1. WHA Improvement Forum For August    “Establishing the Accountable Culture”   Jill Hanson & Stephanie Sobczak Courtesy Reminders: Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) Please do not take calls and place the phone on HOLD during the presentation. 1

2. 2 Today’s Webinar Agenda  The “two jobs” in healthcare  Discovering root causes for the lack of accountability  Strategies to “move” toward a culture of accountability.

3. We all have two jobs 3 1.The job we are hired to do 2.Improving the job we are hired to do Because it just doesn’t work to have others change the work we do.

4. Institutionalize Accountability Question: Can the QI department be totally accountable for clinical and patient outcomes? 4 Answer is: Yes. IF your QI department places central lines, administers medications, performs surgical procedures, removes caths, hangs IVs, applies falls/pressure ulcer/VTE interventions, etc.

5. Clinical Areas & Accountability Clinical areas that “do the process” are naturally the only people who can effect the outcome. 5

6. Unintended consequences If the roles become “murky”…. Quality is tasked with reporting and doing Clinical areas are too far removed from their measureable outcomes Everything is a priority Eyes are taken “off the ball” – something is missed Capacity to be agile and adapt to change ( i.e. new evidence, rules and regs ) is limited. 6

7. “If you do it; you own it” 7 1.Are the clinical areas looking at their outcome data? 2.Are both management and front-line care giving staff invested in the outcomes? 3.Are there ‘in process’ measures that help front-line staff see how their daily actions impact outcomes? 4.Are physicians invested in the outcomes and involved in the improvement?

8. Identifying Root Causes 8

9. Identifying When Improvement Stalls You know it might be stalling when…. 1.Failure to launch – never gets off the ground. 2.Gets “re-prioritized” soon after starting. 3.No complaining, questioning or discussion about the topic – it’s too quiet. 4.Begin to notice “regression” - back to the old way. 5.Your measures don’t move or decline. 6.Team members run the other way when they see you! 9

10. What You Might Hear 10 I don’t have time to do this. I can’t get anyone to help me I don’t know what my role is This is another ‘flavor of the month’ We already tried these things We’re doing fine, why do we need to work on it? I thought (____) was going to do that Its not my job to work on improvement My dog ate my PDSA form

11. Are these the true issues, or is there an underlying reason? 11

12. Typical Reasons 1.Lack of clear accountability or lack of a process to hold people accountable. 2.Leaders don’t clearly emphasize the importance of the improvement work during the day to day. 3.Process to move forward isn’t followed (such as PDSA). 4.No one looks at the data, or measurement isn’t even happening  no way to see if the work makes sense. 5.Missed opportunities for coaching or getting feedback on how it’s going. 12

13. Key Root Cause Questions What? – Determine the issue: missing data, not meeting, no progress Who? – The person ultimately accountable for the project outcome – The leader to whom the team reports How? – Ask to see documentation (such as examples of small tests of change) or data regularly When? – Regularly scheduled opportunity to share data/results AND – Just-in-time opportunities to ask 13

14. Addressing Accountability Taking a Tight-Loose-Tight approach to managing can help with issue of accountability The origin is from management guru Tom Peters. He coined the term “Tight/Loose” Later the other “Tight” was added which refers to accountability for the deliverables and/or outcome. (credited to Baldrige consultant Doug Sears) 14

15. T-L-T Defined Tight – What has to be done? Who is accountable for doing it? What the parameters and expectations are? When it should be completed? Loose – How it is done and who gets to participate. Tight – Timelines and deliverables are met; Progress is made and, if not, there are consequences. 15

16. T-L-T Actions Tight – Model the importance of improving quality and safety; make clear who is accountable for leading improvement and actively participating in improvement initiatives. Make clear your expectations for knowing about the progress of the work. Be transparent about limitation – financial or otherwise. 16

17. T-L-T Actions Loose – Give advice to teams; Model effective project management; Provide access to resources; Assist in addressing barriers to the work. Give the team the space to try new things. 17

18. T-L-T Actions Tight – Informally, and frequently, ask for updates on progress; Solicit formal reports; Arrange presentations; Ensure access to key committees for formal reporting, sharing proposals and updates; Insist on seeing data Ensure there are consequences for not following-through 18

19. 19 What & Who?How?By When?What you will get: Loose Chaos; the ‘tail wagging the dog’; ineffective, “loose-y goose-y” workplace. Tight “Micro-managed” staff that seem like they won’t work independently; can’t get along with others; describe work as “walking on eggshells”. Tight Loose Staff work on projects and seem busy, but no real beneficial outcome occurs (i.e. projects that go on forever….) TightLoose Poorly executed delegation, empowering staff handle the why, but forgetting the outcome TightLooseTight Staff that know what is important, and what is expected – and get the job done.

20. The Secret Formula 20 Tight - Loose- Tight Results!

21. What Is Different In This Approach? Makes improvement work more real-time & real Less “management” led and more front-line led Greater emphasis on measuring process Quicker decision making about changes Emphasis on spreading change and adopting change in weeks (not months) Focus on tracking improvement for sustaining success 21

22. The Tight-Loose-Tight Worksheet for Managers 22

23. 23 Tight – Loose – Tight Worksheet

24. Using the Tool - Example 24

25. Using the Tool - Example 25

26. Using the Tool - Example 26

27. Using the T-L-T Tool Review prior to meeting with the accountable person/s Use for self-coaching about T-L-T Not meant to be a permanent tool to use, just to help ‘hardwire’ your management practices around accountability. 27

28. Institutionalizing Accountability 28

29. Governance & Accountability Quality and/or Practice councils: Review the outcomes Make decisions on what are the priorities Communicate the priorities house wide Marshall the resources to do the work Refrain from “doing the work” Hold clinical areas accountable for their outcomes. 29

30. Managers Role in Accountability Ensure the department priorities align with those of the hospital Communicate the priorities to staff & discuss Clearly define expectations ( ex: Is participating in improvement a requirement of the job?) Support with needed resources Apply Tight – Loose – Tight management 30

31. QI’s Role in Accountability Provide a structured approach for improvement. Provide access to the outcome results for the clinical areas. Provide assistance interpreting those results. Advocate for the clinical areas needing assistance. Assist with strategizing plans to take action. Facilitate the process of improvement. 31

32. Next Month: September 26 32 Managing the Improvement “Portfolio” September Noon  Methods for Sustaining great outcomes  Monitoring Multiple Projects  Taking Action when Action is Needed

33. References Quality Improvement Workbook Sections 1 and 5 The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, Langley, Moen, & Nolan WHA Quality Center Tools and Templates http://www.whaqualitycenter.org/PartnersforPati ents/PfPTools.aspx http://www.whaqualitycenter.org/PartnersforPati ents/PfPTools.aspx 33

34. Announcements Partners for Patients – Improvement Leader Fellowship (ILF): Helps staff boost their QI knowledge to better execute their HEN projects as well as future improvement work your organization may take on. Beginning August 21 st, two-hour webinar Fellowship sessions every two weeks through the end of the year. These sessions will blend QI knowledge along with the content of the 10 HEN topics. Low-risk/low-investment to expose staff to this material without having to arrange travel, staff coverage, etc. Each session will provide CEU credits. Questions/More Information – Contact Travis Dollak (tdollak@wha.org) or Tom Kaster (tkaster@wha.org)tdollak@wha.orgtkaster@wha.org 34

35. Thank You! Questions Please complete 3 question survey when closing webinar window. 35