L eading for safety thoughts on structure culture and governance
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L eading for Safety: Thoughts on Structure, Culture and Governance. March 4, 2011 Debbie Barnard, MS, CPHQ Victoria Inn Winnipeg, Manitoba. Presentation Outline. Introduction Reflections on Governance/Leadership, Structure/ Infrastructure and Culture Case Study Table Top Discussions

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L eading for safety thoughts on structure culture and governance

Leading for Safety: Thoughts on Structure, Culture and Governance

March 4, 2011

Debbie Barnard, MS, CPHQ

Victoria Inn Winnipeg, Manitoba


Presentation outline

PresentationOutline

  • Introduction

  • Reflections on Governance/Leadership, Structure/ Infrastructure and Culture

  • Case Study

  • Table Top Discussions

  • Report Out/Reflections

  • Closing Comments


Our promise to patients residents

Our Promise to Patients/Residents

  • Safety – “not harming people with our care”

  • Effectiveness – “matching science to care”

  • Patient centeredness – “nothing about me without me”

  • Timeliness – “avoiding needless delays”

  • Efficiency – “Avoiding waste”

  • Equity – “Closing the gap”


L eading for safety thoughts on structure culture and governance

IOM Report 1999 & CAES 2004

“The current care systems cannot do the job. The chassis is broken.

Trying harder will not work; we must change the systems of care.”

Source: www.iom.edu


Are we up to it

Are we up to it


Case study dana farber cancer institute

Case Study: Dana-Farber Cancer Institute

FROM

TO

Errors are everywhere

Excellent, not perfect

Great care in a high-risk environment

Principles of fair and just culture, guidelines, algorithms, flow sheets

  • Errors are rare

  • Everything’s great

  • Great care

  • Made it up as you go along


Case study dana farber cancer institute1

Case Study: Dana-Farber Cancer Institute

FROM

TO

Moral duty, risk on nondisclosure, transparency

Great systems, great staff

Board, C-Suite, Chiefs, Chairs drive the work

  • Risk of disclosure/ confidentiality

  • Great staff, poor systems

  • QI, RM, Safety staff drive the work


Case study dana farber cancer institute2

Case Study: Dana-Farber Cancer Institute

FROM

TO

Actively engage

Actively engage, nothing possible without them

Partner with patients and families

  • Keep the board out

  • Keep doctors out of QI and RM

  • Deliver care to patients


Case study think differently video

Case Study(Think Differently- video)


Governance leadership

Governance & Leadership

HOT TOPIC!

  • Boards on Board – IHI 5 Million Lives

  • Effective Governance for Quality and Patient Safety - OHA Regional Programs 2011

  • CPSI Board Resources & Toolkit


What does the evidence tell us

What Does the Evidence Tell Us?

  • Outcomes are better in hospitals (organizations) where:

    • The board spends >25% of its time on quality and safety.

    • The board receives a formal quality measurement report.

    • There is a high level of interaction between the board and medical staff on quality strategy.

Vaughn T, Koepke M, Kroch E, et al. J of Patient Safety. 2006;2:2-9.


What does the evidence tell us1

What Does the Evidence Tell Us?

  • Outcomes are better in hospitals (organizations) where:

    • Senior executive compensation is based in part on quality and safety performance.

    • The CEO is identified as the person with the greatest impact on QI, especially when so identified by the QI executive.

Vaughn T, Koepke M, Kroch E, et al. J of Patient Safety. 2006;2:2-9.


Six things that boards can do

Six Things That Boards Can Do

1. Set a specific aim to reduce harm this year and make an explicit, public commitment to measurable quality improvement (e.g., reduction in unnecessary mortality or harm).

2. Select and review progress towards safer care as the first agenda item at every board meeting.

  • Get data on harms and hear stories; put a “human face” on data.


Six things that boards can do1

Six Things That Boards Can Do

3. Establish and monitor a small number of organization-wide “roll-up” measures that are updated continually and are transparent to the entire organization and its customers.

4. Commit to establish and maintain an environment that is respectful, fair, and just for all who experience pain and loss from avoidable harm.

  • Patients, their families, and staff at the sharp end of error


Six things that boards can do2

Six Things That Boards Can Do

5. Develop the capability of the board.

  • Learn how the “best in the world” boards work with executive and MD leaders to reduce harm.

  • Set an expectation for similar levels of education/training for all staff.

    6. Oversee the effective execution of a plan to achieve the board’s aims to reduce harm, including executive team accountability for clear quality improvement targets.


Culture

Culture


L eading for safety thoughts on structure culture and governance

  • “Every enterprise has fourorganizations:

  • the one that is written down,

  • the one that most people believe exists,

  • the one that people wished existed, and

  • the one that the organization really needs.”

  • NHS Building & Nurturing an Improvement Culture


Scope for leaders

Scope for Leaders

  • What is the meaning of organizational culture?

  • How to measure organizational culture?

  • How to build/change organizational culture?


L eading for safety thoughts on structure culture and governance

Tribal Wisdom of Healthcare

When you discover you are riding a dead horse, the best strategy is to:

  • Beat the horse --> it may rise from the dead

  • Change riders --> it is clearly the rider’s fault the horse is not moving

  • Appoint a committee --> if more people look at the horse , it may not be really dead .

  • Arrange to visit other sites--> See how they ride dead horses

  • Lower the standards: make dead horses acceptable


Structure infrastructure

Structure/ Infrastructure


L eading for safety thoughts on structure culture and governance

Low

Level of Detail

High

Viewing the Organization as a System:

Linkage of Processes at appropriate Level of Detail

Source: L. Provost, Senior Fellow IHI


Planning for improvement

Planning for Improvement

Source: L. Provost, Senior Fellow IHI


Can you build a house without a frame

Can you build a house without a frame?

  • Committees

  • Technology Supports

    • Databases and IT systems that communicate

  • Reporting System

  • Human Resources

    • Orientation & Competency Programs

Source: L. Provost, Senior Fellow IHI


Execution of improvement work in organizations

Execution of Improvement Work in Organizations

Projects

?

Division or Department Level

?

Whole Organizational level

Source: L. Provost, Senior Fellow IHI


Execution structure

Execution Structure

Organizational Level (whole system)

Sub-system Level

Sub-system Level

Sub-System Level

Project

Project

Project

Project

Project

Project

Project

Project

Source: L. Provost, Senior Fellow IHI


Table work and discussion

Table Work and Discussion


Governance leadership1

Governance & Leadership

1. What do you think the leadership team did at DF to create their “to state”?

2. Leadership for improvement is difficult; what do you find most challenging in your organization?

3. What are some of the key strategies that the board and leadership team can do to “walk the talk”?


Culture1

Culture

What’s at least one successful strategy or tactic you can share from your organization’s improvement journey?

Pretend you are coaching a new leader, how can you help them to begin to use a system view of their organization as a way of creating a new culture?


Structure infrastructure1

Structure & Infrastructure

How do you think the leadership team at DF began to redefine their processes so that they could view their organization from a whole system perspective

How can this approach support your team to connect structure, strategy and improvement?

Does your quality infrastructure require any changes to improve how quality improvement work gets done?


Report outs

Report Outs

  • Observations & reflections from your group’s discussion

  • Your contribution to the “Ten Powerful Ideas for the Future Now”


Closing video

Closing Video


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