1. Conflict of Interest Declaration
We declare that we have no conflict of interest linked to the work presented.

2. High-Impact Leadership
Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; Available on

3. New Mental Models “Volume” “Value” Patient Satisfaction
Increase Top Line Revenue
Complex All-Purpose Hospitals and Facilities
Quality Departments and Experts
“Value”
Persons as Partners in their Care
Continuously Decrease Per Unit Cost
Care Organized by Business Model
Quality in Daily Work-Everyone

4. High-Impact Leadership Behaviors
Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; Available on

5. High Impact Leadership

6. “If you are dreaming about it… you can do it.”
Sensei Chihiro Nakao

8. Why is Change So Hard?
Culture Lack of Shared Vision Misaligned Expectations No Urgency Ineffective Leadership

9. Compact Expectations members of an organization have that are:
Unstated yet understood
Reciprocal
The give
The get
Mutually beneficial
Set up & reinforced by society and the organization 9

10. Clash of “Promise” and Imperatives
Traditional “Promise”
Legacy Expectations
Imperatives
Improve safety/quality
Implement EHR
Create service experience
Be patient-focused
Improve access
Improve efficiency
Recruit/retain quality staff
Autonomy
Protection
Entitlement 10

11. Vision Is Context for Compact
Societal needs
Local market
Competition
Organization’s strengths
Physicians give:
What the organization needs to achieve the vision
Organization gives:
What helps physicians meet commitment
What is meaningful to physicians
STRATEGIC VISION

12. Virginia Mason Medical Center Physician Compact
Organization’s Responsibilities
Foster Excellence
Recruit and retain superior physicians and staff
Support career development and professional satisfaction
Acknowledge contributions to patient care and the organization
Create opportunities to participate in or support research 
Listen and Communicate
Share information regarding strategic intent, organizational priorities and business decisions
Offer opportunities for constructive dialogue
Provide regular, written evaluation and feedback
Educate
Support and facilitate teaching, GME and CME
Provide information and tools necessary to improve practice 
Reward
Provide clear compensation with internal and market consistency, aligned with organizational goals
Create an environment that supports teams and individuals
Lead
Manage and lead organization with integrity and accountability 
Physician’s Responsibilities
Focus on Patients
Practice state of the art, quality medicine
Encourage patient involvement in care and treatment decisions
Achieve and maintain optimal patient access
Insist on seamless service
Collaborate on Care Delivery
Include staff, physicians, and management on team
Treat all members with respect
Demonstrate the highest levels of ethical and professional conduct
Behave in a manner consistent with group goals
Participate in or support teaching
Listen and Communicate
Communicate clinical information in clear, timely manner
Request information, resources needed to provide care consistent with VM goals
Provide and accept feedback
Take Ownership
Implement VM-accepted clinical standards of care
Participate in and support group decisions
Focus on the economic aspects of our practice
Change
Embrace innovation and continuous improvement
Participate in necessary organizational change

13. The VMMC Quality Equation
Q = A × (O + S) W
Q: Quality A: Appropriateness O: Outcomes S: Service W: Waste

14. Our current management system?
© DC Comics

15. World-Class Management
Daily Management:
Leaders Have Two Jobs
Run your business
Improve your business
Daily Management
So what is Daily Management? It is what leaders are doing everyday and how they act every day to meet customer demand and identify and solve problems with their team.
Know at a glance status of daily work
Completing planned work
Understand status of upstream and downstream processes
Variance from standard work and causes
What action to take when variance occurs (countermeasures)
Engage the staff to take action

16. The FIVE Principle Elements of Daily Management (Standard Work for Leaders)
Visual Controls
Create linked visual systems that drive action
Daily Accountability Process
Establish rounding process at all levels
Leader Standard Work
Leaders routinely complete key activities necessary to run and improve their business
Discipline
Leaders consistently verify the health of processes and systems
Root Cause Analysis
Asking “why” and using data and analysis to attack problems
This
Or This
As we looked at these metrics, and went back to our Toyota training and readings to see what we were missing, we realized that we had tacked the tools and methods from Toyota onto our existing management methods. Emphasis on plural as we had as many methods as we had managers. No wonder our managers were telling us that they were too busy to do their improvement work. We hadn’t fundamentally changed how we were running our organization. And we certainly weren’t all doing our work as leaders in a standardized way.
What we learned when we went back to our training is that we had neglected to understand the importance of having all of the components of what Toyota calls a “world class management system” in place in order to allow us to create an environment where we could both make the improvements and sustain them.

