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  1. Implementing Quality as the core organizational strategy Edward F. Crooks MD, CMQ, CLSSBB

  2. Implementing Quality as the Core Organizational Strategy • Increased premium on implementing change, focused on improving healthcare quality. • Changing paradigm of competition • Literature have volumes of articles written on the value of HCQI framework . • TQM • CQI

  3. Implementing Quality as the Core Organizational Strategy • Many organizations and foundations have focused energy and resources on improving HCQ. • IOM • IHI • Leapfrog Group • NQF • National Commission for Quality Long-Term Care • Brookings Institute • Commonwealth Fund • Robert Wood Johnson Foundation • RAND Corporation • Center for Health Transformation

  4. Implementing Quality as the Core Organizational Strategy • Prestigious awards have been offered as a way to encourage quality. • Malcolm Baldrige National Quality Award

  5. Implementing Quality as the Core Organizational Strategy • Despite these efforts, the healthcare systems is faced with more challenges related to QI today than ever before. • Regina Herzlinger – Who Killed Health Care ? (2007) – “the hospital is an increasingly dangerous place for a sick person” • U.S. Health Care System • Largely private. • Subject to more competition than virtually anyplace else in the word. • Unsatisfactory performance in both cost and quality.

  6. Implementing Quality as the Core Organizational Strategy Commonwealth Fund International Health Policy Survey (2007) Patient (%) = percentage of patients with two or more chronic conditions reporting either a medical, medications or lab test error.

  7. Implementing Quality as the Core Organizational Strategy • Error rates and other quality challenges continue to plaque our health care system despite the large amount of money spent on it. • AHRQ – 2005, the nation’s hospital bill reached a record of $873 billion (nearly doubling the 1997 spending, adjusted for inflation.

  8. Implementing Quality as the Core Organizational Strategy Implementing a culture that has QI at its core is an important goal for providers: • Serve their patient better. • Gain support of healthcare providers. • Stay ahead of government regulation. • Meet consumers’ demand for transparent information on quality and cost. • Gain a competitive advantage in the marketplace.

  9. Implementing Quality as the Core Organizational Strategy • Incorporating quality as a central element of an organization’s culture and strategy must begin with leadership from. • The board of trustee, • The CEO, and • The executive team • Visionary leaders who are willing to take calculated risk, approach their journey to quality with the realization that the first step is to establish an organizational culture that will support this excursion.

  10. Implementing Quality as the Core Organizational Strategy • Developing focus on improving quality is a challenge for most health care organization because of many competing agendas: • The rapidly changing competitive environment shaped by providers, employees and policymakers • Under-appreciated impact of organizational culture on QI • Daily conflicts • Declining revenues and market share • Union difficulties • EMR • HIPPAA requirements • Joint Commission

  11. Implementing Quality as the Core Organizational Strategy • Employee recruitment and retention • Malpractice concerns • Physician relations • Community expectation

  12. Implementing Quality as the Core Organizational Strategy Balanced Scorecard - Kaplan and Norton (2001) • Perspective of the patient and family. • Internal processes – clinical pathway. • Learning and growth opportunities – focus on employee. • Financial performances. • Adopting this broader and more balanced view, an organization show an understanding of the wide range of interdependent factors that must be addressed on the pathway to the implementation of a change strategy that will focus on quality of care,

  13. Implementing Quality as the Core Organizational Strategy Leaders in such an organization • Ask financial questions about market share, profit margins, quality implication of purchasing new equipment • Raised question related to satisfaction of internal and external customers. • Probe into the way in which business processed must change to improve and sustain quality.

  14. Implementing Quality as the Core Organizational Strategy BNQP Criteria for performance excellence • Describes the role of leadership and the interdependence of the elements of an organization that has a culture of performance excellence. • Culture has all-encompassing role of creating and sustaining performance excellence

  15. Baldrige National Quality Program

  16. Baldrige National Quality Program Culture Culture Culture Culture

  17. Implementing Quality as the Core Organizational Strategy The change toward quality starts with leadership that creates and drives a system of excellence that will bring about sustainable results.

