Engaging Hospital Leaders in HAI Prevention: The Social Movement Model

1. Engaging Hospital Leaders in HAI Prevention: The Social Movement Model HIDA Training Session September 1, 2010

3. Redefining Excellence in Patient Care What is the ultimate we believe our health system can and should accomplish to dramatically improve the safety and quality of the care and the health of the patients we serve?

4. The Road to High Performing Health Systems: Where Are You Now? Do you believe your hospital has established a system-wide culture of safety? Is your �leadership triad� actively engaged with your QI/patient safety program? Is accreditation/regulatory standards compliance the floor or ceiling of your QI/PS program? Do physicians/senior clinicians lead all of your clinical QI teams? Do you have patients on your teams?

5. The Road to High Performing Health Systems: Where Are You Now? Have you established a clearly defined set of system-level aims and performance measures? Do you have a consistent process for conducting QI/PS projects and activities? Have you actively integrated your CME program with your QI/PS program? Does your frontline clinical staff feel safe to report near misses and medical errors?

6. The Road to High Performing Health Systems: Where Are You Now? Does your system have �zero tolerance� for poor professional conduct/disruptive behavior? When serious adverse events occur, do you have a consistent system for review and disclosure? Have you been able to attain, sustain and spread measurable improvements system-wide? Are you actively using public reporting data to guide and track your QI/PS projects?

7. IOM Six Aims for Improvement Patient care that is: Safe- avoidance of unintended pt. harm Effective- evidence-based Patient-centered- focused on needs and rights of the individual patient Timely- avoidance of delays & barriers to patient care flow Efficient- elimination of waste Equitable- fair access to comparable health care services for all

8. National Priorities Partnership Engage patients and families in managing their health and making decisions about their care Improve the health of the population Improve the safety and reliability of America�s healthcare system

9. National Priorities Partnership Ensure patients receive well coordinated care w/in and across settings and levels of care Guarantee appropriate and compassionate care for patients with life-limiting illnesses Eliminate overuse while ensuring the delivery of appropriate care

10. 10 National Priorities Partnership Safety Goals All healthcare organizations and their staff will strive to ensure a culture of safety while driving to lower the incidence of healthcare-induced harm, disability or death toward zero. They will focus relentlessly on continually reducing and seeking to eliminate all HAIs and serious adverse events. All hospitals will reduce preventable and premature hospital-level mortality to best in class. All hospitals and their community partners will improve 30-day mortality rates following hospitalization for select conditions to best in class. As patients transition from setting to setting, they are often unprepared to manage their care in the next setting frequently receive conflicting advice regarding the management of their illness Experience high rates of medication errors, incomplete or inaccurate transfer of information, and a lack of appropriate follow up care (Coleman, EA, et.al., The Care Transitions Intervention, Archives of Internal Medicine, September 25, 2006; 166:1822-8.)As patients transition from setting to setting, they are often unprepared to manage their care in the next setting frequently receive conflicting advice regarding the management of their illness Experience high rates of medication errors, incomplete or inaccurate transfer of information, and a lack of appropriate follow up care (Coleman, EA, et.al., The Care Transitions Intervention, Archives of Internal Medicine, September 25, 2006; 166:1822-8.)

11. NQF Safe Practices - 2009 7 Functional Categories: Creating & Sustaining a Culture of Safety Informed Consent, Life-Sustaining Treatment, Disclosure, Care of Caregiver Matching Health Care Needs with Service Delivery Capability Facilitating Information Transfer & Clear Communication Medication Management Healthcare Associated Infections Condition and Site-Specific Practices

12. NQF Safe Practice Standards Prevent ventilator associated pneumonia by implementing VAP bundles Adhere to effective methods of preventing central line associated infections Annually immunize healthcare workers and high risk patients against influenza Comply w/ CDC Hand Hygiene guidelines Prevent surgical site infections- Appropriate use of antibiotics; post-op glycemic control; appropriate hair removal

13. Value-Based Payment: Next Generation Incentives for �Best Practice� levels of value- connected to specific performance indicators Bundled payments for individual procedures and episodes of care for chronic conditions Non-payment for �never events� and other healthcare associated conditions (HAC) Non-payment for specific categories of readmissions Incentives for EHR application and meaningful use

14. Stepping Back: Why do we need �Leadership Leverage� ? We have become good at making improvement happen for one condition, on one unit, for a while. We haven�t learned how to get measured results, quickly, across many conditions for the whole organization.

