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Take you and your organization to the next level
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6
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High Reliability Heats Up in Federal Healthcare with Amanda Bonser, managing director, Huron
The Journey to Zero at Golden Valley MemorialHow Communication, Collaboration, and Discipline Paid Offwith Stephanie Ashworth, RN, CPHQ, CSSGB, CPBE, CIC, director of quality management and infection control, Golden Valley Memorial Healthcare (GVMH), Clinton, MO
Is Innovation Compatible with High Reliability?Q&A with Innovation Expert David Duncan, senior partner, Innosight
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Summer 2017RESULTS®
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Is Your Organization Highly Reliable?Getting the People Part of Change Management Right by Craig Deao, MHA, senior leader and national speaker, Studer Group and Dave Marshall, managing director, Huron
Q: How can we master the ‘people part’ of change management?
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HARDWIRED RESULTS®
Stephanie Ashworth, RN, CPHQ, CSSGB, CPBE, CIC is director of quality management and infection control at Golden
Valley Memorial Healthcare (GVMH), Clinton, MO.
Amanda Bonser is managing director at Huron, Chicago, IL.
Dave Marshall is managing director at Huron, Denver, CO.
David Duncan is senior partner at Innosight, Lexington, MA.
Craig Deao, MHA is senior leader and national speaker at Studer Group, Pensacola, FL.
Contributors
Summer 2017 ISSUE 24 HARDWIRED RESULTS® | 1
oday in healthcare, more and more, we recognize the need to remove optionality and reduce variance to improve quality and deliver better results. Deploying systematic processes using Six Sigma or Lean methodologies—or applying a performance improvement framework like Baldrige—can help improve organizational effectiveness and increase value and outcomes.
And yet, leaders are still struggling with the people part of change management. As Craig Deao and David Marshall point out in this month’s cover story Is Your Organization Highly Reliable? on page 2, that’s a problem. We’ve made little progress in reducing errors since the landmark IOM report To Err Is Human was released in 1999.
If your organization is in search of a high reliability strategy that really works, Studer Group’s Evidence-Based LeadershipSM model and high reliability offering can help. Many of the same tools and tactics you already use to hardwire consistent leadership behaviors in other areas—like rounding, huddles, stoplight reports, and more—will deliver consistency in organizational high reliability as well. To better understand how this works in practice, see The Journey to Zero on page 6, which includes an HRO case study about Golden Valley Memorial Healthcare in Clinton, MO. On page 5, Huron’s Amanda Bonser also shares how high reliability is making a difference in the federal healthcare space. And finally, can we drive both high reliability and innovation consistently? Innosight expert David Duncan weighs in on page 8. The short answer? Yes. When we harness the skill and talent of our team to deliver service and performance excellence, the sky’s the limit!
Yours in service,
Debbie Ritchie
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In an age when the healthcare industry has engineered world-class clinical solutions with complicated healthcare robotics and transformed the flow of medical information through widespread adoption of digital medical records, the people part of care delivery remains elusive.
Other Industries Excel at High ReliabilityAnd yet, nearly every other high-risk industry—from oil/gas and nuclear power to commercial aviation and the military—have successfully adopted high reliability strategies to dramatically improve operational efficiency, quality, and safety. They too function in high-risk, high-stress conditions under extreme time pressures, face a complex regulatory framework with economic pressures, and need to operate at high capacity during peak demand.
If the problem is that to err is human, how can we design processes and collaboration among healthcare teams that are harm-free? Imagine the possibilities if we could hardwire zero patient harm and medication errors through reliable systems to prevent, intercept, and mitigate the harm that human error causes.
What if we could also use the same skillset to reduce any variation in human behavior for consistently excellent results in things as diverse as HCAHPS performance across
different nursing units or monthly revenue collection? Wouldn’t we face fewer unplanned readmissions if we explained medication side effects to every patient every time? The principles of high reliability apply to all of our goals across the organization.
High Reliability DefinedHigh reliability is the science of achieving efficient, error-free operation. That means that a High Reliability Organization (HRO) is an organization with predictable and repeatable systems in place that allows for the consistent execution of operations while catching and correcting potentially catastrophic errors.
It’s all about reducing variability. When it comes to clinical variation management, the goal is to decrease unwarranted variation in the delivery of care while improving clinical results and reducing costs. To achieve that, organizations must stop chasing averages and focus instead on variations. An HRO is focused at every level on creating predictability and process consistency.
Without a dedicated and reliable process improvement engine, organizations will continue to achieve average results…at best. A culture of excellence and high reliability includes a strategic commitment to continuously strive toward predictable, repeatable behaviors and reliable, consistent processes.