17. Leaders’ Role in Signal Generation
“Leaders are signal generators who reduce uncertainty and ambiguity about what is important and how to act.”
Charles O’Reilly III
This
Or This
As we looked at these metrics, and went back to our Toyota training and readings to see what we were missing, we realized that we had tacked the tools and methods from Toyota onto our existing management methods. Emphasis on plural as we had as many methods as we had managers. No wonder our managers were telling us that they were too busy to do their improvement work. We hadn’t fundamentally changed how we were running our organization. And we certainly weren’t all doing our work as leaders in a standardized way.
What we learned when we went back to our training is that we had neglected to understand the importance of having all of the components of what Toyota calls a “world class management system” in place in order to allow us to create an environment where we could both make the improvements and sustain them.

18. “Distress” and Adaptive Work
Disequilibrium
Limit of tolerance
Adaptive challenge
Productive range of distress
Threshold of learning
Time
Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108

19. VMPS Standard Work for Leaders
CEO
Board
COO
Board VP
Board AD
Board
Director
Board
Supervisor Board
Front Line
Board

20. Effective Sponsorship
Vision of success
Set stretch goal
Provide resources
Remove barriers
“Fail forward fast”
Celebrate achievements

21. Genchi Genbutsu “It’s all lies” Go where the action is
Know your people and let them know you
Vulnerability is ok
Connect the dots

22. Managerial Courage It will be worth it Patients and staff depend on it
Leading change is hard work
Skeptics can become champions

23. Flu Vaccination “Fitness for Duty”
Do we put patient first?
Compelling science
Staff resistance
Staying the course
Organizational Pride

24. VMMC Influenza Vaccination Rates

25. Ongoing Challenges - Culture
Patient First
Belief in Zero Defects
Professional Autonomy
“Buy In”
“People are Not Cars”
Pace of Change
Victimization
Leadership Constancy
Rigor, Alignment, Execution
Drive for Results

26. Copyright © 2009 Virginia Mason Medical Center. All Rights Reserved.
“In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists.”
Eric Hoffer
Copyright © 2009 Virginia Mason Medical Center. All Rights Reserved.

27. Creating a Culture of Quality and Safety
Making Excellence a Way of Life
James M. Anderson
President and CEO,

28. 2

29. Cincinnati Children’s (Fiscal 2013)
Registered beds 598 Operating revenue $1.9 billion Employees 13,852; 97 nationalities Research grants $158 million Locations 16 Patients from 50 states; 53 countries Department of Pediatrics for the University of Cincinnati College of Medicine

30. 4
Video

31. Tressel Fragile System Transparency5
Tressel
Fragile System
15 years of intense work improving quality and safety
34% decrease in hospital-wide mortality
43% decrease in ICU mortality
Transparency
With families
With employees
With other institutions
With the outside world
We need to be able to talk about these things

32. Requirements to Create a Culture of Quality and Safety6
Requirements to Create a Culture of Quality and Safety
Vision: Take time to develop it thoughtfully Plans: Focus on what needs to be done, not on trailing results, like financial results Consistent message: Consistent behavior, even when there is increased risk Management process that delivers sustainable outcomes

33. Our Vision: To be the leader in improving child health7
Our Vision: To be the leader in improving child health
If we can deliver outstanding results in some areas, why not all?
What results are we delivering?
How are we measuring them?

34. 8
Creating a Culture

35. Business Units: Participants9
Business Units: Participants
Physician, nursing and business leaders
Shared objectives
Single budget
Access to senior leadership team
Predictable, recurring meetings

36. Business Units: Template Reports10
Business Units: Template Reports
Financial
Activity over time expressed in numbers
Holistic view as a framework for change
Non-financial
How will we be safer, more accessible, patient-centered, innovative?
Focused attention on transformation

37. Other Tools Real time data Strategic planning Transparency11
Other Tools
Real time data
Strategic planning
Transparency
High-reliability systems
Learning from other high-risk industries

38. 12
Final Thoughts
Each part of the organization must perform well for the whole organization to perform to potential
Organizational structure reflects priorities
Mechanisms must be hard-wired, predictable and must foster agility
Institutionalize boundaryless thinking, risk taking, transparency, small tests of change
Institution needs a shared, compelling vision and high aspirations

39. Creating a Culture of Excellence
Michael J. Dowling
President & Chief Executive Officer
North Shore-LIJ Health System
Paris, France
April 2014

