1. Unpacking Executive Accountability
Thursday 22nd July 2010
What gets my back up: “The Board seem focused and work well together, and there many examples of clinical excellence and high quality care delivery, but…. the problem is middle management.
I am not here as an expert. I am here as a colleague who has sat where you are sitting and have a sense of respect for what you are dealing with.
Want to offer you some perspectives of things I have learnt through my involvement in the 1000 Lives Campaign that I hope might be relevant to you.
It is important to do this, because, the Campaign talked a lot explicitly about Board level engagement, and about clinical team engagement, but it talked very little about the critical centre.
Unpacking Executive Accountability
Tim Heywood
Insert name of presentation on Master Slide

2. Some questions for today…
Who should be an ‘Executive lead’?
What do they need to do?
How should they interact with improvement teams?
What should they do when they encounter problems?
What does this mean for organisational arrangements?

3. Who should do it?
Accountability for all improvement programmes must track all the way from a clinical team to the Board.
This means that the chain of accountability for all improvement programmes should explicitly name an accountable Executive Director.
Some reasons to include all Exec Directors:
It is a useful way of giving a signal to the wider organisation that quality and safety improvement is core business for the whole Board.
May ‘shorten’ the route to the Board.
It can enhance Board level understanding and joined up thinking about the implications of using the Model for Improvement as an improvement tool.
Exec Directors (particularly those not primarily clinically facing) find it rewarding and energising.
Senior leaders who are not Executive Directors can fulfill the role well, as long as:
Their delegated role on behalf of an Executive Director is clear and explicit.
They have clearly delegated responsibility and authority to make the decisions required to hold teams accountable and remove obstacles to progress.
Further delegation may be appropriate, but the same rules apply. Remember – delegation does not absolve you of accountability.
(for the remainder of this session, I will use the term ‘Executive Lead’ to refer to the person with delegated responsibility and authority to Execute an improvement programme) Ge

4. The Framework for Execution
Achieve strategic Aims
Manage local improvement
Develop workforce
Spread & sustain
Build leadership
and accountability
Exec Team
Divisional Teams
Directorate/locality Teams
Ward/department teams
This is a modified version of the Model for Execution that is included in the ‘Leading the way to quality and safety Improvement guide’.
When working on the early stages of an improvement programme, it can be appropriate for the organisational level leader to work directly with frontline teams, finding out what the real system issues are, and supporting and challenging through use of data. However, as entering the spreading and sustaining phases requires far more focus on Directorate and Divisional roles.
Directorates and localities also importantly initiate improvement activities, but they must be clear about how this links to organisational level purpose and priorities.

5. What the executive lead needs to do: 1. Clarify purpose
What are we trying to do? (e.g.design a new process? Improve an existing one?)
Why is this important?
How does it link to organisational priorities? (reducing harm, waste and variation).
How does it impact on patients?
What data/analysis supports this choice?
What is the potential downside of the effort?
What are the expected outcomes
Specific objectives to be achieved
Quantified goals to be attained
Impact on quality and cost
Driver diagrams can really help here….
What are we trying to do – e.g. design a new process, improve an existing product or service

6. What the executive lead needs to do: 2. Use the Model for Improvement
Understand the importance of testing, implementing reliable processes, spreading and sustaining changes.
Be alert to words like ‘audit’; ‘pilot’ and ‘roll-out’
Always insist on basing conversations around the data.
The requirement to ‘implement or justify’ does not mean abandoning the M4I methodology

7. What the Executive lead needs to do: 3
What the Executive lead needs to do: 3. Understand what measures are for
Measurement for Improvement
Measurement for Assurance
Board level
Frontline team level
Core assurance measures
Mortality rates
Harm rates
Improvement measure e.g.’s
Care bundle compliance
Uptake of evidence-based
practice
Measuring for improvement and measuring for assurance are different. The AOF requirements to demonstrate requirements are a snapshot of the improvement journey – the assurance is around whether people are looking at and measuring the right things.