Is Your Organization Highly Reliable?Getting the People Part of Change Management Right
by Craig Deao, MHA, senior leader and national speaker, Studer Group and David Marshall, managing director, Huron
t’s been 18 years since the U.S. Institute of Medicine released its seminal report To Err Is Human urging healthcare organizations to place a priority on finding a fix for an estimated 98,000 annual hospital deaths due to preventable
medical errors. And yet, little progress has been made.
I
PredictableBehavior + =reliable
processculture ofexcellence
Craig Deao, MHA is senior leader and national speaker at Studer Group, Pensacola, FL.
Dave Marshall is managing director at Huron, Denver, CO.
An HRO focuses at every level on creating predictable behavior and a reliable process.
Summer 2017 ISSUE 24 HARDWIRED RESULTS® | 3
A Successful Change FormulaThe reality is that across the healthcare spectrum, more than 70 percent of change and transformation initiatives fail. Why? For starters, 80 percent of the work in managing successful process improvement has nothing to do with tools and everything to do with perceptions. There’s a slow drift away from the norm towards catastrophic failure with workarounds, short cuts, and organizational pressure…especially when workers feel forced to make decisions without support from leaders.
So what works to ensure that front-line staff consistently embrace the agreed-upon process…even during a busy shift? It’s a comprehensive approach to high reliability that includes: (1) a shared vision; (2) skills and training; (3) incentives; (4) resources for support; and (5) required action. The absence of any one of these five ingredients puts lasting change in jeopardy.
The Engine for High ReliabilityAt the heart of a successful HRO strategy is a solid foundation of leadership development and accountability. Studer Group’s Evidence-Based Leadership provides the foundation by modeling, creating, and sustaining a culture where alignment, accountability, and standardization are at the very heart of the organization’s high reliability journey. In essence, it provides the “chassis” to bolt on specific HRO initiatives.
Because goals cascade to every level and department, high reliability no longer risks becoming a project on the quality side of the house. So many efforts at high reliability in healthcare have failed because they focused on process improvement—like Lean or Six Sigma—
at the expense of examining the habits of people who need to implement such processes when time or staff are in short supply. Conversely, Evidence-Based Leadership systematizes process improvements through goals and skill-building to address variation through role modeling to sustain consistency over time.
Engagement Is EssentialLeader, clinician, and employee engagement are also critical. As noted in Craig Deao’s recent book The E-Factor: How Engaged Patients, Clinicians, Leaders, and Employees Will Transform Healthcare, the research confirms the importance of unlocking the team’s potential and building the capacity of front-line staff in the high reliability journey.
When you engage your team, you build efficacy and self-confidence in speaking up. Likewise, engaged leaders have an important role to play in supporting the team through continually improving processes and ensuring sufficient resources to deploy to provide excellent care without exception.
In the end, high reliability is about providing the kind of care we would demand for each of our own family members. Healthcare needs to restore trust that we will get it right for every individual every time…just as we trust that when our plane drops during turbulence at high altitudes, the odds of something bad happening are almost non-existent.
The good news is this: There are already HRO trailblazers succeeding in our industry today. High reliability is increasingly well understood and efficient to apply. It’s a great time to embark on the journey.
Source: Adapted from Knoster, T., Villa, R., & Thousands, J. (2000). A framework for thinking about systems change.
The Formula for Successful Change
Successful change requires all five ingredients. Otherwise, consistent excellence is in jeopardy.
4 | HARDWIRED RESULTS® Summer 2017 ISSUE 24
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Summer 2017 ISSUE 24 HARDWIRED RESULTS® | 5
High Reliability Heats Up in Federal Healthcare with Amanda Bonser, Huron managing director
As in the private sector, the federal government is tapping into best practices in high reliability due to an increasing focus on patient safety and providing top quality care. “In some cases—such as for the VHA and military—hospitals face high visibility in the media and congressional scrutiny. That provides additional impetus to ensure a culture of zero harm,” adds Bonser.
Overcoming ChallengesMilitary hospitals face an additional layer of complexity: chronic high turnover due to frequent and predictable military transitions. And yet, they must still foster engagement effectively to sustain a culture embracing the five principles of high reliability. (See below:
“5 Ways HROs Excel at Safety.”)
As a result, they’re embracing Studer Group tactics such as AIDET®, Hourly Rounding®, Leader Rounding on Employees, and stoplight reports to solicit and recognize specific high reliability behaviors they want to see repeated.
“For example, during Leader Rounding on Employees, a leader may ask, ‘Who would you like to recognize for practicing a specific safety behavior?’”
