1. The 4 Disciplines of Execution Quality Forum 2015
BC Patient Safety Quality Forum – Rapid Fire Session
February 19, 2015
Michael McMillan, Chief Operating Officer, NI HSDA
Suzanne Campbell, Director Community Services, Prince George
Sherri Tillotson, Manager Surgical Inpatients, UHNBC

2. Improving Patient Flow
- The 4DX Approach -

3. The 4 Disciplines of Execution
Chris McChesney, Sean Covey & Jim Huling, the authors of the book the 4 Disciplines of Execution have studied this common problem through countless organizations. They have distilled the common elements among organizations who seem most able to successfully execute on their most important goals.
We have a video clip that gives the briefest of overviews of their thinking, for those who haven’t been introduced to the concepts in the book as of yet.

4. The 4 Disciplines of Execution
Focus on the Wildly Important
Act on Lead Measures
Keep a Compelling Scoreboard
Create a Cadence of Accountability
The video clip introduced some really important concepts worth highlighting.
They’ve taken this knowledge and developed what they call “a roadmap to execution” that helps us:
Discern which goals are the right goals to take on
How to keep our focus on those few goals
How to NOT get consumed by the competing pressure of the whirlwind of everyday operations

5. WIG Wisdoms: The Whirlwind
All the work that is required just to keep your operation going on a day to day basis…
“The enemy of execution”
The whirlwind:
In reality, we know what is presented on the previous slide it’s easier said than done. You will always have to balance the urgency of the whirlwhind with the importance of the WIG
Urgent vs. important:
The Whirlwind is those things that are URGENT.
The Whirlwind acts on you whereas Goals are IMPORTANT; we act on them
A way of looking at this….
If you ignore the URGENT (whirlwind), it can kill you today BUT
If you ignore the IMPORTANT, you may be fine today it will kill you tomorrow.
The 4 disciplines described by McChesney, Covey, & Huling are proposed as an antidote to the whirlwind stealing our focus

6. 1. The Wildly Important Goal
If everything else remained status quo, what is the one area where change would make all the difference?
VERB, X to Y, by when?
For our organization, the term “WIG” has become a word loaded with meaning:
A WIG means a focused, committed, mission-critical, drop whatever else you’re doing and get this done piece of work.
Has brought a sense of alignment and collaboration.
Don’t ask what is most important because everything is important (Kaizen reveals multiple areas for improvement but then what) Instead ask yourself: if everything else remained status quo, what is the one area where change would make all the difference.
Once you arrive on that goal it is fundamental that you can articulate and create a sense of urgency around the goal
“We’re not advocating goals that are easy to reach. Set a goal that challenges the team to rise to their highest level of performance but not beyond it. In other words, create a WIG that is both WORTHY & WINNABLE.

7. Lead Lag 2. Act on Lead Measures Predictive Retrospective
Influenceable
Unchangeable
Discipline 2:
Distinguish between lead & lag:
LAG
A lag is retrospective – it’s the outcome, its already done. The WIG is a lag measure.
Health care is plagued with lag measures - infection rates, mortality, Musculoskeletal Injuries for staff, etc.
LEAD
Lead measures – are what we can act on to generate a change. Often require a change in practice or behaviour.
The LEAD you select must have a laser sharp connection to the overall Wildly Important Goal.
We are starting to get better at lead measures – measures like completion of our surgical safety checklist, use of stroke protocols - are predictive of a better patient outcome.
We have found that Lead measures can be tricky to measure; BUT powerful because when lead measure changes you can predict the lag measure will also change
Influence-able – Needs to be related to action or behaviour change that the team themselves can do – not be dependant upon others changing. Similar to other QI approaches in empowering staff directly to own the change. .

