ihi high impact leadership framework - case...

Executive Quality Academy

Institute for Healthcare Improvement

IHI High Impact Leadership Framework Barbara Balik EdD, RN

[email protected] 16, 2015

ACMA Leadership

Conference

Learning Objectives

Describe IHI’s High Impact Leadership Framework and its

three major components

Explain how High Impact Leadership can enable leaders to

achieve the Triple Aim – better health, better care, lower costs

Define strategies for applying the High Impact Leadership

Framework to your department, organization, and community

Field of Dreams



What You Know

Two Questions

Why did you get into

healthcare?

Why have you stayed?

The Heart of Leadership, Balik & Gilbert

© 2010 Balik and Gilbert All Rights Reserved

Think of a Leader

A leader who influenced How you describe them

A leader who made a

positive difference

One you learned great

positive lessons from

A leader who helped you

grow

Think of a phrase or a few

words that describes them





Triple Aim

Care better than we’ve ever seen, health

better than we’ve ever known, at a cost

we can all afford

Leading Improvement and Innovation

“Every system is perfectly designed to

produce the results it gets.”

Dr. Paul Batalden

11

As leaders you own the results

IHI High-Impact Leadership for Improvement and

Innovation

An update on IHI thinking

– What is required for improvement and innovation today

Guide

– For leaders at all levels to achieve Triple Aim results for

the populations that they serve

– IHI White Paper

– http://www.ihi.org/resources/Pages/IHIWhitePapers/HighImpactL

eadership.aspx



There is no cookie cutter (or magic carpet!) approach

– Framework is designed to help identify where leaders should focus efforts, resources and tactics

– Agnostic to popular personal leadership theories

– Leaders have to adapt to their specific organizational culture, capabilities, and challenges

Leading Improvement

A useful definition…

Leadership is a process of social influence, which

maximizes the efforts of others, towards the

achievement of a goal

Kevin Kruse Forbes.com What is Leadership April 9, 2013

Kevin Kruse

Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce

Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.

High-Impact Leadership:Care better than we’ve ever seen, health better than we’ve ever known, at a cost we

can all afford





IHI High-Impact Leadership FrameworkWhere Leaders Focus Efforts

High-Impact Leadership BehaviorsWhat Leaders Do to Make a Difference



Mental Models

Here is Edward Bear, coming downstairs now, bump, bump,

bump, on the back of his head, behind Christopher Robin. It

is, as far as he knows, the only way of coming downstairs, but

sometimes he feels that there really is another way, if only he

could stop bumping for a moment and think of it.

Winnie-The-Pooh, A.A. Milne



Mental Models

How leaders think shapes behavior

– Beliefs, theories and assumptions provide a “lens” through

which leaders view and filter challenges and define the

universe of potential solutions and actions

Mental Models Evolve Over Time20

Improve Facilities

and & technology

Improve Customer Service

Improve the Patient

Experience

Patients & Families

Partners in Care

Physicians as

Customers

Physician Cooperation

Physician Engagement

Physicians as Leaders

Manage resources & inputs

Manage length of stay and access

Remove waste from processes

Redesign care

Meet accreditation requirements

Meet public reporting & compliance

requirements

Use Quality data for

improvement

Use Quality data for payment

Leadership

Issue

Patient

Satisfaction

Role of

Physicians

Reduce Cost

Performance

Measurement

10‘s80‘s 00‘s90‘s

Mental Models Evolve Over Time –

Case Managers

21

Manage length of

stay

Instructions for going

home

Doing For Patients

hospital to home

Partner with Patients across

continuum

Silos

UR Nurses/SW

Integrating within

departments

Expansion to Case

Management

Leaders in Triple Aim

Cut costs

Manage length of stay and access

Understand root of costs

Redesign care for

value

Meet insurance

requirements

Teaching, preparing for

discharge

Reduce readmissions

Improve patient

satisfaction

Triple Aim Outcomes

Leadership

Issue

Patient care role

Case Manager

Roles

Resource Mgmt

Performance

Measurement

10‘s80‘s 00‘s90‘s



Mental Models: Cost vs. Value

Clinical

Processes

Direct Inputs

•Supplies

•Labor

Measures

•Patient Experience

•Clinical

•Engagement

•Financial

•Value across

the continuumIndirect Inputs

•Structure

•Technology

Traditional

Strategy:

Control Inputs

Support

Processes

*waste = unintended

variation, rework, error,

valueless care, needless

complexity, etc.