Best PracticesOther best practices to emulate from federal healthcare? “A strong onboarding plan to address anticipated turnover and promote a robust safety culture,” suggests Bonser. “And training. Military hospitals offer a great example of how to align disparate cultures since they need to bridge the static civilian workforce and constantly changing military workforce. Ensuring a ready medical force is a key objective.
“That’s why they commit to holding quarterly off-site Leadership Development Institutes. It’s a great way to cascade messaging throughout the organization and build skills that drive communication and accountability,” she adds.
“When you combine goals and accountability to metrics, with dedication from leaders to round on employees and patients for real-time feedback, you get to the very heart of a successful safety-first culture.”
n recent years, the federal government has stepped up its interest in high reliability, implementing initiatives in key branches of the military under the Defense Health Agency as well as in the Veterans Health Administration (VHA).
“They’re taking note of the traction high reliability organizations (HROs) are gaining in the private sector and getting on board,” explains Huron Managing Director Amanda Bonser.
I
1. THEY’RE SENSITIVE TO OPERATIONS. HROs recognize early threats of harm to patients and staff through vigilance to potential threats. They’re constantly aware of what might go wrong and are never complacent with a long, dependable safety record. They don’t ignore a gut feeling that something might be wrong; instead, they follow up.
2. THEY ARE RELUCTANT TO SIMPLIFY. HROs are preoccupied with all the nuances and complexity of how a failure happens. They avoid overly simple explanations to better understand the true reasons and causes that lead to patient harm.
3. THEY ARE PREOCCUPIED WITH FAILURE. Rather than viewing near-misses as proof that the system has effective safeguards, they are viewed as symptomatic of areas in need of
more attention. They use checklists across the organization (not just in the operating room!) to guard against harm.
4. THEY DEFER TO EXPERTISE. When confronted with a threat, HROs have a mechanism in place: they defer to the individual with the most knowledge in a critical situation, regardless of title or rank. Leaders and supervisors must be willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face.
5. THEY ARE RESILIENT. HROs consistently recognize and contain errors quickly to prevent major catastrophes. Leaders and staff are trained and prepared to know how to respond when system failures occur and rapidly correct the process leading to the bad outcome.
5 WAYS HROS EXCEL AT PATIENT SAFETY
Amanda Bonser is managing director at Huron, Chicago, IL.
6 | HARDWIRED RESULTS® Summer 2017 ISSUE 24
The Journey to Zero at Golden Valley MemorialHow Communication, Collaboration, and Discipline Paid Off
with Stephanie Ashworth, RN, CPHQ, CSSGB, CPBE, CIC, director of quality management and infection control, Golden Valley Memorial Healthcare
“We have more work to do, but we’re laser focused on patient safety,” explains GVMH Director of Quality Management and Infection Control Stephanie Ashworth, RN, CPHQ, CSSGB, CPBE, CIC. “In fact, we post ‘days at zero’ on key measures by each unit on communication boards. No one wants to be the one who ends a 1600-day streak!”
Fostering Open,Honest CommunicationWhen The Joint Commission mandated new checks for MRSA, GVMH initiated a comprehensive hand hygiene campaign with accountability for non-compliant staff—including physicians—and added a new question on the patient survey asking patients if their caregivers had consistently washed their hands.
Secret observers also share their findings with the Infection Control Department, which then delivers an observation report to those who are out of compliance. The report reviews the
hand hygiene policy and asks each individual to sign the report as a commitment to future compliance.
“It was a huge culture change but we did see a big improvement after implementing the observers and reports,” notes Ashworth. “There were lots
of excuses at first …even tears. We tend to think that we are always compliant; it’s our co-workers who are not…so it can be jarring to receive a pink slip (i.e., observation report).”
But in the end, the individual observation approach made all the difference, where initially reporting out compliance by discipline hadn’t budged the numbers. Today, GVMH hand washing compliance is 90 percent and climbing. Hardwiring Tools that WorkA safety culture doesn’t happen by itself. To ensure organizational alignment in consistently providing safe, high quality care, GVMH uses these tools:
1. Culture of Safety Team (COST)—This multidisciplinary team of directors and frontline staff meets monthly and includes representatives from pharmacy to food and nutrition. In short, everyone that has a role related to patient contact and patient support is included. Every quarter,
each director asks staff, “What is the next way we are likely to harm a patient in this unit?” and requests their suggestions for addressing it. Departments report out to COST which then identifies the type of rapid cycle improvement team needed to address it.
“There’s just no substitute for insight from fresh eyes at the bedside,” suggests Ashworth. For example, Environmental Services recently pointed out that too many electronic devices plugged into outlets in patient rooms posed a tripping hazard, so cords were consolidated.
