WHA Improvement ForumFor 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

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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.

We all have two jobs

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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.

Institutionalize Accountability

Question: Can the QI department be totally accountable for clinical and patient outcomes?

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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.

Clinical Areas & Accountability

• Clinical areas that “do the process” are naturally the only people who can effect the outcome.

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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.

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“If you do it; you own it”

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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?

Identifying Root Causes

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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!

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What You Might Hear

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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

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

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Typical Reasons1. 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

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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

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Addressing AccountabilityTaking 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)

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T-L-T DefinedTight – 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.

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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.

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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.

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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

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What & Who? How? By When? What you will get:

Loose Loose Loose Chaos; the ‘tail wagging the dog’; ineffective, “loose-y goose-y” workplace.

Tight Tight 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 Tight Loose Staff work on projects and seem busy, but no real beneficial outcome occurs (i.e. projects that go on forever….)

Tight Loose Loose Poorly executed delegation, empowering staff handle the why, but forgetting the outcome

Tight Loose Tight Staff that know what is important, and what is expected – and get the job done.

The Secret Formula

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Tight - Loose- Tight

Results!

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

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The Tight-Loose-Tight Worksheet for Managers

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Tight – Loose – Tight Worksheet

Using the Tool - Example

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Using the Tool - Example

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Using the Tool - Example

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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.

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Institutionalizing Accountability

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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.

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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

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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.

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Next Month: September 26

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Managing the Improvement “Portfolio”

SeptemberNoon

Methods for Sustaining great outcomes Monitoring Multiple Projects Taking Action when Action is Needed

References• Quality Improvement Workbook Sections 1 and 5

• The Improvement Guide: A Practical Approachto Enhancing Organizational Performance, Langley,

Moen, & Nolan

• WHA Quality Center Tools and Templates http://www.whaqualitycenter.org/PartnersforPatients/PfPTools.aspx

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AnnouncementsPartners 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 21st, 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)

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Thank You!Questions

Please complete 3 question survey when closing webinar window.

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