bad outcomes for the team Set realistic change expectations Build the plan around their strengths Describe specific corrective actions to overcome weaknesses Indicate any training that may be required and how they can obtain it.

18 Sixth Rule of Coaching Confidentiality: What you observe, recommend, or help the team with stays in “Vegas” If you must report your finding to some one higher in the organization let the team know at the outset

19 Seventh Rule of Coaching Follow-Up: Set a time to follow-up with the team to see if progress has been made Ask them to send you brief updates on a regular basis – what is and is not working

20 Coaching Exercise #2 Choose a partner for this exercise. You will practice coaching techniques. Look at the three most important elements for a successful coaching intervention each of you chose during exercise 1. Choose one element to practice with your partner. You can each choose a different element. Continued…

21 Coaching Exercise #2 The first “coachee” sets up the situation in which the “coach” will provide support. The coach LISTENS to the “coachee” to understand their coaching need. The coach then explores different approaches (DO NOT TELL) to that scenario with the “coachee.” Take no longer than 5 minutes for the exchange. Take two minutes for the “coachee” to express observations of the helpfulness of the coaching. Swap roles and repeat with the second partner.

22 Summary Coaching Fundamentals: LISTEN EMPATHIZE (not sympathize) ASK DON’T TELL

23 Team # 1 QI Tool

24 Team Analysis and Decision Making

25 Problem Solving vs. Decision Making Whenever teams encounter a problem, we are involved in decision making. We are involved in decision making even when there is NOT a problem. Quality Improvement is about process, not only the outcome of our processes (W. Edwards Deming)

26 Improvement versus Redesign for QI 26

27 The Basic Feedback Loop

28 Align Quality Improvement Measures Three steps for generating data for analysis and decision making: Assessing: Identifying, defining, prioritizing – Plan Analyzing: Examining and investigating – Do and Check Answering: Finding solutions - Act Act Do Check/ Study Plan

29 In Reality; There Are Two Qualities 1.A product or service – Attribute Quality What you deliver to the client 2.A management tool – Method Quality What do you do internally to deliver the product or service to the client? How does the service you provide support the critical goals of your Department? We all work in Quality. We all work to improve the department. Quality isn’t about titles or departments, It’s about methods and their impact on individuals, our communities and how well we use our resources.

30 Break

31 Analyzing Goals and Measures of Success Activity preparation: What organizational goals do you have in common with others in this session? Focus on the most operational goals possible for this activity Group in teams of 4 or 5 who have at least 3 common goals.

32 What and How How You Do It WrongRight What You Do Right Things Wrong Things RTRRTW WTWWTR % % %

33 RTR Analysis and Decision Making 15 Minutes: Using the RTR matrix handout, identify: Which of the identified goals are the right or wrong priorities based on your most critical stakeholder needs? Which actions taken to meet the identified goals are either the right or wrong ones to successfully meet those goals? Share your RTR observations

34 Team # 2 QI Tool

35 Listening and Communicating A good coach is an outstanding listener and effective communicator

36 Listening and Communications Communications is a two-way process Speaker has to accurately convey their thoughts to the listener The listener must make sure they understand the message This seems simple enough

37 Listening and Communications When the message understood by the listener matches the message intended by the speaker we have successful communications Whenever we communicate there are two basic factors at work: Ideas Feelings

38 Listening and Communications Ideas – thought process which contains the concept we are attempting to communicate Feelings – emotions associated with the concepts we are communicating

39 Listening and Communications An Idea-feeling relationship is in balance most of the time During stressful situations the feel factor will take over and distort the message Stressful situations require an emphasis on effective listening

40 Listening and Communications IdeasFeelings Normal Ideas Feelings Stressful

41 Class Exercise Break into teams of two each and sit back to back One person faces the screen; the other makes sure you cannot see the screen The person facing the screen must instruct the person sitting behind them to draw the figure to be shown You have 3 minutes Quick debrief – what happened and why

42 Class Exercise

43 Now turn and face each other One person faces the screen; the other makes sure you cannot see the screen The person facing the screen must instruct the person sitting in front of them to draw the figure to be shown You have 3 minutes Quick debrief – what happened and why

44 Class Exercise

45 What Happened and Why?

46 Listening and Communications Cues of Communications: Verbal Vocal Visual


48 Cues of Communications: Verbal: What we say and our choice of words Big versus little words no slang Speak from our experience which may not be your listener’s experience - disconnect

