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Unit Clinical Leadership Model:A Successful Partnership between Front-Line
Clinicians, Quality, and Senior Leaders
University of Pennsylvania Health SystemDecember 8, 2009
IHI 2009 National Forumon Quality Improvement in Health Care
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Who we are
Victoria Rich, PhD, FAAN, RNChief Nursing Executive, University of Pennsylvania Medical CenterAssociate Professor, University of Pennsylvania School of Nursing
PJ Brennan, MDChief Medical Officer & Senior Vice PresidentUniversity of Pennsylvania Health System
Elizabeth Riley-Wasserman, PhDSenior Vice President, HR & Organizational Development, Mercy Health System(Formerly Chief Learning Officer, University of Pennsylvania Health System)
Linda May, PhDPrincipalCFAR
Larry Hirschhorn, PhDPrincipalCFAR
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The frame for today’s discussion
Tapping into people’spassions andinterests
Developing theeveryday workpractices — largeand small — that makeit possible for people totake responsibility
A new take onaccountability
Helping the organizationlearn from itself and lookfor places where pockets ofinnovation are alreadybeginning to emerge
The leader’s job is to developthe strategic radar toidentify weak signals andamplify them
A new take oninnovation
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Today’s discussion
Unit Based Clinical Leadership — what and why
Playing with other people’s cards
Learning from ourselves
Knitting with hard wire
12 Getting there — and sustaining the gains
3 A “Campaign” approach to change
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Unit Based Clinical Leadership —what and why
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Penn Medicine
Hospital of the University of Pennsylvania #8 US News & World Report/ Magnet
Pennsylvania Hospital
Penn Presbyterian Medical Center
Home Care & Hospice Services
Good Shepherd Penn Partners
University of PennsylvaniaMedical School
University of PennsylvaniaHealth System
Adult admissions — 77,500
Employees — 12,700
#2 NIH ranking
Faculty — 1,347
Med students — 741
Grad students — 1,079
Residents/ Fellows — 978
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This is the story of a physician/ nurse/ qualitypartnership at the top and on the frontline
CMO/CNOAlliance
Unit BasedClinicalLeadership
Working alliance oneach hospital unit —Physician Leader, NurseLeader and ProjectManager for Quality.
Working alliance of theCMOs and CNOs from allthree hospitals, homecare,rehab, and physician practice.
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We needed to bring UPHS’ clinical strategyto the bedside
Unit clinical leadershipAccountability
Interdisciplinary roundingCoordination of care
Reduce hospital-acquiredinfections
Reduce medication errors
Reduce variations inpractice
Transition planning Medication management
Transitions in care
Priority ActionsFour Imperatives
UPHS Blueprint forQuality and Patient Safety
UPHS’ overarching quality goal is to reducemortality and reduce 30-day re-admissions.
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We discovered we needed a “Swiss Army knife”
The institutionwas tired ofplaying “whacka mole.” Everyyear we’d developthree or four newinitiatives — butthen anotherproblem wouldcome along.
This isn’t a project, it’s away of doing things. Youcan bolt differentstrategies onto it.
“
—UPHS CFO”
We needed amulti-purposesolution on theunits to handlealmost any Qualityproblem.
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What our “Swiss Army knife” looks like
Physician Leader andNurse Leader are paired atthe unit level — with a ProjectManager for Quality whobrings real-time data and projectmanagement skills.
We call these trios “UBCLs,”for “Unit Based Clinical Leadership.”
Three-Way Partnership Manages Qualityon the Hospital Units
Physician Leader
Project Mgrfor Quality
Nurse Leader
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We started modestly on purpose so the UBCLscould learn to work with each other
20082007 2009
13 pilot units in 2007
The job: Weekly operations meeting
of the Physician Leader, NurseLeader, Proj Mgr. for Quality
Interdisciplinary rounding
Orienting house staff
Two improvement projects
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Today we’ve covered the house and the UBCLs are readyto take on Transitions, a major system-wide initiative
20082007 2009
The job: Today the triosmanage Quality on the unit,drawing in others as needed.