  18. Implementing Quality as the Core Organizational Strategy Leading Change (1996) – Kotter’s seminal work • Unfreezing the old culture • Forming a powerful guiding coalition • Developing a vision and strategy • Communicating a vision and strategy • Empowering employees to act on the vision and strategy • Generating short-term wins • Consolidating gains and producing more change • Refreezing new approaches in the culture

  19. Implementing Quality as the Core Organizational Strategy Unfreezing the Old Culture. • Leadership • Essential trait – Courage to set a direction. • Establish a vision • Define a culture that has quality as its core and to establish clear and specific expectations from employees involved in the quality journey. • Most difficult step • Culture’s influence on employee behavior • Employees’ desire to resist change and impede progress

  20. Implementing Quality as the Core Organizational Strategy Organization Culture Comprises • Values • Underlying assumptions • Behaviors • Ceremonies • Symbols • Language • Learned and shared activities

  21. Implementing Quality as the Core Organizational Strategy • Management Information Systems • Organizational structure • Behaviors that employee are encourage to follow • Elements like shared values • Behaviors that influence employee and persist • overtime

  22. Implementing Quality as the Core Organizational Strategy Culture contributes to: • Employees’ identification • Success or failure of strategy execution. Leadership often overlooks or minimize the role of culture and tend to focus on highly visible changes such as improved financial performance.

  23. Implementing Quality as the Core Organizational Strategy • The first step is for leadership to define and communicate the idea that the status quo is no longer acceptable. • They must be able to communicate a sense of urgency about an opportunity or potential crisis without creating a sense of fear or resistance among employees. • Leadership must create a sense of urgency that will move people from the comfort of the status quo to new culture that reflects the values of quality.

  24. Implementing Quality as the Core Organizational Strategy Leaders • Must motivate employees to change. • The transformation must be both personal and organizational. • Deal with resistance to change

  25. Implementing Quality as the Core Organizational Strategy Urgency to change: • Weakening financial performance • Employee discontent • Declining dominance in the market place

  26. The Essence of an effective unfreezing process Too Much Disconfirmation Enough Disconfirmation Optimal level of Anxiety/guilt • Learning Anxiety • Denial • Repression • Rejection

  27. Implementing Quality as the Core Organizational Strategy • Unfreezing the cultural iceberg and transforming the organization must start with education. • Making employees understand that changing the organization to embrace quality is required for growth and survival.

  28. Implementing Quality as the Core Organizational Strategy Creating a Guiding Coalition Creating a strategy of QI: • Requires a team (no single leader can drive a sustainable change) • Need the rest of leadership on the bus and in the correct seat. • Need to determine the skills it need in specific leadership position. • Senior leaders must coach, promote and hire people who: • Understand the urgency • See the need to change • Possess the set of skills essential to guide and support the change.

  29. Implementing Quality as the Core Organizational Strategy Leadership that is responsible for communicating this challenge must recognized the feelings and prospective of employee.

  30. Implementing Quality as the Core Organizational Strategy • First step is to move senior leadership to a mission-centric position. • Leadership must understand its job and expected objectives • The CEO must ensure that Team Members clearly understand expectation for their performance and then provide effective and timely feedback on their behavior. • Senior leadership including the board must be held accountable for their performance. • This requires the tenacity, focus and skills of “authentic leadership” • The understanding about expectation and accountability creates the ‘Guiding Coalition’ - Kotter (1995)

  31. Implementing Quality as the Core Organizational Strategy Team Members Desire, Knowledge, + Skill Support the vision Direct the change Deal with resistance

  32. Implementing Quality as the Core Organizational Strategy The role of the Guiding Coalition is to help the organization develop a shared understanding of the vision and the goal to move toward a new organizational culture, based on quality.

  33. Implementing Quality as the Core Organizational Strategy Guiding Coalition Executives Produce and support the change Effective Communication Common Ground Doctors Nurses Clinical Staff Drive the QI Process Mutual Trust

  34. Implementing Quality as the Core Organizational Strategy Developing a Vision and Strategy • Allow every one in the organization to understand what the future will look like and what they have to do to achieve this future state.