Quality

Strategy:

Redesign and

Remove Waste*

Changing the Way We Think About Health Care

What’s the Matter?

What matters to you?

IHI High-Impact Leadership – Mental Models

Individuals and families as partners in their care

Compete on value with continuous reduction in

operating cost

Reorganize services to align

with new payment systems

Everyone is an improver



Leadership BehaviorsDriven by Persons and Community

• Communicate that we are always people

• “patient” is a temporary condition

• Nothing about me without me

• What if nothing was designed or improved for patients and community members without their being part of the process?

• Communicate why and model partnerships

• Spend time learning about health and healthcare from community members

– Social service agencies, community health, education, public safety, law enforcement

• Assure health literacy and shared decision making

Leadership BehaviorsDriven by Persons and Community

How leaders think about challenges and solutions

– Who leaders talk and think with – how define partners

– Where leaders get their ideas and who view as experts

– How leaders understand the lived experience of

patients and community members

– What data leaders use for decisions and its source

– The boundaries leaders eliminate to improve the health

of the community

– How leaders describe their work – their

accountabilities

When We are at Our Best . . .

This is how we demonstrate Driven by Person and

Community:



Current State

Large barrier to “Driven by Person and Community”

– We already think we are!

Deeply embedded belief (hubris?) that we – within

healthcare – are the experts vs. merged expertise:

– People are experts in their own health and lived experience

– Healthcare professionals as experts in content

Pervasive systems that reinforce those beliefs

– Dismissive treatment of patients

– Systemic disrespect – waiting; wasteful systems for everyone*

*Lucian L. Leape, MD, Miles F. Shore, MD, Jules L. Dienstag, MD, Robert J. Mayer, MD, Susan Edgman-Levitan, PA, Gregg S. Meyer, MD, MSc,

and Gerald B. Healy, MD. A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians. Acad Med.

2012;87:845–852. A Culture of Respect, Part 2: The Nature and Causes of Disrespectful Behavior by Physicians. Acad Med. 2012;87:853–858.

Barbara Balik

What Patients and Families Want

Dignity and respect

Information sharing

Participation

Collaboration

Institute for Patient- and Family-Centered Care

Partnerships - Words Matter

Not ‘engagement’ – they already are

Experience is the whole deal – safety, quality, respect

To – For – With � Co-design

o “Nothing about me without me”

o Co-design care, systems, policies

o Change the balance of power*

*Don Berwick, Change from the Inside Out; JAMA 2015



Personal Characteristics

Passion for Patient Care is a Personal Value

1I do not know if others

know of my commitment to patient care

5Many know of my

commitment but not everyone; I lack

consistency in words/actions about

patient care as a personal value

10My passion for patient

care shows up in everything I do; my

colleagues would say my actions demonstrate it

How will I find out?

© 2010 Barbara Balik and Jack Gilbert . All Rights Reserved



Leadership Behaviors

Disciplined Action

Meeting Questions – How many times?Executive Team

Sample Questions “How does this strategy/tactic improve patient care?”

“How does this reduce variation in care?”

“What patients developed complications in the past 24 hours? What

have we learned from that?”

“What patients or community members have we asked about this?”

“What value does this add to patient care and patient experience?”

“What patients/family members or community members do we have

on teams?”

“What other organizations are helping us with this strategy?”




Shape Culture

Engage Across Boundaries

Create Vision & Build Will

Deliver ResultsDevelop

Capability

Driven by

Persons &

Community

IHI High-Impact Leadership Framework



Culture

What is it?