40. North Shore-LIJ Health System

41. The System Today Partnerships Clinical Enterprise
Educational Enterprise
Research Enterprise
Insurance Enterprise “CareConnect”
Community Health Enterprise
Inpatient facilities
Ambulatory / outpatient
Long Term / Home Care
Hospice
Joint ventures
GME / CME
Medical School / Elmezzi
CLI
Discoveries
Publications
Clinical trials
Risk
Capitation – Bundled payments
Product offerings
Joint product offerings
Employer products
Population health
Community benefit
Access and education programs
Veterans’ programs
Children’s programs
Partnerships

42. An Integrated System
Largest provider of health care in NY State – one of the largest employers
Major academic teaching center
Major commitment to research – The Feinstein Institute
Single governance – not just a collection of distinct, individual entities
Administratively and clinically integrated; Service Line approach to care delivery
Single system-wide management – clinical and administrative
Densely populated; competitive and diverse environment
Provides full continuum of care
Possesses insurance license and capabilities to take risk and sell products

43. We’re With You Every Step of the Way

44. North Shore-LIJ Culture Blueprint

45. Behavioral Expectations: Core Competency Model
Individual Contributor
Team Leader
Operational/Strategic Leader
Competency #1
Execution: Displays technical and functional expertise. Takes ownership of work, structures job tasks and maintains appropriate pace in handling multiple deadlines to achieve excellence by:
Behavioral Demonstration
Completing assigned tasks accurately and within established timeframes and budget, and adopting a resourceful and results-driven approach.
Ensuring team performance in achieving excellence through organizing resources, adjusting for complexities, measuring results, and planning for improvements.
Creating a culture of excellence and accountability through motivation of talent, translation of strategy into reality, exercising sound judgment, and aligning communication, people, processes and resources.
Competency #2
Organizational Awareness: Understands how to overcome obstacles and ably works through the realities of a large healthcare organization. Applies best approaches to achieve business goals by:
Collaborating with peers, managers and internal/external customers to solve problems in formal and informal settings and within the guidelines of key policies and practices.
Displaying superior understanding of group behavior and organizational politics, culture and operations, and exhibiting strong decision-making skills that align to key business priorities and objectives.
Understanding the competition, creating solid cross-functional partnerships, and successfully navigating the organization’s culture to obtain the buy-in necessary to drive critical business outcomes.

46. Individual Contributor Operational/Strategic Leader
Team Leader
Operational/Strategic Leader
Competency #3
Enable Change: Willingly adapts to shifting business needs and seeks opportunities to champion new processes and ideas. Anticipates and responds to change to improve work outcomes by:
Behavioral Demonstration
Seeking and acting on feedback to identify improvement opportunities, displaying enthusiasm for expanding one’s knowledge and scope, and thinking differently to find new solutions.
Regularly offering feedback, analyzing successes and failures to identify improvement opportunities, and planning for and creating avenues to implement process enhancements within the team.
Creating a climate that embraces new and different solutions, removing barriers that limit change, maintaining a global line of sight, and gaining commitment and partnership from others to execute change plans.
Competency #4
Developing Self: Takes consistent action to increase knowledge and skills. Embraces challenging assignments and seeks learning opportunities to enhance performance by:
Exercising self-accountability for becoming a subject matter expert within one’s own job role, seeking performance-related feedback, and identifying learning opportunities to explore with one’s manager.

47. Behavioral Expectations: Core Leadership Competency Model
Team Leader
Operational/Strategic Leader
Leadership Competency #1
Managerial Courage: Acts with conviction to make the right decisions for the right reasons. Exercises sound judgment and takes action to preserve the integrity of the organization by:
Behavioral Demonstration
Adhering to a strict ethical and moral code in all business decisions and dealings with people, delivering critical messages honestly and effectively, displaying the ability to make difficult decisions in a timely manner, rewarding those who display desirable behaviors, and holding direct reports accountable for poor performance. Also ensures direct reports are compliant with mandatory trainings, educational processes and system initiatives.
Empowering and standing behind direct reports and others to make ethical decisions, removing political barriers that may limit or prevent positive change, and implementing practices to ensure that employees in assigned area(s) are held accountable for their behavior and performance at all levels. Additionally ensures all employees in area(s) of responsibility comply with mandatory training, educational requirements and system initiatives.
Leadership Competency #2
Motivating and Inspiring Others: Leverages and embraces diversity and shares wins and successes. Motivates and energizes others to achieve high-level results by:
Celebrating the efforts and achievements of individuals and teams, creating a feeling of belonging within the team, conveying confidence in the ability of others to make valuable contributions, and ensuring that team members have the skills, support and resources necessary to produce the desired results. Also ensures direct reports are rewarded/recognized for good performance, and that, when appropriate, consequences are delivered to drive the right behaviors.
Creating opportunities to promote team successes at department and system levels, managing with an “open door” policy, ensuring assigned area(s) understand how each contributes to the larger goals of the organization, and continuously taking inventory to ensure assigned area(s) are equipped with the resources necessary to achieve superior results. Additionally empowers leaders in area(s) of responsibility to reward employees for good performance and to deliver consequences, as appropriate, to drive the right behaviors.

