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Verification, Validation, & Accountability. Colleen Thornburgh. February 13, 2009. Education. People. Growth. Research. Service. Finance. Quality. Strive to develop the highest quality medical education programs for all levels of learners.

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verification validation accountability

Verification, Validation, & Accountability

Colleen Thornburgh

February 13, 2009








Strive to develop the highest quality medical education programs for all levels of learners

Advance medical and scientific knowledge through basic, transitional, and clinical research

Strive to be among the highest ranked health care providers by both regulatory and health care scoring systems

Promote consistently positive experiences for our patients, staff and community

Grow the enterprise to better serve patients and physicians and support the fundamental missions of teaching and research

Preserve a focus of fiscal responsibility and multidisciplinary planning

Instill and reinforce standards of behavior that will attract, develop and retain outstanding staff, physicians, faculty and students

2008 – 2009 Pillar Goals

  • All programs meet or exceed national benchmarks
  • Increase COM class size by 15% by 2010
  • Submit CTSA application by October 2008
  • Increase sponsored research by 8%
  • Maintain or achieve top 10% in publicly reported JCAHO Core Measures
  • Improve ease of obtaining test results to 50th percentile
  • OUP : > 89.5
  • Reduce COM turnover rate by 5%
  • Maintain a voluntary turnover rate of 18% or less at OUP and OUMC
  • Improve patient satisfaction scores across the enterprise:
    • OUMC to 2nd quartile
    • Overall score of
    • > 3.51
    • OUP to 50th percentile
    • Adult: > 92.1
    • Children’s: > 89.5
  • Increase inter-departmental and physician satisfaction scores by 2 ½%
  • Grow overall OU Medicine market share by 0.5%
  • Grow hospital admissions by 3%
  • Grow clinic visits by 4%
  • OUMC: Increase net income before taxes by 7.44% over 2007 pre-tax net income
  • OUP: Increase payments by 5%
  • COM: All departments should meet cash reserve goals and have overall operating margin of 5%
evidence based leadership ebl
Evidence Based Leadership (EBL)

Rev 6.07




Leader Evaluation

Leader Development

Must HavesSM

Performance Gap



Aligned Goals

Aligned Behavior

Aligned Process

Implement an organization-wide leadership evaluation system to hardwire objective accountability

Create process to assist leaders in developing skills and leadership competencies necessary to attain desired results

Must HavesSM

Rounding ☺

Thank You Notes ☺

Employee Selection

Pre and Post Phone Calls ☺

Key Words at Key Times


Standards of Behavior

Re-recruit high and middle performers

Move low performers up or out

Agendas by pillar

Peer interviewing

30/90 day sessions

Pillar goals

Leader Eval Mgr (LEM) ☺ (2/16)

Staff Eval Mgr (SEM)

Discharge Call Manager (DCM)

Rounding Mgr

Idea Express

verify and validate what you expect
Verify and Validate what you expect

Verification Tools

  • Rounding
  • Observation
  • Monthly Meeting Model
coach behaviors
Coach behaviors
  • Specific
  • What’s working well
  • What could be better
  • Facilitate problem solving
aidet example
AIDET Example
  • Observe the behavior
  • Give specific feedback
  • Incorporate into rounding
  • Coach performance
  • Facilitate problem solving
aidet verification validation coaching
AIDET – Verification, Validation, Coaching
  • Lisa, I’m rounding on the unit today and would like to hear what you believe is going well?
  • Is there any individual or physician that I should recognize in the unit?
  • When I came onto the unit, I heard you introduce yourself to one of your patients using AIDET. I appreciate your doing this and so do your patients. VERIFICATION
  • I thought you did an excellent job introducing yourself, your skills and experience. SPECIFIC
  • I heard you review Mrs. Jones schedule for the day, but didn’t explain why she would need to have tests completed in radiology. How might you have provided this information to her in a way she might understand? FACILITATE PROBLEM SOLVING
aidet verification validation coaching1
AIDET – Verification, Validation, Coaching
  • When you take the time to use AIDET, you reduce patients’ anxiety and provide information that is helpful to their compliance and outcomes COACH SPECIFIC BEHAVIOR
  • Over the next month, I’ll be listening for AIDET as I visit each of our units SET STAGE FOR FURTHER VERIFICATION
  • As I do, I’ll be giving feedback and asking how I might support you
  • Is there anything I can do to help you with AIDET or any issues in the department that I need to be aware of?
  • Thanks…….
you be the coach
You be the coach!
  • Specific
  • What’s working well
  • What could be better
  • Facilitate problem solving
what gets recognized gets repeated
What gets recognized, gets repeated!
  • John, I noticed how you worked with the family members of Mr. Smith to ensure they had a translator who could answer their questions about his care.
  • Thank you for modeling standard of caring by ensuring their needs were met
  • Sandy, when you managed up Dr. Hoover to your patient today, you made it easy for Dr. Hoover to come in and take over coverage this weekend. When patients hear that they are in good hands, they are more likely to ask questions and provide important information that helps all of the staff provide better care for them
  • Thank you for demonstrating excellent communication by managing up members of the care team
what do you want repeated
What do you want repeated?


  • Specific Feedback
  • What they did well
  • Why it matters… connect the dots
  • Thank them for doing the right thing
monthly meeting model

Monthly Meeting Model

Leader Accountability

(n) the quality or state of being accountable; especially: an obligation or willingness to accept responsibility or to account for one's actions

monthly meeting model mmm
Monthly Meeting Model (MMM)

Leaders bring the following items and results to their immediate supervisor for discussion:

  • Leader Evaluation - LEM
  • Monthly Report Card
  • 90-Day Plan-Professional Development
  • Linkage Grid from Leadership Development Institute Workshop
  • Rounding Logs
  • Thank you notes
  • People Trends and Issues-Standards of Behavior
  • Additional Verification Tools as implemented
mmm what
MMM: What?

Tool for leaders to hold meaningful dialogue and measure progress on goals

  • Identify wins, and opportunities for improvement (OFIs)
  • Coach leader performance:
    • Recognize great performance (H)
    • Provide coaching (M)
    • Clarify expectations (L)
    • Communicate consequences (L)
mmm hold leaders accountable
MMM: Hold Leaders Accountable

Tell me what your plans for follow up are.

What is your timeline?

What are your next steps?

What prevented you from meeting the deadline?

mmm hold leaders accountable1
MMM: Hold Leaders Accountable

Let’s be sure you understand the expectation.

Let’s review the timeline and deliverables.

If ________ is not delivered/accomplished, our next steps will be ____________.

What questions do you have?

How can I further support you?

mmm why
MMM: Why?

It’s what leaders do!

Starts at the top and cascades down

If we don’t do it … who will?

Leader’s tool for understanding and driving results

real barriers
Real Barriers
  • Pocket Veto
  • Feigned buy-in