8. Characteristics of measurement indicators
Measurement for assurance
Unambiguous interpretation
Unambiguous attribution
Definitive marker of quality
Good data quality
Good risk adjustment
Statistical reliability necessary
Cross-sectional
Used for sanctions and rewards
For external use
Data for public use
Stand alone
Risk of unintended consequences
Measurement for improvement
Variable interpretation possible
Ambiguity tolerable
Screening tool
Poor data quality tolerable
Partial risk adjustment tolerable
Statistical reliability preferred
Time trends
Used for learning/changing practice
Mainly for internal use
Data for internal use
Allowance for context possible
Lower risk of unintended consequences
Source: Raleigh and Foot (2010) – Getting the Measure of quality improvement opportunities and challenges. Kings Fund

9. Make sure the right people will be attending.
What does this look like in practice – Formal review meeting between the executive leader and team..
Beforehand…
Make sure the right people will be attending.
Clarify the purpose and meeting process with the team in advance.
Ask for a one-page report – with data.
Check your own understanding of how this project fits with organisational priorities and aims.
Formal reviews are important.
Executive leadership happens when the leader meets the team – not when the leader sits round the table with other leaders.
This is a review meeting, not a WalkRound…
The ‘right people’ will depend on what level of spread you are at.. 9

10. Bringing the requirements together –During the review meeting..
Ask the team to describe their purpose to you (check they understand the organisational context).
Move straight to the data.
Ask about the tests of change and how these link to data run-charts.
Check where the team is getting its ideas
clarify the obstacles and barriers to progress
Formal reviews are important. This is a review meeting, not a WalkRound… But some similarly specific guidance can be helpful… 10

11. Obstacles and barriers
When progress is difficult, this is likely to relate to one or more of the following:
Failure of Will e.g. a few strong “blockers,” lack of investment in training and education, lack of back-up from the Board level.
Failure of Ideas e.g.Haven’t read the ‘How to’ Guide, or not participating in Learning Sets.
Failure of Execution e.g. The leader does not have the authority (as well as the responsibility) to deploy the resources s/he needs. Cross- service links have not been clarified. Competing priorities have not been reconciled. The Model for Improvement is not being used. 11

12. Can you short-cut the M4I?
Level of team commitment
to the change
Risk

13. Bringing the requirements together – Following the review meeting..
Feed-back the agreed actions to the team.
Check you have clarified the obstacles and barriers to progress that they need you to sort.
Take actions within your scope of delegated authority.
Communicate outstanding actions to the person to whom you are accountable (SBAR format is useful here).
Formal reviews are important. This is a review meeting, not a WalkRound…
This is about a chain of accountability… if you are a directorate a manager you need to be clear about who you are accountable to for progress. 13

14. Spreading improvements How not to do it..
Do not start with a large scale pilot devised by experts.
Do not rely on one person to champion and deliver changes.
Do not expect sheer hard work and vigilance to sustain your changes
Do not ‘roll-out’ changes: spread requires active testing.
Do not ask a team that has been successful in one area to take responsibility for large-scale spread.
Do not look at data quarterly – data on progress needs to be gathered frequently to inform decisions about changes.
Do not hold teams accountable for outcomes straight away – hold them accountable for delivering reliable processes

15. So what does this mean for organisational structures

16. Division/Clinical Programme Group
Accountability between the Board and each improvement progamme must be clear
Levels of delegated authority and accountability will change as programmes progress, but the leadership requirements do not. More complex links make delegation more challenging
Division/Clinical Programme Group
Diretorate/ locality
Ward/ service team

17. Next steps
Get your teams ready for Learning Set 1 of forthcoming mini-collaboratives:
Falls - 21st September
HCAI - 13th September
Medicines Management - 29th September
Chronic Heart Faiure - 9th September
Mental Health - 1st October

18. For feedback, comment or further advice, contact