– The total learned, shared, taken-for-granted

assumptions that a group has learned throughout

its history; base of daily behavior

– Deep, broad, stable– Schien, Corporate Culture Survival Guide, 1999

– Seen in behavior

– Changed over time by working on behaviors that

eventually shift mental models

How Culture is Embedded

Primary• What leaders do, pay attention to,

measure and reward on a

regular basis

• How leaders react to critical incidents and organizational crises

• Deliberate role modeling, teaching and coaching

• Observed criteria by which leaders allocate rewards and status

• Observed criteria by which leaders recruit, select, promote, and terminate organizational members

Secondary• Organizational design and

structure

• Organizational systems and procedures

• Organizational rites and rituals

• Design of physical space and buildings

• Stories, legends and myths about people and events

• Formal statements of organizational philosophy, values and creed

E. Schein, Organizational Culture and Leadership,1994

Or This?This?



Culture - What is it?

Finish the statement:

– This is an organization where . . .

What Culture do You Want?

Current State Desired State

Where are you in the Journey?



Doing To – When:

We say – you do: schedules; visiting hours

We waste your time – come to the clinic & wait

We assume we know what the community needs

Information is not shared or understandable

Health sciences students lack skills to partner with patients

Participation in research studies is not equitable

We determine if you are compliant

There is helplessness – when the patient/family say:– I don’t know what is the plan of care or what happens next

– I don’t know who is in charge of my care

– I don’t feel like you know me

Barbara Balik

Doing For – When:

We keep the patient or community member in mind when designing or improving programs, research studies – then ask

We design the teams to help you – without you

We manage your expectations about waiting, what healthcare can do, or what the community needs

Early use of health literacy

We teach you – lots & lots & lots

We are beginning to get it about cross-continuum but don’t know much about the white spaces

We assume we know everything about health and healthcare

Barbara Balik

Doing For – Service Design

What Matters to You?



Doing For

“We are really good

about caring what you

think about us. We are

not good about caring

what you think.”– Catherine Lee, VP Service Excellence, McLeod

Regional Medical Center

Barbara Balik

Doing With – When:

Patient/family and community member advisors are essential team members to design or improve programs that follow the patient journey; to design research or evaluation outcomes

All key decisions are mutual – including who is on my team

All staff are viewed as caregivers and are skilled in respectful communication and teamwork

Health Literacy is everywhere in patient care

Senior leaders model that patient’s safety and community well-being guide all decisions

Staff, providers, leaders are recruited for values and talent

Barbara Balik

Doing With – Mental Health Design



Where are you in doing to-for-with?

To-For-With Assessment

1. Individually – Complete 1-2 examples in each category

2. Review as a group at your table

3. What do your lists tell you? What gets in the way of doing with?

Doing To – Patients, Families, Community Members

Doing For – Patients, Families, Community Members

Doing With – Patients, Families, Community Members

Barbara Balik

Shape Culture

Engage Across Boundaries

Create Vision & Build Will

Deliver ResultsDevelop

Capability

Driven by

Persons &

Community

IHI High-Impact Leadership Framework



Understand care and health from partners’ view – their

journey and needs

Move knowledge not people*

Focus on what determines health: Work with community

– “I was standing in the river looking for water”

– Education

– Social and Community Context

– Health and Healthcare

– Neighborhood and Built Environment

– Economic Stability

Boundarilessness Thinking

*Don Berwick, Change from the Inside Out; JAMA 2015

Leading Across Boundaries

Establish a shared purpose – don’t assume

Communicate a shared vision

Ask questions and listen to responses

Build consensus

Show respect for the partner’s strengths, business models,

and constraints

Adopt a collaborative approach and demonstrate patience

Volunteer resources when needed

Ensure that the right people are in the room

Maternal and

Neonatal Mortality

Due to Faulty

Referral Processes

Inadequate Clinical Skills &

Management

Transportation & Communication

Barriers

Sociocultural Barriers

Late/no identification of high-risk clients

Failure to stabilize client before referral

Poor documentation of indications for referral & interventions to date

Lack of readiness of receiving facility

Poor hand-off management processes

Unreliable use of referralprotocols

Unavailability of local transportation

Insufficient funds for transport & telephone credits (both family & staff)

Long distances, poor roads/bridges

Inadequate ambulance services

Unreliable telecom services

Preference for home/TBA deliveries and self-medication (hospital as last resort)

Delay in decision to seek skilled care (recognition, permission, financial etc.)