  35. Implementing Quality as the Core Organizational Strategy Vision and Strategy Non Profit For Profit Improving profits Mission-Oriented No Margin, No Mission

  36. Implementing Quality as the Core Organizational Strategy Survival requirements take priority over higher-level needs until the survival needs are met – Maslow 1943 Organization in financial straits Emphasizes bottom-line Compromise improvement • Critical step – Leader who can create a • succinct and inspiring vision. • Transforming the organization • Attractive to individuals • Have achievable goals • Allow for individual interests Less competitive organization

  37. Implementing Quality as the Core Organizational Strategy Vision – What do we want to be? • The answer to that question should motivate employees to move in a common direction and give them a clear sense of the future. • The bedrock of any strategy are vision, values and mission and must be aligned with and totally integrated in the organization’s culture.

  38. Implementing Quality as the Core Organizational Strategy Effective strategy • Built on the organization’s vision, values and mission. • Describe activities needed to implement the strategy (Goals) • Goals should answer the question, What do we expect to achieve? • Tactical initiatives clarify how the organization will accomplish these goals. • Essence of strategy is in these activities (Porter 1996) – choosing to perform activities differently or to perform different activities than rival.

  39. Implementing Quality as the Core Organizational Strategy How do we know we are there? • Develop key metrics that will drive change. • Metrics are critical to strategy adjustment and reinforce new behaviors and processes. • Measure the organization’s performance on those metrics. • Fewer metrics are usually better.

  40. Implementing Quality as the Core Organizational Strategy Selecting the metrics • Involve key stakeholders • It ensure their ownership of the strategy and the efforts to measure progress. • Clinical staff’s engagement in this step is imperative. • To ensure physicians and other providers support they must be committed and involved from the beginning.

  41. Implementing Quality as the Core Organizational Strategy Targeting physicians’ participation in QI and Change Program • Physicians need to understand how the proposed QI initiatives will affect their practice style and behavior. • Physician will change, when they understand the inadequacy of the current behavior or process. • Physician often have divergent views based on past experience. • Physician have financial conflict of interest. • Physician are independent businessperson and sees the hospital only as a place to admit patients. • Hospital committee work and time spent on QI infringes on time that physician can use to see patients.

  42. Implementing Quality as the Core Organizational Strategy Strategic Management System • Strategy • Resource allocation • Action plans • Communication plan These elements must be aligned for the strategy to be successful.

  43. Implementing Quality as the Core Organizational Strategy • Do not confused strategic planning with other planning such as operational planning. • Operational planning is a necessary part of management but it is not strategy. • Strategic planning process involves deciding what to do rather than how to do it. • Strategic planning must look beyond the organizational boundaries. • Understanding opportunities in the external environment that match internal strengths is a starting point of a solid strategy.

  44. Implementing Quality as the Core Organizational Strategy Communicating a Vision and Strategy • The cornerstone of transformation is vision and strategy. However for it to drive change successfully majority of employees need to hear and understand the message. • For committee discussion to be effective, key leaders must be enthusiastic supporters of the change before the meeting begins. • Before presenting a new initiative to a group, ensure that key individuals have seen and support the information. • Letters, emails, phone call, bulletin board messages tend to be ineffective in moving projects forward. • Leadership must do the real work through a series of one-on-one and small group discussions.

  45. Implementing Quality as the Core Organizational Strategy Communicating a Vision and Strategy • Effective communication depends on a clear understanding of the terminology and language. • Physicians use a clinical and patient specific lexicon • Administrators speak the language of tem, systems and populations

  46. Implementing Quality as the Core Organizational Strategy Communicating a Vision and Strategy CEO who fails to define success and communicate their vision of it, and fail to make their expectations clear to employees, produce meaningless culture. (Hamm 2006)

  47. Implementing Quality as the Core Organizational Strategy Empowering Employees to Act on the Vision and Strategy • The ultimate measure of a strategy’s is how it is executed. Hindrances to successful execution: • Poor planning • Lack of clear priorities • Failure to empower the employees

  48. Implementing Quality as the Core Organizational Strategy Empowering Employees to Act on the Vision and Strategy • Trust the employees • Give them the responsibility and authority to make decision on a day-to-day basis. • Do not act like the implementation is centrally controlled. • No leadership team can transform an organization to a culture of quality without empowering the employee.

  49. Implementing Quality as the Core Organizational Strategy George and Sims (2007) – the book True North “results achieved by empowering people throughout their organization with passion and purpose are far superior to what can be accomplished by getting them to be loyal followers”