49 Cues of Communications: Vocal – how we say it – tone, pitch, volume, inflection Volume – too soft suggests uncertainty Pitch – high pitch suggests excitement or nervousness Tone – may suggest skepticism or disagreement Inflection – upward pitch at the end of a sentence may make a statement sound like a question

50 Listening and Communication Research indicates that: 50% of our communications comes from body language 43% from tone of voice 7% from the actual words we speak


52 Every Body’s Talking A way to read emotions not put into words Nonverbal speak loudly – sometimes louder than words Watch your intended message recipient or audience for these clues Washington Post, Section F 1, June 24, 2008


54 Listening and Communications Three types of listening: Passive listening Acknowledgement response Active listening

55 Three types of listening 1.Passive listening: Listener may or may not be paying attention No response to spoken words – silence Limited or no body movement Voice can whine

56 Three types of listening 2.Acknowledgement response:  Listener hears and understands  Response acknowledges message  Direct eye contact  Body movement – gestures of acknowledgement

57 Three types of listening 3.Active Listening:  Listener uses feedback  Listener tries to gain additional information  Eye contact  Positive body gestures

58 Active Listening Know the purpose Pay attention Interpret Evaluate Respond

59 Remember The busy employee spends 50% of their time listening to people and still does not remember half of what is said We forget 1/3 to 1/2 of what we hear within one to eight hours We forget an additional 25% in the next 48 hours We forget more in the first eight hours than in the next six months

60 Remember We ignore, forget, distort, and/or misunderstand 75% of what we hear

61 Listening Is A Skill Find areas of interest – worth of the message – match your experiences Judge the content not the delivery Hold your fire – listen to the content, not the hot button words – do not jump in right away – over stimulated Listen for ideas or facts that are interesting Be flexible and open minded

62 Listening Is A Skill Work at listening – be prepared physically Resist distractions Exercise your mind Keep your mind open – do not go to the deaf spot Capitalize on thought speed

63 Communications Model M C R S N Message Channel Receiver SourceNoise Feedback

64 Summary We need to make sure we keep our listener(s) fully engaged or they will drift off Use visuals, exercises, handouts, etc. to fill in the voids that words cannot possible do

65 Summary Research indicates that we can: Speak at 100 words per minute Hear at 200 words per minute Think at 600 words per minute

66 Lunch

67 Team # 3 QI Tool

68 Being an Effective Team QI Team Building The following material is from the text “Growing Teams” by G. Fetteroll, G. Hoffherr, and J. Moran, Goal/QPC, 1993

69 16 Guidelines For Teams To Work Effectively 1.Establish goals and objectives all team members accept 2.Let each team define its own standards of performance 3.Allow members to disagree in a constructive way to resolve problems 4.Review past actions when making plans for the future 5.Make decisions by consensus 6.Remain cohesive and maintain a sense of unity 7.Strive for synergy 8.Develop a comfortable working atmosphere 9.Use physical space that is conducive to the team process

70 16 Guidelines For Teams To Work Effectively 10.Listen to each other and provide useful feedback 11.Use constructive criticism to facilitate group interaction 12.Allow members to express their ideas fully and frankly 13.Recognize individuals for the contribution they make within the team 14.Assist members when it ensures successful completion of team goals 15.Highly value creative approaches to problems 16.Incorporate flexibility in the team’s thoughts and action

71 Roles and Responsibilities Sponsor: Set improvement project goal Select the team leader Participate with the team leader to select team members Remove barriers Empower Monitor Review progress Help implement final improvement

72 Roles and Responsibilities Facilitator: Keep the team on track Train if needed Assist the team leader Help overcome negative behaviors Impartial observer – give the team constructive feedback

73 Roles and Responsibilities Team Leader: Conducts the meetings Prepares agendas Participates actively in the team meetings Represents the team to management Follows up on action items between meetings Secures needed resources for the team

74 Roles and Responsibilities Team Members: Give your undivided attention Take responsibility for comprehending Listen to understand rather than to refute Control your emotions Listen for the main ideas, not the details Put your mind to work

75 Teaming “I not only use all the brains that I have, but all that I can borrow.” Woodrow Wilson

76 How to Build a Strong Performing © PHF 2009

77 Starting Teams Develop: 1.Team charter 2.Ground rules 3.Measures of team progress

78 Selecting Team Members “Hire for attitude, train for skills Skunk works Softball at recess Conscripted Volunteer ….

79 Maintaining Teams Agree on the improvement model to use. Use proven methods based on data and knowledge. Manage team dynamics.