Delay in acceptance of referral

Low risk awareness & management of obstetric/neonatal complications

Negative perceptions about health facilities as places to “go and die”

Primary Drivers Secondary DriversOutcome

Delay in providing care

Governance & Accountability Inadequate supervision, monitoring

Individual & Family BarriersComplexity of

problem



• Be consistently person-centered in word and deed.

• Be consistently person-centered in word and deed.

Person-centeredness

• Be a regular, authentic presence at the frontline and a visible champion of improvement.

• Be a regular, authentic presence at the frontline and a visible champion of improvement.

Frontline Engagement

• Remain focused on the vision and strategy.

• Remain focused on the vision and strategy.Relentless Focus

• Require transparency about results, progress, aims, and defects.

• Require transparency about results, progress, aims, and defects.Transparency

• Encourage and practice system-thinking and collaboration across boundaries.

• Encourage and practice system-thinking and collaboration across boundaries.Boundarilessness

High-Impact Behaviors



Team Engagement

Can each person answer yes each day?

– Am I treated with dignity and respect by

everyone?

– Do I have what I need so I can make a contribution

that gives meaning to my life?

– Am I recognized and thanked for what I do?

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. 2013. Lucian Leape institute of the National Patient Safety

Foundation; NPSF.org

Another View – Engaging Others

Choice/Respect

Mastery

Purpose

Barbara Balik; Modified from D. Pink, Drive



What are Vital Few Behaviors?

Those few behaviors that:

─ Move rapidly toward the desired outcome

─ Are teachable, coachable, observable

Often in evidence already:

─ E.g. To help low achieving children read: more praise than

punishment; constantly alternate teaching and questioningFrom: Patterson et al. Influencer: The Power to Change Anything (2007)

Heart of LeadershipWhat We Learned from Transformational

Leaders

Words and actions matchAuthenticityHumility

Passion for patient care isa personal value

IntelligentHungry for LearningReflective


Organizational Characteristics

Grow others

Positive future orientationAims highChallenges status quo

Transformational Results through a Single-Brain Organization

Patient care constancy of focus

Disciplined actionPart of the team,part of the solution Genuinely care

about and trust others

Engage everyone





The patient matters most to her

He is unwavering about the mission; he has a constancy of purpose

She has a strong sense of integrity of what’

’’

’s right for patients---she lives and breathes it


Passion for Patient

Care is a Personal

Value

The Heart of Leadership, Balik & Gilbert© 2010 Balik and Gilbert All Rights Reserved

She is not distracted by the crisis of the day; she doesn’

’’

’t jump around or vacillateOur strategic plan is alive and well: What is best for the patient? What will make a perfect experience for the patient?


Patient Care

Constancy of Focus

Disciplined Action



Enough

I pray you enough sun to keep your attitude bright no matter how gray the day may appear

I pray you enough rain to appreciate the sun even more

I pray you enough happiness to keep your spirit alive and everlasting

I pray you enough gain to satisfy your wanting

I pray you enough challenges to think

outrageously big!



Resources

ResourcesNew Rules for Radical Redesign in Health Care

Change the balance of power by co-producing health and well-being in partnership with patients,

families and communities.

Standardize what makes sense to reduce unnecessary variation and increase the time available for

individualized care.

Customize to the individual's needs, values and preferences, guided by the understanding of what

matters to the person, in addition to the typical "What's the matter?”

Promote well-being and focus on outcomes that matter the most to people, appreciating that their

health and happiness may not require health care.

Create joy in work by cultivating and mobilizing the pride and happiness of the health care workforce.