48. Operational/Strategic Leader
Team Leader
Operational/Strategic Leader
Leadership Competency #3
Strategic Agility: Seeks opportunity to gain/share expertise with other areas to create innovative strategies. Exercises both narrow and broad perspective to ensure business success by:
Behavioral Demonstration
Demonstrating complete understanding of department’s workflow, operations and necessary skill sets, leveraging the talents of the team to brainstorm and anticipate future consequences and solutions, and partnering with other areas to share knowledge and influence strategy development outside of normal defined scope.
Ensuring operations of assigned area(s) align with the larger organizational goals, establishing formal and informal processes for high performers to become involved in cross-organizational improvement efforts, and leveraging connections with other organizational leaders to develop and execute breakthrough strategies that impact organizational operations on multiple levels.
Leadership Competency #4
Developing Others: Continuously seeks opportunity to develop the capabilities of others. Provides challenging stretch assignments and tasks to enhance departmental performance by:
Holding frequent performance and development discussions with direct reports, providing diverse opportunities for team participation in projects outside of normal defined scope, and shaping team roles to leverage skills, build capabilities and foster team collaboration.
Developing high performers through mentorship and coaching, creating opportunities for joint problem-solving and cross-functional learning through shared projects, and embracing feedback for one’s own improvement.

49. Behavioral Expectations: Core Values
Individual Contributor
Team Leader
Operational/Strategic Leader
Core Value #1
Customer Experience: Addresses the needs of customers to exceed expectations by:
Behavioral Demonstration
Building relationships with customers while understanding and reacting to their concerns and expectations daily.
Maintaining relationships with customers and developing practices to ensure customer satisfaction within assigned area.
Expanding departmental relationships with customers and identifying opportunities to increase customer satisfaction through cross-department collaboration.
Core Value #2
Integrity: Acts honestly and ethically to promote excellence at all levels by:
Respecting others at all times, serving as a role model, and adhering to privacy and confidentiality practices.
Leading by example, protecting confidentiality, and ensuring all team members are empowered to make decisions in the best interests of the organization.
Acting as a leader of leaders to ensure assigned area(s) are held accountable for acting in the best interests of the organization at all times.
Core Value #3
Excellence: Promotes quality in work performance to achieve business outcomes by:
Producing results of the highest standards while demonstrating passion for the job, function, department and organization.
Ensuring the team collaboratively produces results of the highest standards and fostering a work environment that recognizes and celebrates successes.
Ensuring assigned area(s) produce results of the highest standards and identifying/executing opportunities to bring quality to the next level.

50. Individual Contributor Operational/Strategic Leader
Team Leader
Operational/Strategic Leader
Core Value #4
Teamwork: Inspires others to work together to achieve organizational goals by:
Behavioral Demonstration
Helping others to succeed and collaborating to identify and solve problems with the whole team.
Helping direct reports and others succeed through team-building, mentoring, coaching and fostering an environment of workforce engagement.
Helping those in assigned area(s) to succeed through mentoring and creating practices and processes that reinforce teamwork and engagement at every level.
Core Value #5
Caring: Demonstrates empathy toward others to promote an environment of trust by:
Treating everyone with compassion and sincerity regardless of background, appearance or orientation.
Fostering two-way dialogue with customers and direct reports to explore concerns and ideas, and creating a work atmosphere where each employee feels valued.
Establishing practices to ensure a workplace and customer environment where all individuals feel confident that their concerns and ideas will be heard and addressed.
Core Value #6
Innovation: Generates creative solutions to positively impact business goals by:
Displaying openness to and suggesting new ideas, challenging the status quo, and respecting the creative influence of others.
Encouraging the formation of new ideas and promoting an environment where impactful suggestions are recognized and considered for implementation.
Establishing a work environment that welcomes new ideas and assisting assigned area(s) with implementation of ideas through use of leadership and influence.