80 Essential Team Characteristic s

81 Team Roles & Responsibilities The Public Health Quality Improvement Handbook Table 21.1 (Handout) 15 minutes: Review the Team Roles and Responsibilities Discuss: Why so many different “positions?” Which are hard? Which are easy? Why? Be prepared to share your observations with the group © PHF 2009

82 4 Stages of Team Development Forming Storming

83 Achieving long-lasting success using teams. © PHF 2009

84 The Team Leader as Coach Reinforce Request Information Resources Responsibility Role Repeat

85 Reserve judgmentReserve judgment Concentrate on the act not the personConcentrate on the act not the person Get their perspectiveGet their perspective Maintain your own self worthMaintain your own self worth React only to the current situationReact only to the current situation Dealing with “Difficult” People © PHF 2009

86 What if the difficult person is me? © PHF 2009

87 Be directBe direct Ban blamingBan blaming Stay focusedStay focused NegotiateNegotiate Realign prioritiesRealign priorities Say lessSay less Let it goLet it go Don’t Nag © PHF 2009

88 88 Put your shields upPut your shields up Act like a coffee filterAct like a coffee filter Pretend you’re Sherlock HolmesPretend you’re Sherlock Holmes Say “you’re right”Say “you’re right” Receiving Criticism © PHF 2009

89 89 Hearing is not listening Acknowledging is not agreeingAcknowledging is not agreeing Acknowledging is not yieldingAcknowledging is not yielding When You Disagree © PHF 2009

90 Leading Effective Meetings Preparation. Use an agenda, distribute early. Fill key meeting roles. Facilitator Timekeeper Scribe Involve participants actively. Take and distribute minutes.

91 Hear Hear Clarify Clarify Dialogue Dialogue Gain agreement Gain agreement Summarize Summarize Act/follow-up Act/follow-up Hand off Hand off Build a Loyalty Action Plan © PHF 2009

92 RACI Charting Establish an Effective Team

93 Topics We Will Cover What is Responsibility Charting When do you use Responsibility Charting Key Definitions The Four-Step Process for Responsibility Charting Tips for Analyzing a Responsibility Chart

94 Objectives Describe the need for and benefits of having clearly defined roles and responsibilities within teams Analyze and develop an effective RACI chart

95 So What is RACI Charting? A systematic and participative technique to: Identify all functions (activities, tasks, and decisions) that have to be accomplished for effective operation Clarify roles and individual levels of participation in relation to each function Develop best methods for individuals to fill these roles

96 Therefore, with clear roles and responsibilities we should expect to see... Increased productivity through well defined accountability Increased capacity by eliminating overlaps and redundancies Less confusion/misunderstandings by encouraging teamwork Streamlined work process by eliminating unnecessary interfaces and assigning ‘accountability’ where it belongs Improved team effectiveness by allowing disciplines to cooperate and share responsibility

97 Unclear roles and responsibilities result in comments like these… “My team leader always overrules my recommendations whenever he/she wants” “The approval process for even the simplest item takes so long today” “It seems every department has someone putting together a spreadsheet on the same data” “Things are always slipping through the cracks” “I have the responsibility, but not the authority, to get the job done” Clear roles and responsibilities can be identified through RACI charting

98 R: Responsible A: Accountable C: Consult I: Inform RESPONSIBLE: Do The Job. Execute. These are the individuals who actually complete the task or activity and are responsible for action and/or implementation. Responsibility is often shared, with each individual’s degree of responsibility determined by the individual with the “A”.

99 R: Responsible A: Accountable C: Consult I: Inform ACCOUNTABLE: Make the decision. Take ultimate ownership. This is the individual who carries the “yes” or “no” authority and has full veto power for an activity. It is important to clarify the levels of accountability and to distinguish between management accountability and operational accountability. Only one “A” can be assigned to a task or activity and authority must accompany accountability.

100 R: Responsible A: Accountable C: Consult I: Inform CONSULT: Communication before. In the loop. These are the individuals who must be consulted prior to a final decision or action. “Consult” implies two-way communication.