Make it easy, continually reducing waste and all non-value-added requirements and activities for

patients, families and clinicians.

Move knowledge, not people, exploiting all helpful capacities of modern digital care and continually

substituting better alternatives for visits and institutional stays.

Collaborate and cooperate, recognizing that the health care system is embedded in a network that

extends beyond traditional walls.

Assume abundance by using all the assets that can help to optimize the social, economic and physical

environment, especially those brought by patients, families and communities.

Return the money from health care savings to other public and private purposes.

Berwick, D., et al. Change From the Inside Out: Health Care Leaders Taking the Helm, 3/26/2015

http://jama.jamanetwork.com

Balik, B., Gilbert, J. (2010). The Heart of Leadership: Inspiration and Practical Guidance for Transforming Your Health Care Organization. Chicago: AHA Press.

Balik B, Conway J, Zipperer L, Watson J. The Patient and Family Experience. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011.

Braaten, J, Bellhouse, D. Improving Patient Care by Making Small Sustainable Changes. Nursing Economics, May-June 2007, Vol 25, No. 3, 162-66.

Collins, J. (2009). How the Mighty Fall. NY: Harper Collins

Collins, J. (2001). Good to Great, NY: Harper Business.

Collins, J. (2005). Good to Great & the Social Sectors: A Monograph to Accompany Good to Great. Boulder, CO: www.jimcollins.com

Duhigg, C. (2012). The Power of Habit: Why We Do What We Do in Life and Business. NY: Random House.

Edmondson, A. (2012). Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: Jossey-Bass.

Gilbert, J. (2007). Strengthening the Ethical Wisdom: Tools for Transforming Your Healthcare Organization. Chicago: Health Forum

Resources

Barbara Balik



Resources

Heath, C. & D. (2010). Switch: How to Change Things When Change is Hard. NY: Random House.

Heifetz, R. (1994). Leadership Without Easy Answers. Cambridge, MA: Belknap Press.

Heifetz, R., Grashow, A., Linsky, M. (2009). The Practice of Adaptive Leadership. Boston: Harvard Business Press.

Kenagy, J. (2009). Designed to Adapt. Second River Publishing.

Kouzes, J., Posner, B. (2002). The Leadership Challenge. San Francisco: Jossey-Bass.

Kouzes, J., Posner, B. (2003). Encouraging the Heart: A Leader’s Guide to Rewarding & Recognizing Others. San Francisco: Jossey-Bass.

Krause, T. (2007). NASA after Columbia & Lessons for Healthcare. National Patient Safety Board of Governors presentation. June 2007.

Keroack, M., Youngbird, B., Cerese, J., Krsek, C., Prellwitz, L., Trevelyan, E. Organizational factors associated with high performance in quality & safety in academic medical centers. Academic Medicine 82: 1178-1186, December 2007

Barbara Balik

ResourcesMoss Kanter, R. (2004). Confidence: How Winning Streaks & Losing Streaks Begin & End. NY: Crown Business.

Patterson, et al., (2008). Influencer. New York: McGraw-Hill.

Pink, D. (2009). Drive: Surprising Truth About What Motivates Us. NY: Riverhead Books.

Rother, M. (2010). Toyota Kata: Managing People for Improvement, Adaptiveness, and Superior Results. NY: McGraw Hill.

Schein, E. (1999). The Corporate Culture Survival Guide: Sense & Nonsense About Cultural Change. San Francisco: Jossey-Bass.

Schein, E. (2004). Organizational Culture & Leadership, 3rd Edition. San Francisco: Jossey-Bass.

Senge, P., Kleiner, A., Roberts, C., Ross, R., Roth, G., Smith, B., (1999). The Dance of Change: The Challenges of Sustaining Momentum in Learning Organizations. New York: Doubleday.

Spear, S. (2010). The High Velocity Edge. New York: McGraw Hill.

Barbara Balik

Resources

Spear, S., Bowen, HK. Decoding the DNA of the Toyota Production System. Harvard Business Review, Sept-Oct 1999; 77; 99-106.

