Angela Barron McBride Distinguished Professor-University Dean Emerita Indiana University School of Nursing Chair, Board Committee on Quality & Patient Safety Indiana University Health

The need for a 21 st -century view of health care and for 21 st -century health professionals The demand for leadership in light of the development of accountable care organizations Leadership=full career development We must each be prepared to lead change— establishing a sense of urgency, forming a guiding coalition, creating a vision, and so forth Overview of Presentation

20 th -Century21 st -Century Integrated delivery systems/managed transitions Capitated payment; bundled services Outcomes oriented (value of what is done) Focus of care shaped increasingly by evidence- based protocols Care episodic Fee for service Process-oriented (what professional does) Focus of care shaped largely by expertise of providers Shifting Paradigms: Health Care

20 th -Century21 st -Century Wring out unnecessary variation No time/place limitations Team-based care Emphasis on improving context for provider- patient relationships Workarounds/variation the norm Care time and place bound Organized into hierarchical professional silos Emphasis on provider- patient relationship

Defenses ACCIDENT Individual Institution Information Technical Organization Complex System Failure: Quality and Safety Involve Much More Than the Behavior of the Individual Provider 5

Accountable Care Organizations 6 Integrated delivery systems that align financial incentives, electronic health records, team-based care, and resources to support cost-effective, non- fragmented quality care New clinical models characterized by greater coordination and collaboration, evidence-based protocols, and information flow across the care continuum New payment models that reward providers that can deliver higher value—bundled payments, readmission penalties, shared savings

Information technology assumes greater importance— increasingly coordinated, reliable, integrated and cost- effective care made possible by embedding best practices into clinical workflows and sharing vital clinical data about patients across episodes and times ACO focus more necessary than ever before because of economic constraints, aging of population, increasing prevalence of chronic disease, and the patient safety agenda

ACO Ideas Shaped by Many IOM Reports 8 Crossing the Quality Chasm (2001) emphasized safety, effectiveness, patient centeredness, timeliness, efficiency, and equity Health Professions Education: A Bridge to Quality (2003) said all healthcare professionals need to be prepared to provide patient- centered care, work as part of interdisciplinary teams, employ evidence-based practices, apply quality-improvement methods, and utilize informatics

9 Keeping Patients Safe. Transforming the Work Environment of Nurses (2004) urged that nurses exert transformative leadership, take responsibility for the design of work and workspace to prevent and mitigate error, and serve as prime movers in developing non-fragmented organizational cultures of safety

Leadership Demanded 10 Leadership is inspiring and catalyzing others to realize shared mission and goals in a complex environment that is constantly changing and requiring us to design new ways of achieving our values Not synonymous with administrative title Ranges from individual performance and productive teamwork to inspiring higher performance in others and creating enduring excellence (Collins, 2006)

More Important Than Ever Before  Leadership as personal—analytic, creative, resilient, courageous, responsive, self-aware, self-regulating, persistent, tolerant  Leadership as goal attainment—problem solving, team building, interpersonal and communication effectiveness, resource development (human and otherwise), managing performance  Leadership as transformational—grasp of complexity, strategic vision, innovation, altering organizational realities, choosing excellence

Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-Wesley. Dalton, G. W., Thompson, P.H., & Price, R. L. (1977). The four stages of professional careers: A new look at performance by professionals. Organizational Dynamics, 6, Leadership=Full Career Development

Preparation Independent Contributions Development of Home Setting Development of Field/Health Care Gadfly (Wise Person) Period Key Transitions in A Career and Mentoring Needed

Stage I. PREPARATION Central Activity: Learning Primary Relationship: Student, Teaching/Research Assistant Major Theme: Assimilating values, knowledge base, and clinical/inquiry skills important to a practice profession and health care

Stage I Mentoring Model values and practices Encourage problem solving Help set short-term and career goals Guide to experiences that build skills and expand vision Welcome to profession and identity as a healthcare leader

Stage II. Independent Contributions Central Activity: Demonstrating ability to work independently and interdependently, while moving from fledgling to competence Primary Relationship: Colleague Major Theme: Dealing with the inevitable gap between ideals learned and the realities of work setting

Stage II Mentoring Help navigate inner workings of institution Direct to resources Involve in governance Facilitate networking Provide feedback so abilities improve Keep focus on meeting institutional and professional benchmarks of success

Stage III. DEVELOPMENT OF HOME SETTING Central Activity: Facilitating home institution while moving personally from competence to expertise Primary Relationship: Mentor, Committee Chair, Manager, Supervisor Major Theme: Assuming responsibility for development of others and of setting

Stage III Mentoring Help ask right question(s) Provide feedback regarding strategy and tactics Suggest possible “next steps” Discuss how to improve mentoring Help person make best use of others Nominate for opportunities

Stage IV. DEVELOPMENT OF FIELD AND HEALTH CARE Central Activity: Shaping future of health care and profession/specialty Primary Relationship: Leader, Board Member, Administrator Major Theme: Exercising power of authority and creating a vision for the future

Stage IV Mentoring Recommend for discipline-specific and inter-professional opportunities Provide tips on effective board behavior Expand vision Help strategize Sponsor for honors

Stage V. GADFLY “Wise Person” PERIOD Central Activity: Continue to shape health care and profession Primary Relationship: Coach, Leader, Board Member Major Theme: Exercising power of authority when no longer constrained by institutional obligations

Stage V Mentoring Assist in envisioning “post-retirement” opportunities Discuss how to help today’s leaders

Transformational Change Moving from transitory, isolated performance improvements by many individuals to sustained, integrated, comprehensive organizational change Moving an institution or some aspect of health care down a new path with different expectations, structures, and/or ways of realizing values in light of changing conditions

Establish a sense of urgency Form a powerful guiding coalition Create the vision Communicate the vision Empower others to act on the vision Plan for and create short-term wins Consolidate improvements and produce more change Institutionalize new approaches (Kotter, 2005) Leading Change

There aren’t enough resources to continue business as usual, and resources are likely to decrease further, yet our current level of quality isn’t what we want To attract both, clinical facilities must be a values proposition for patients and staff alike— respectful and supportive—but our HCAHPS scores aren’t as we would wish nor are our staff’s beliefs about the quality of our environment what we would wish Establish A Sense of Urgency

Maximum reimbursement is going to be tied increasingly to realizing the highest levels of quality and millions of dollars are at stake, e.g., Anthem contract Readmission penalties already exist and additional penalizations are likely to be instituted if organizations do not meet quality goals

A shared emphasis on our clinical facilities each becoming “a community of learning”—this implies that all concerned are truly committed to lifelong learning and constantly improving how we identify and address problems and how we deal with people who do not demonstrate our values Certain behaviors will not be tolerated—belittling, humiliating, withholding information, acting in a condescending manner—and organizationally acceptable ways of addressing these problems will be developed and implemented by one and all Form A Powerful Guiding Coalition

One way each hospital will become a learning community is to establish a mentoring culture whereby senior individuals consistently work to promote the development of more junior individuals Building an effective mentoring culture requires that all concerned know how to give feedback in an ego-enhancing fashion and themselves regard feedback on their performance as the key to professional growth

Team-based care, characterized by coordination and collaboration, is the means by which each hospital will improve outcomes and become an Accountable Care Organization because….. Faulty communication is a factor in almost all errors For maximum effectiveness, everyone must work at the top of her/his license and abilities, and we must use the overall expertise of the team in fashioning inter-professional care plans Create A Vision

inspiring and catalyzing others to realize shared mission and goals in a complex environment that is constantly changing and requiring us to design new ways of achieving our values Are We Each Prepared to Exert Leadership?