51. Making the Workforce Your Competitive Advantage
Leadership Loyalty
Ensuring leadership is accessible and loyal to our employees
Recognize Value
Display Caring
Workforce
Engagement:
Creating a multi-dimensional,
trust-based relationship
with the workforce
Recognizing the value of the workforce
Caring for all workforce members and their families
Provide Growth
Providing opportunities for growth and development
Solicit Feedback
Soliciting input from the workforce & involving employees in collaborative decision-making
Respect Diversity
Promote inclusion
Two-Way Communication
Offer Reinforcement
Performance
Management
Clear communication channels between managers and employees
How each employee’s work contributes to the organization’s goals
Linking vision, goals and values to individual performance

52. The Center for Learning & Innovation: Organizational Structure
ORGANIZATIONAL DEVELOPMENT
BEGINNINGS
LEADERSHIP DEVELOPMENT
COACHING
WORKFORCE DEVELOPMENT
CHANGE MANAGEMENT FACILITATION
CUSTOMIZED SESSIONS
PATIENT SAFETY INSTITUTE
SIMULATION BASED EDUCATION
INTER-PROFESSIONAL TEAM EDUCATION
CLINICAL SKILLS EDUCATION
EDUCATIONAL RESEARCH
PHYSICIAN LEADERSHIP INSTITUTE
PHYSICIAN BEGINNINGS
DEPARTMENT SPECIFIC EDUCATION
DEPARTMENT TEAM BUILDING
CLINICAL EDUCATION AT PATIENT SAFETY INSTITUTE
SCHOLAR PIPELINE
ADMINISTRATIVE FELLOWSHIPS
MEDICAL SCHOLARS PIPELINE PROGRAM
NEW YORKERS FOR CHILDREN PROGRAM
INSTITUTE FOR HEALTH PROFESSIONS
IS 59 PARTNERSHIP
DOMESTIC AND INTERNATIONAL INTERNSHIPS
EMERGENCY MEDICAL INSTITUTE
PARAMEDIC
EMERGENCY MEDICAL TECHNICIAN
ADVANCED EMT
AEMT & EMT RECERTIFICATION
ACLS/BLS
CONTINUING MEDICAL EDUCATION
HOFSTRA NORTH SHORE LIJ SCHOOL OF MEDICINE
EVALUATION AND ASSESSMENT
CLINICAL SIMULATION
BIOSKILLS EDUCATION CENTER
ATTENDING AND RESIDENT PHYSICIAN PROGRAMS
HYBRID SIMULATION
VENDOR SPONSORED PROGRAMS
CLINICAL TRANSFORMATION
LEAN / SIX SIGMA PROGRAM
PROGRAM / PROJECT MANAGEMENT
EHR CONTENT DEVELOPMENT
CLINICAL COLLABORATIVES
INDUSTRIAL ENGINEERING

53. How Leadership is Built: Leadership Capabilities
In order for education to make a business impact, it needs to focus on the four core elements of learning. The Business needs to design educational processes that help build capabilities that drive change with knowledge, actions, beliefs and networks.
Knowledge
What do people need to know that is different?
Actions
What do people need to do that is different?
Beliefs
What do people need to believe that is different?
Networks
What networks need to be different?
Self awareness
Team leadership tools
Strategic thinking
Influencing and network techniques
Innovation tools
Lead high performing teams
Demonstrate increased self awareness of strengths and potential derailers
Drive strategy development and market knowledge
Leadership’s impact on strategic results and value
Engagement and play to your strengths
Drive the industry, company and self forward
Collaborative medicine
Program participants and alumni
Support teams and resources

54. 12 Principles of Leadership
Be authentic, accountable and caring
Be humble and recognize the power of team
Energize your culture every day
Paint the picture
Create systems behind the smiles
Be positive and enthusiastic
Grow talent including your own
Communicate and engage
Foster an environment of low fear and high trust
Celebrate innovation and risk taking
Recognize, recognize, recognize
Ethics are everything

55. A Sample of Specific Strategies
Beginnings
Selection, recruitment, on-boarding
Setting expectations early
Talent development and management
Creating multiple opportunities for learning and growth
Identification of emerging leaders and high potentials
Focus on opportunities at all levels of the organization, not just the top
Succession planning
Cross-fertilize and promote transparency

56. Maximize the use of simulation
Real life experiences that enhance teamwork, communication and skill
Engagement and input
Allow free flow of ideas from all parts of the organization
Recognition and reward
Feedback – closing the loop

57. “Perfection is not attainable, but if we
chase perfection we can catch excellence.”
-Vince Lombardi