Spear, S. Learning to Lead at Toyota. Harvard Business Review, May 2004; 78-86.

Spear, S. Fixing Health Care from the Inside, Today. Harvard Business Review, Sept 2005; 78-91.

Spear, S., Schmidhofer, M. Ambiguity & Workarounds as Contributors to Medical Error. Annals of Internal Medicine, April, 19, 2005, Vol. 142, No. 8, 627-630.

Tucker, A. & Edmondson, A. Why Hospitals Don’t Learn from Failures: Organizational & Psychological Dynamics that Inhibit System Change. California Management Review, Vol. 45. No 2, Winter 2003, 55-72.

Weick, K., Sutcliffe, K. (2001). Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass.

Barbara Balik



Heart of LeadershipAdditional resources

Four Personal Characteristics

Patient care is my North Star

My actions show commitment to that North Star

Words and Actions Match;

Authenticity; Humility

Words and Actions Match;

Authenticity; Humility

Care about and Trust OthersCare about and Trust Others

Passion for Care is a Personal ValuePassion for Care is a Personal Value

Intelligent; Hungry for

Learning;Reflective

Intelligent; Hungry for

Learning;Reflective

Others can count on what I say

Others at all levels say I build trustI do not consider myself superior to anyone

I am comfortable not knowing

I am hungry to learn from anyone and anythingI regularly step back from everyday pressures

I genuinely care about the welfare of others

I trust others unless given good reason not to



Five Organizational Characteristics

•I have a bold aspiration not easily attained•I am always challenging others to reach for “the next best”

Patient Care Constancy;

Disciplined Action

Patient Care Constancy;

Disciplined Action

Part of the Team and the SolutionPart of the Team and the Solution

Grow OthersGrow Others

Positive Future Orientation;

Aims High; Challenges Status

Quo

Positive Future Orientation;

Aims High; Challenges Status

Quo

Engage EveryoneEngage Everyone

•I have an unrelenting and primary focus on the safety and quality of care

•I am known for developing disciplined processes

•I make sure everyone in our organization has a voice•I reach out regularly to engage others at all levels

•I don’t make significant decisions alone•I seek diverse views to reach the best solutions

•I often see talents in others before they do•Helping others realize their potential is thrilling for me





Organizational CharacteristicsPatient Care Constancy of Focus -Disciplined Action

Capacity Description

Our Performance Improvement (PI) system is ………

The expectations of all leaders to demonstrate PI competency is …

Percent of leaders who can successfully guide complex PI activities is …

How do I demonstrate PI skills in my work?



Words and actions matchAuthenticityHumility

Passion for patient care isa personal value

IntelligentHungry for LearningReflective



Grow others

Positive future orientationAims highChallenges status quo

Transformational Results through a Single-Brain Organization

Patient care constancy of focus

Disciplined actionPart of the team,part of the solution Genuinely care

about and trust others

Engage everyone


There’’’

’s a “““

“thereness”””

”

when she’’’

’s with others. She will swivel her chair, move in, and doesn’

’’

’t look at her computer while listeningHe has a desire to be with and around people to hear what is important to them, what they need


Genuinely Care

About and Trust

Others





Genuinely Care About & Trust Others

Describe when have you experienced this from

another leader?

What do you do daily to demonstrate this?

Encourage the Heart reflections:I express high expectations about what people are capable of accomplishingI personally acknowledge people for their accomplishmentsI get to know, at a personal level, the people I work with




She finds out what is good in people, exposes it, grows it, and helps you master it in pursuit of the group goal.

She hired me with no hospital operations experience… She said she was looking for leadership skills and that operations could be taught.

Grow Others

© 2010 Barbara Balik and Jack Gilbert All Rights Reserved



Grow OthersThe people I am currently mentoring:

I am clear on the successor(s) for my position

Yes: Who?:

Why them?:

I am growing this person’s skills to move into the position –

list:

No:

Who is someone I might identify

An example of when I hired non-traditional people when

filling positions is …



ihi high impact leadership framework - case...

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