101 R: Responsible A: Accountable C: Consult I: Inform INFORM: Need to know. Do not change the decision. These are the individuals who need to be informed after a decision or action is taken because they, in turn, may take action or make a decision based on the output. “Inform” is FYI and implies only one-way communication.

102 The output RACI Matrix can initially look quite complex RACI’s provide lots of information in a very simple format R C A I RC A I C CI R A IR C A R CA I RC A I I R C A Roles of Participants Decisions or Activities

103 R = Responsible (execute) A = Accountable (Yes or No) C = Consulted before I = Informed After RACI Chart for Validating Open Position See for the Grading sub process next page

104 R = Responsible (execute) A = Accountable (Yes or No) C = Consulted before I = Informed After RACI Chart for the grading/regrading

105 The 4–Step Process 1.Determine the activities 2.Prepare a list of functional roles 3.Develop the RACI chart 4.Get feedback and buy-in (validate)

106 Guidelines for developing a RACI Chart (to-be) Remember new ‘culture’ philosophy when defining roles and responsibilities:  Eliminate “checkers checking checkers”  Encourage teamwork  100% accuracy is not always required Place ‘accountability’ (A) and ‘responsibility’ (R) at the lowest feasible level There can be only one accountability per activity Authority must accompany accountability Minimize the number of ‘consults’ (C) and ‘informs’ (I) All roles and responsibilities must be documented and communicated (use team charter)

107 Obtain Feedback and “Buy–In” The RACI chart is shown to people that represent the functional roles on the chart These individuals are asked for their input, and the RACI chart is revised as appropriate The RACI chart may be validated in conjunction with the other products generated by the QI teams

108 Common Errors ‘RACI’ everything (instead of thinking about what is value-added) Do not take into account that people are trying to justify their jobs Do not eliminate the "coordinators & consolidators" Do not use enough ‘action’ verbs in constructing the “Activities” list Do not understand it will change Do not consider "interface" issues Learn about it in training and think they can do it without practice

109 1. If you have an "R“ (to someone else's "A") it becomes your "A“ in most cases. 2. If you have the "A" that means you have no constraints or limits in your decisions…for that task. 3. To ensure good communication in an organization, we should encourage many "consults" and "informs" on a task. 4. It is quite common to see the VP in an area have the "Accountability" for a task, and an Operator to have the "R," so we should be okay with that. 5. The structure of RACI allows even the most recent of Core / Process team members to successfully complete it. 6. RACI is interesting as an exercise, but it doesn't help to eliminate the "non value-added" work/functions. 7. When in doubt, give the "A" to the highest ranking individual in the room. True False Let’s see what we know

110 Team # 4 QI Tool

111 Break

112 Getting Teams Started and Keeping Them Going

113 Before the first team meeting, the Team Leader should: Review the team charter and direction with the Team Sponsor* Clarify roles Draft a plan Identify pertinent existing data Set meeting logistics Draft an agenda * Some organizations and Sponsors develop the team charter before the team comes together. Others see value in having team members define their own charter for greater empowerment.

114 A Team Charter provides the initial focus for a quality improvement project. This is an example of a simple team charter. This document should be drafted as one of the first activities when a team is created. The Team Charter is a living document and should be reviewed and modified to reflect the progress of the team through the different phases of the project. Create and Maintain a Team Charter 114

115 Goals for the first few meetings: Build relationships: Get to know each other Learn to work as a team Work out decision making issues Set ground rules Understand the project: Review the charter Develop a work plan Identify stakeholders Learn new tools and skills: The scientific approach (PDCA) Team behavioral skills Basic quality tools

116 The Team Meeting Cycle Design the Meeting Develop the agenda Design the format Conduct the Meeting Agenda review Discuss items ID follow-up actions Evaluate the meeting Carry out between meeting assignments Collect information needed to design the next meeting

117 Team # 5 & 6 QI Tools

118 Q&A On Using Individual QI Tools

119 Outstanding Issues

120 Wrap-up Day 1

121 Review of Day 1 Comments Questions Suggestions Scan agenda for Day 2

122 Communicating Team Progress

123 Follow the Communication Plan in your Team Charter Internal team communications according to ground rules (informal) Tollgate reviews with Sponsor, process owner and Senior Management (formal) Involvement of key stakeholders (formal and informal) Effective project management tools: (formal) Project deadlines, action items and tracker Gantt chart Meeting minutes

124 What is a Tollgate Review A Tollgate Review, as the name indicates, is like a checkpoint in an improvement project where the various team members meet with the Team Sponsor to determine whether the work has been performed as indicated in the project plan and whether the objectives planned have been achieved.