Stephanie Ashworth, RN, CPHQ, CSSGB, CPBE, CIC is director of quality management and infection control at Golden
Valley Memorial Healthcare (GVMH), Clinton, MO.
hree years ago, Golden Valley Memorial Healthcare (GVMH), an integrated rural healthcare system in Clinton, MO, committed to transforming into a “zero defects” safety culture. Today, GVMH has reduced catheter-associated
urinary tract infections (CAUTI) and central-line associated bloodstream infections (CLABSI) to zero for over three years, healthcare-associated Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (C-Diff) infections to zero in 2016, and reduced falls by 41 percent.
T
“What is the next way we are likely to harm a patient in this unit?”
Summer 2017 ISSUE 24 HARDWIRED RESULTS® | 7
2. Multidisciplinary rounding and bedside shift report—Multidisciplinary teams round together on patients at the bedside to examine what’s best for the patient. In the morning, for example, the team might include some combination of a clinical pharmacist, social worker, nurse, hospitalist, and certified nursing assistant (CNA) depending on what’s being discussed. Rounding is also coordinated with physicians to ensure productive decisions.
Because reducing CAUTIs has been a priority, a CNA—affectionately nicknamed the “Catheter Czar” at GVMH—questions the necessity of every patient catheter during rounds. Nurses also use bedside shift report to share fall risk scores of patients so oncoming nurses are always aware of safety issues.
Tips for SuccessAshworth attributes GVMH’s success with getting to zero on its CAUTI improvement project to diligent recruitment of frontline staff to champion culture change with coworkers and processes in individual units. “Otherwise, leaders can rewrite policies and processes all day long, but the wheels will fall off when it comes to implementation,” she explains.
And finally, validate, validate, validate! “Leaders have to be willing to have that uncomfortable conversation to ensure every individual is actually following the protocol every time until it’s hardwired and part of the culture.
“You don’t want to inadvertently throw out the process because it seems ineffective when actually it’s just not being followed consistently,” Ashworth adds. “That’s why Studer Group tools like huddles, rounding, and observing non-compliance are so effective,” she emphasizes. “They coach to very specific feedback.”
Looking for a high reliability 101 road map? LEARN ABOUT OUR HRO OFFERINGS:
1. HRO Kickstarter ProgramA quick and easy way to start planning an HRO strategy for your organization. This 120-day program is designed to bring a core group of administrators, nurses, physicians, board members and staff together to advance an HRO strategy.
2. HRO Strategy WorkshopPractical tools in a two-day workshop format.Train your team in this hands-on interactive workshop designed to operationalize HRO tools and technologies to achieve zero harm.
3. HRO Leadership AcademyA 24-month program to accelerate and benchmark HRO strategy. This intensive, hands-on HRO collaborative program provides the crucial assessments, planning, strategy and execution of a high reliability journey. Build skills to lead frontline staff, nurses, physicians, and administrators to successfully execute a high reliability strategy.
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Is Innovation Compatible with High Reliability?Q&A with Innovation Expert David Duncan, Innosight and High Reliability Expert Craig Deao, Studer Group
HR: Can you begin, David Duncan, by sharing a bit about Innosight and how what you do there can be helpful to healthcare organizations?
DD: At Innosight, we work with leaders confronting disruptive changes in their industries—changes that often require them to fundamentally rethink how they will be successful in the future. We help them to navigate this type of change through an integrated approach focused on mid-to-long-term strategy and innovation.
When change is happening on such a large and rapid scale, as it is in healthcare, the traditional approach companies take to develop strategies— often based on extrapolating a set of assumptions from the world of today—doesn’t work. You need a longer view…what we call “Future Back Strategy,” because it starts by asserting a view of the future and then working backwards. We’ve applied this approach successfully with some of the largest companies in the world, in industries that range from healthcare and life sciences to telecom and energy.
HR: High reliability and innovation are both critical capabilities in healthcare today. Are they mutually exclusive? How do you manage a team for zero tolerance in some areas and ensure they have tolerance for failure in others?
CD: With respect to high reliability, risk must be minimized. But that assumes there’s already a known “best” way to do something. In that case, the goal is to lock it in and deploy it with zero variation…only allowing carefully controlled experimentation where harm can’t
occur. Conversely, to innovate, you need to place some bets with full knowledge that some will fail. So we must do both things: Require a preoccupation with failure when it comes to high reliability—how to anticipate it to mitigate it—while demonstrating a willingness to tolerate failure for innovation.