8. 3. Keep a Compelling Scoreboard
Motivation
Engagement
The scoreboard is for the whole team. To drive execution you need a PLAYERs scoreboard that has a few simple graphs on it indicating:
Here’s where we are right now, and there’s where we need to be.
Is it simple?
(Think football. As a coach, you need lots of data – but the players don’t…)
Can the team see it easily? It HAS to be visible to the team – Visibility drives accountability
Can we tell at a glance if we’re winning?
Lead measure data is hard to get and most teams don’t have sytsems for tracking lead measures – but success on lag measure absolutely requires tracking the lead measures
It the WIG is truly wildly important, you must find ways to measure the new behaviours

9. 4. Create a Cadence of Accountability
Hold WIG sessions as scheduled – same day, same time, regardless of the whirlwind
Keep the WIG session brief (20-30 min)
Set the standard as a leader: begin every WIG session by reviewing the overall results on the scoreboard and then reporting on your own commitments.
Post the scoreboard – update it before the meeting (or if you have delegated this task, make sure it is done ahead of the WIG session)
Celebrate successes – both individual and team
Share learnings
Refuse to let the whirlwind enter
Clear the path for each other
Execute in spite of the whirlwind – hold team members unconditionally accountable
The rigour: Spend a disproportionate amount of time on the lead measure - 20% of your time
McChesney, C., Covey, S., & Huling, J. (2012) The 4 Disciplines of Execution. New York: Free Press

10. By Jan 31, 2015, increase from 35% to 55%, the # of patients admitted through the UHNBC ED being transferred to an inpatient bed within 10 hrs of triage
ALC designation
No more than 15 net new ALC patients in hospital by Jan 2015
Complete a discharge screen on all patients
Schedule discharge meeting date for patient identified as “complex”
Host discharge planning meeting for patient identified as “complex”
Care Planning
Have a visible, and up to date care plan, from 0 to 100%, on medical & psychiatric patients by Jan 2015
Estimated date of discharge on all patients
Activate, on admission, a Plan of Care for 100% of patients
Utilize Plan of Care documents in daily huddles and update as required
Responsiveness of services
Mobilize community services to meet urgent clients needs for home support within 8 hrs of identification 90% of the time by May 2015
4DX Prince George
So how did we bring the 4DX to life in Prince George. Our wildly important goal, probably similar to many of you in the room was around the ED wait times – we brainstormed around the lag measure – identifying many buckets of work that could influence the WIG and landed on what we thought were the three biggest influencers: current occupancy of beds within the hospital – represented by our ALC bucket of work; patient planning & flow moving through their stay – represented by care planning bucket; and we know that the ability of our community services to respond impacts our Eds. Within each of those buckets of work – we identified a lead measure, which we then cascaded down even further to further identify key processes necessary to achieve each of these leads.

11. What Have We Learned - methodology
Strengths
Struggles
Brings organizational focus
Complexity of healthcare
Builds discipline & accountability
Success requires 20% of our time
Measuring activity
Measuring quality
CUSP and releasing time to care – we felt 4DX superior than other methods because of focus
Culture
Quality
Measurement ought to be derived from process
In healthcare - the whirlwind is actually a category 5 tsunami with competing priorities that have the same sense of urgency
Not too dissimilar from any other approach that says engagement at the ground level

12. How are we doing?
Discuss the overcapacity challenges, flu season, and the intense overcapacity and yet we haven’t WORSENED. Perhaps we are bending the curve!?

13. “You have to decide what your highest priorities are and have the courage - pleasantly, smilingly, unapologetically - to say no to other things. And the way you do that is by having a bigger “YES” burning inside.”
Key Takeaways:
Our efforts at work can be thought of like the energy from the sun:
It can radiating out in a multitude of directions – diffuse, warm, OR
We can focus that same energy together to ignite change.
To do this we must:
Learn how to say no to good ideas
Don’t try to make everything in the whirlwind a goal.
Because there will always be more good ideas than there is capacity to execute….pg. 29.
Eg. Tim Cook – CEO of Apple to shareholders: “WE are the most focused company that I know of or have read of or have any knowledge of. We say no to good ideas every day. We say no to great ideas in order to keep the amount of things we focus on very small in number so that we can put enormous energy behind the ones we do choose. The table each of you is sitting at today, you could probably put every product on it that Apple makes, yet Apple’s revenue last year was $40 billion.

14. Learnings and Benefits
One Wildly Important Goal is difficult to define
Discipline and focus is necessary for implementation
A ‘Cadence of Accountability’ is necessary
Other Projects
Increased residential bed capacity
SAMI Programs
Rapid Home Support
High Acuity Beds
Master Planning