125 Tollgate Review Tools Tollgate Review Plan Tollgate Review Do Tollgate Review Check Tollgate Review Act Tollgate Review Standardize The diagram below indicates how a tollgate review is carried out at the end of each stage. When the goals have not been met, activities within the stage need to be re-visited. For example, Check Sheets, Project Deliverables Document and List of Milestones. Read more:

126 Tollgate Preparation To ensure successful tollgate review outcome, it is important to conduct pre-review groundwork. This may involve the following: Ensuring all required attendees are informed of the review. Blocking time in everyone’s work-day for the duration of the review. Preparing a suitable presentation consisting of check sheets, milestone lists, etc. for review. Creating a structured agenda for the presentation. Read more:

127 Build individual task lists Milestones Assignments Measures Accountability Final outcomes 127 Set project deadlines

128 A Gantt chart is a matrix diagram The vertical axis lists all the tasks to be performed for a project Each row contains a single task identification The horizontal axis is headed by columns indicating estimated task duration in hours, days, weeks, months, etc. Gantt Charts



131 Henry L. Gantt – WWI Franklin Arsenal 1910 Progress Chart Work planned and accomplished are shown in the same space Emphasizes work movement through time Deals with plans and progress Helps identify and eliminate obstacles Gantt Chart

132 Establish order of tasks: Sequential and Parallel Identify resources requirements Timing of resource needs Identify the critical path Monitor the project “On-Time” Schedule Alerts where remedial action is required Use Of Gantt Charts

133 Task: City of XYZ HD29-Feb7-Mar14-Mar21-Mar28-Mar Finalize assessment analysisX Gain consensus on prioritiesX Identify comm. with elected off.X Plan PHF consultant visitX Set agenda and travel scheduleX City HD/PHF PI meetingX On Schedule Watch Late or at Risk Traffic Light Gantt Chart

134 Communication Activity Time allotted: 20 minutes In your QI teams, identify: Team Sponsor Process Owner Key Stakeholders Core team members Draft a timeline for communicating team progress with each of the above individuals. Identify the communication subject and choose either formal or informal format. Be prepared to share your thoughts with others.

135 TEAM # 7 QI TOOL


137 Audience Analysis Definition: Study that describes the nature of the worker or students. Who are they? What do they already know? Are they confident? Have they volunteered to participate? How many are in the target population? Are they local or remote? What kinds of technology support are available to them? Are their managers interested in this topic? Are their managers supportive of their career growth?

138 Analyzing the training needs Definition: Study to design and develop instructional and informational programs and materials. After the performance analysis has determined that training or informational materials are indeed appropriate Needs assessments involve: Subject matter study Audience analysis Determination of prerequisite skills and attitudes Error and work product examination Resolution of disagreements among experts Definition of the details that drive training approaches

139 Activity:Describe your audience Time allotted: 15 minutes Assume that you have been asked to facilitate an improvement project in your own local HD Answer as best you can the questions on the audience analysis slide using your HD colleagues as the “target population.” How would you estimate the skill and attitude level of your LHD colleagues in QI tools and techniques? Entry, Working Knowledge, Advanced? Be prepared to share your assumptions with the class.


141 TEAM # 8 QI TOOL

142 Building the agenda and materials exercise Time allotted: 40 minutes Using all the materials and activity output from the last session and this session: Draft an agenda for training your Health Department on QI tools and techniques. List the materials you will use to introduce and reinforce the lessons you share with the students. Be prepared to share your agenda items and material suggestions with your class mates.


144 Project Presentations 1-8 1.AIM statement 2.SIPOC + CM 3.Flowchart 4.Cause & Effect 5.Measures of Current State 6.Areas for Improvement 7.Timeline 8.Next steps: Current Activities 9.If done: Outcomes 10.Lessons Learned



147 Contact Information Jack Moran T: 207- 439 – 0560 Grace Duffy T: 352-406-8262 cell

148 Organizational Wisdom on Improvement and Change Understand the history behind the current culture. Don’t tamper with systems, improve them. Be prepared to listen and observe. Involve everyone affected by the change in making it.

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