Goal-setting is useful here. In some areas, you can set goals around zero defects; in other areas, set goals that anticipate failure. Leaders need to develop both sets of tools and understand when to use the right one. When pathways are clear and context is fixed, use high reliability approaches. When pathways aren’t present and the environment is very dynamic, use the innovation toolkit.
In the same way, language is important. While it’s the right thing to say you’re striving for
“zero harm,” that’s very different than saying you have a “zero tolerance for failure,” which squelches innovation and intelligent risk-taking.
HR: When it comes to innovation, do structure and constraints help or hurt?
DD: If your goal is to enable innovation in an organization, it may seem that establishing structure or constraints around that is somehow antithetical to what you’re trying to accomplish. But in fact, constraints can generate more innovation because they focus both your efforts and scarce resources on what matters most.
One type of constraint we recommend is to define the “innovation types” you want to pursue in your company. Clearly defining these types ensures that you are pursuing the innovation that is needed for your specific
igh reliability is about reducing variation…identifying a best practice and then relentlessly scaling it in search of perfection. And yet, the art of leadership is about accepting and operating in uncertainty, which requires the
ability to adapt and innovate. Can an organization be successful doing both? In this interview, David Duncan, senior partner at Innosight and Craig Deao, senior leader at Studer Group, weigh in.
H
David Duncan is senior partner at Innosight, Lexington, MA.
Craig Deao, MHA is senior leader and national speaker at Studer Group, Pensacola, FL.
Summer 2017 ISSUE 24 HARDWIRED RESULTS® | 9
strategy – and this typology can then be used to organize the goals you have for innovation, as well as the systems and processes that enable it. Another type of constraint we often help leaders to develop is what we call the
“innovation guidelines and boundaries.” An organization might be looking to pursue new, more transformational business models that, by definition, look quite different from what it does today. But important questions always then arise, including “How different are we willing to consider?” and “What’s out of bounds?” We help leaders to answer these questions, and, importantly, to align on their answers, because again they focus innovation energy.
HR: Are there other ways to constrain and focus innovation?
DD: Innovation always involves some level of exploring new, unfamiliar areas; therefore, it’s important to have a disciplined process around how to learn what you don’t know and then adapt your ideas to what you learn. There are well-established processes for intelligent risk taking—these go by a variety of names, including emergent strategy, discovery-driven planning, and “testing & learning.” What they have in common is a disciplined approach to identifying assumptions and sources of uncertainty, and then testing them in a methodical way before expending too much energy and resources, much as entrepreneurs do.
Another technique we use to provide structure and focus to innovation at a more strategic level is what we call “strategic opportunity areas” (SOAs). You can think of these as defined “fishing holes” for where to look for new opportunities to create growth and value. An SOA is narrower than an innovation type but still general enough to encompass many
potential innovation ideas, and is typically the intersection of a customer group, a set of unmet customer needs, and a high-level type of solution.
An example: A hospital looking for new growth opportunities might study trends and conclude that there is an “SOA” defined by improving weight management (the unmet problem) for baby boomers in Florida (the customer group) using data tracking & analytics technologies (the high-level type of solution). This intersection then becomes a fishing hole to explore for new growth and innovation ideas.
HR: One of the challenges with respect to high reliability is that we have excellent people, but broken processes. That combination frequently delivers results that are just average. How can we innovate to get to even fewer defects?
DD: I think it’s important to separate the aspects of the problem that have already been successfully addressed from those that need work or that might be improved further. Then separate the teams (or the processes) that are implementing the current solution that is effective from the teams who can tinker with the next iteration.
It’s not necessarily the job of the people implementing the process to innovate around the method while they are executing on it. It’s up to researchers to test and question, or if the executors are involved, they surface ideas for improvement outside of implementing the process itself. This is how innovation moves you closer to the ultimate goal of zero defects.
“SOAs are fishing holes for opportunities to create new growth and value.”
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1. Staff and leaders have a shared vision, the skills they need, incentives, resources, and urgency for action to consistently drive high reliability.
5. We use checklists across the organization—not just in the operating room—to guard against harm.
6. We actively solicit and include the voice of front-line staff in multi-disciplinary teams designed to improve patient safety.
7. We use tools like rounding, huddles, bedside shift report, and Leadership Development Institutes to train competency and solicit feedback on high reliability initiatives.
8. We are achieving perfect or near-perfect results in key areas of focus.
2. Leadership has created targets around key areas where zero defects should be occurring and goals for those measures are currently set at zero.
3. We are adept and effective at reducing variation across the organization in all areas, from safety errors and fall rates to revenue capture and patient experience.
4. We proactively identify best practices for high reliability on units and in departments so we can replicate them in other locations.
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