15. A �Project�

16. Achieving a System-Level Aim

17. Project vs. System-level Change Lower rates of central line infections in one clinical unit Improved hand washing compliance in one unit or w/ one group of clinicians Antibiotic use protocols in place for selected surgeons Reduced rates of all central line infections across health system Improved hand washing rates in all units and with all health care workers Standardized pre-op antibiotic protocol for all relevant surgical cases and specialties

18. IHI Comprehensive Framework: Leadership for Improvement

19. IHI Seven Leverage Points:Places to start, if you want to achieve system-level results� Set specific system-level aims and oversee their achievement at the highest levels of governance. Build an executable strategy to achieve the aims, and oversee the execution at the highest levels of administration. Channel attention to system-level aims and measures Get patients and families on your team! Engage the CFO in achieving the aims Engage physicians in achieving the aims Build the improvement capability necessary to achieve the aims This is a theory, not a recipe It comes from three sources: complex adaptive systems theory, observation and case study of P2 and other organizations attempting to move big dots, and personal hunches/ideas and experience combined with data from management and leadership literature. It�s offered as a theory: �If you were to some combination of these things well, you would have a shot at moving big dots.� Or, perhaps it could be stated in the negative: �If you fail to do several of these things well, no matter what else you do, you will fail to move the big dots.� We are looking for feedback from you, for suggestions on how to improve the theory. This is a theory, not a recipe It comes from three sources: complex adaptive systems theory, observation and case study of P2 and other organizations attempting to move big dots, and personal hunches/ideas and experience combined with data from management and leadership literature. It�s offered as a theory: �If you were to some combination of these things well, you would have a shot at moving big dots.� Or, perhaps it could be stated in the negative: �If you fail to do several of these things well, no matter what else you do, you will fail to move the big dots.� We are looking for feedback from you, for suggestions on how to improve the theory.

21. Keys to Achieving Performance Excellence- Organizational Culture Transformation Create shared vision and common purpose/aim Develop leadership capacity & behavioral competency Build will to make measurable systemic improvement Attend relentlessly to execution so that improvements can be sustained and spread

22. Keys to Achieving Performance Excellence- Organizational Culture Transformation Promote open, active communication and teamwork Aggressively embrace collaboration and transparency Actively encourage ideas and innovations Establish a work environment built on mutual respect and shared accountability

23. Transformational Leadership Style of leadership in which the leader identifies the needed change, creates a vision to guide the change through inspiration, and executes the change with the commitment of the members of the group Leaders who can help an organization develop a new vision, gather support and buy-in from stakeholders, guide the organization through a transformative phase and possess the capacity to institutionalize changes over time

24. Transformational Change Visionary leadership at all organizational levels Fully shared vision and improvement aims Innovation is embraced from the bottom up Deep and sustained organizational engagement Focus on developing new skills and behaviors Shared accountability throughout organization Metrics to track progress on the journey

25. OIG Report: Adverse Events in Hospitals Estimate of adverse event incidence in hospitalized Medicare patients in two selected counties Identified events from NQF serious reportable adverse event and/or CMS HAC lists; significant patient harm Random chart review of 278 Medicare beneficiaries 15% experienced at least one serious adverse event 2% experienced multiple adverse events Additional 15% had an event causing temporary harm No internal incident report for 93% of adverse events

26. Just Culture=Standards in Action!! Just Culture An atmosphere of TRUST in which people are encouraged, even rewarded, for providing essential safety-related information, but in which they are also CLEAR about where the line must be drawn between acceptable and unacceptable behavior. (Reason 1997) Benefits of a just culture/ standards of behavior Increasing safety reporting/self reporting Trust building/Retention of high performers More effective safety and operational management

27. �Just Culture� principles Match accountability to �risk� Three categories Inadvertent lapses or errors �Risky� behavior Conscious disregard of the �rules� with known risk exposure

28. A �Just Culture�: balancing culpability and blamelessness

29. What Senior Leaders Should Do Set a specific aim to reduce harm this year and make an explicit, public commitment to measurable quality improvement Select and review progress towards safer care as the first agenda item at every board meeting 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

30. What Senior Leaders Should Do Commit to establish and maintain an environment that is respectful, fair, and just for all Develop the capability of the leadership triad Oversee the effective execution of a plan to achieve the board�s aims to reduce harm, including shared leadership accountability for clear quality improvement targets

31. Using Leadership Leverage:Four Questions to Channel Attention Are your executive and physician leaders actively engaged in QI and patient safety activities/reviews? Is all your quality data widely available to staff, whether good, bad, or ugly? Do you start every MEC and Board meeting with a �needless death� report? Could you go public with all your quality and safety data?

32. HAI Prevention as a Social Movement Actively mobilizing leaders and supporters around a common purpose and goal Using the power of story to drive collective action Focus your efforts around preventing patient harm and saving lives (not in reaching a numeric target) Actively including patients and families in the improvement efforts Celebrate every success and use as a platform to reach the next performance peak

33. The Power of the Narrative The story of self- Effectively tell your story as an infection preventionist (scope and depth) The story of us- The impact of HAIs on patients, families and staff; putting a face on patient harm The story of now- Where we are and where we should be from an HAI prevention/patient harm perspective; and what it will take to get to zero

34. Keys to Achieving Performance Excellence- System Reengineering Build infrastructure that actively supports QI and patient safety Provide access to an integrated health information network (HIE) Appropriate use of standardized protocols and processes (clinical bundles) Active monitoring of key process & outcomes data

35. Keys to Achieving Performance Excellence- System Reengineering Focused analysis of any system/process failure (near miss) System modeling for continuous improvement Effective application of technology designed to improve quality and safety off care Develop process excellence skills of workforce and med. staff Focus on clinical and operational integration

36. A Leadership System for Executing Breakthrough Goals:  (Right Side of Execution Model) Set breakthrough goals Develop a portfolio of projects to achieve the goals Deploy resources to the projects sufficient to achieve the aim Establish an oversight and learning system that will increase the likelihood of achieving the aim

37. Build an Executable Strategy

38. Cascading the Strategy: Example

39. HAI Prevention Project Review Checklist Have I reviewed the purpose/aim of the project with the project leader? Have we agreed on he meeting process and expectations for the project leader and team members? Have we developed a summary guiding document of team�s purpose and measureable goal(s)? Have I/we clearly defined and stated how this project fits into the overall QI strategies of our organization?

40. Project Review Checklist: What I Do During the Meeting Ask any member of the team to state the aim of the project in one or two sentences. Do all members share the same aim? Is the aim crisp and clear (�How good, by when?�) Does the aim, as stated, engage the heart? Can the team explain how the aim of this project is related to the organization�s strategic aims, or Big Dots? Did I reinforce the importance of this project to our strategy?

41. Ask: What are the results of the team�s work so far? Are there graphic displays of project results? Is there documentation of �tests of change�? Do the graphic reports include data related to these tests of change? Did I ask for this display of measures within 3 minutes of beginning the meeting? Project Review Checklist: What I Do During the Meeting

42. What project failure modes lurk? Failure of Will (a few strong �blockers,� lack of investment in training and education, lack of support for staffing or system changes, lack of backup from the Board and executive suite�) Failure of Ideas (haven�t accessed existing best practices or encouraged input from team members) Failure of Execution (lack of exec support for scale and spread, stuck in �project mode� and can�t operationalize the improvements�) Project Review Checklist: What I Do During the Meeting

43. Have I finished the meeting by Reviewing specific tasks/assignments Asking the team �What can I do to help?� Encouraging the team to push forward Asking them to keep me posted on their results Post meeting follow-up Have I sent an email to the team leader with a summary of my thoughts, and asking for updated data on results? Project Review Checklist: What I Do At the End of the Meeting

44. Good Principles for Working with Physicians Involve them at the beginning Identify and work with the real leaders and early adopters Display physician involvement to all Display credible results to all Don�t �package� the data Show that you value their process and time

45. Common Agenda: Keys to Success Frame the quality challenge in terms that are important to physicians �Reduce Needless Deaths, Readmissions, Nosocomial Infections, Hassles�� Not �Reduce LOS� or �Improve Productivity� Measure and display the results on important things�show them that together, you�re actually making these things better

48. HAI Prevention as a Social Movement � To every person there comes in�life that special moment when one is tapped on the shoulder and offered the chance to do a very special thing. What a tragedy if that moment finds�you unprepared or unqualified for the work which would be your finest hour."� Sir Winston Churchill (1874-1965) Teaching and learning is aimed at helping people learn and grow, change unproductive behaviors for more productive ones to increase their level of skill, capability, and performance � fundamentally to enhance quality of life both personal and professional. In my own learning experiences II was strongly influenced by American Indian culture growing up very near the Seneca Reservation in upstate New York. Typically outsiders to this culture think the chief to be the most powerful person in a tribe, but the most influential person is the storyteller. The storyteller, often a woman, was the verbal source of wisdom, history, literature, knowledge, moral instruction and learning. Through her, a vision regarding what was required to thrive emerged and was indelibly etched in the collective mind of the tribe. She moved people from interest and intellect to action through the power of story. For all our sophistication as corporate tribes, we have lost the key to sustained positive action � effective execution. Like Dr. Berwick, Quint Studer, Johnnie the Bagger, and others the power of story is driving execution and performance in patient safety. When a hospital or healthcare system is blessed with leaders who express compelling stories about things that matter � grounded in fact and reason, tied to core values that are widely embraced, constructed with logic and expressed in positive, emotionally passionate terms � people not only listen, but are moved to action. As centuries of tribal story telling and three decades of neuroscience research tells us, when people harness the power of story, bonding intellect and emotion, they make lasting change. This is the power of emotional intelligence and being intelligent about creating and using emotion to drive performance. I want to express my thanks to you all for your attendance at this symposium, for your courage to be a fire starter, a trim tab, a maverick, a gadfly sent by the gods to sting into action those needed to continue to bring about change and improve the overall level of excellence of healthcare. May you remain committed to your journey and to your God given calling. My thanks, my regards, and God�s blessing to you all.Teaching and learning is aimed at helping people learn and grow, change unproductive behaviors for more productive ones to increase their level of skill, capability, and performance � fundamentally to enhance quality of life both personal and professional. In my own learning experiences II was strongly influenced by American Indian culture growing up very near the Seneca Reservation in upstate New York. Typically outsiders to this culture think the chief to be the most powerful person in a tribe, but the most influential person is the storyteller. The storyteller, often a woman, was the verbal source of wisdom, history, literature, knowledge, moral instruction and learning. Through her, a vision regarding what was required to thrive emerged and was indelibly etched in the collective mind of the tribe. She moved people from interest and intellect to action through the power of story. For all our sophistication as corporate tribes, we have lost the key to sustained positive action � effective execution. Like Dr. Berwick, Quint Studer, Johnnie the Bagger, and others the power of story is driving execution and performance in patient safety. When a hospital or healthcare system is blessed with leaders who express compelling stories about things that matter � grounded in fact and reason, tied to core values that are widely embraced, constructed with logic and expressed in positive, emotionally passionate terms � people not only listen, but are moved to action. As centuries of tribal story telling and three decades of neuroscience research tells us, when people harness the power of story, bonding intellect and emotion, they make lasting change. This is the power of emotional intelligence and being intelligent about creating and using emotion to drive performance. I want to express my thanks to you all for your attendance at this symposium, for your courage to be a fire starter, a trim tab, a maverick, a gadfly sent by the gods to sting into action those needed to continue to bring about change and improve the overall level of excellence of healthcare. May you remain committed to your journey and to your God given calling. My thanks, my regards, and God�s blessing to you all.