UBCLs are ready this year toshoulder Transitions in Care,a major system-wideinitiative.
Today it’s 34 “official” units— and another dozen whoare “operating as.”
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The UBCLs aren’t the answer to “everything”
Interdisciplinary carecoordination makes a difference
With UBCLs, the team isinterdisciplinary from the start
Physician backup is especiallyneeded
The unit needs the cooperationof another unit or department
Sustaining the gains overtime will be difficult
With UBCLs, the nurse leader cancount on backup from the physicianleader
With UBCLs, there’s a leadership teamto represent the unit in “negotiations”
With UBCLs, accountability is ongoing
UBCLs HAVE THE MOSTIMPACT WHEN …
HERE’S WHY …
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How we got there — and whatwe’re doing to sustain the gains
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Playing with other people’s cards
Learning from ourselves
Knitting with hard wire
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Playing with other people’s cards
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It started with reports of disrespectful behavior,which led to a professionalism self-study
We convened focus groups touncover work practicesthat foster professionalism:
INCIDENT REPORTS
Nurse/physician partnerships
Interdisciplinary rounding
House staff orientation, with seniornurses as one of the teachers
Daily staff huddles
Incident in OR:Physician lashesout verbally at nurseduring procedure …
… disruptiveargument betweennurse and house staff …
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We began on the blue path, but linked up with the red,green & gold to leverage other people’s goals & actions
20082005 2006 2007 2009
Magnet
Professionalism/ CMO-CNO Alliance
Clinical Strategy
Center for Evidence Based Practice
Unit BasedClinicalLeadershipPatient Progression/ Transitions in Care
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We’re tapping into “Other People’s Energies.”Our biggest job is keeping them aligned.
Vendorslooking topartner ontele-health
CMO/CNOAlliance focusedon Transitionsthis year
Unit-basedpharmacists
New HUPTransitionsCommittee
Insurers looking toreducereadmissions —and willing tonegotiate gain-sharingarrangements.
TRANSITIONSIN CAREfor better patientoutcomes &reducedreadmissions
Penn MedicineLeadership Forum“action learning”focused onTransitions thisyear
CNO Councilfocused onnew roles forTransitions
INTERNAL
EXTERNAL
Healthcare reform
Pay-for-performancecontracts
Public reportinginfluencespatient choice
Transitions in Care is a good example. We have a tiger by the tail.
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Playing with other people’s cards — lessons learned
By tapping into other people’s energyand momentum, you can createresults and critical mass asyou go.
You get change that sticks,because people are creating itthemselves.
You don’t have to do all thework yourself.
Your job is to align what mightotherwise work at cross purposes.
Tapping into other people’s energy and momentumcreates “pull” for the changes you want to make. Otherpeople pull the changes along.
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Learning from ourselves
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The seeds were there. We turned them intoUnit Based Clinical Leadership.
Pennsylvania Hospital wasputting physicianleaders on the units …
Penn PresbyterianMedical Centerwas looking todecentralizeQuality to theunits …
Natural nursemanager/physician pairson a few unitsalready …
Interdisciplinaryrounding, in variousshapes, on many unitsalready …
We took those seeds andhelped the organization dosomething with them:
Gave it a name — “UnitBased Clinical Leadership”
Pulled people together withlike-minded others —and gave them visibilityand credit
Tapped into otherpeople’s energies, topull the changes along
Created structures andsupports to make it work
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We convened summits to learn from each other, makecommitment visible, and create educated consumers
InterdisciplinaryRounding Summit
Transitions in Care“Pilots” Conference
“System-in-the room” summitsof 100+ stakeholders each
The summits helped us: Learn from each other
what’s already workingat UPHS
Make commitmentsand momentumtangible
Create “educatedconsumers” for thechanges to comeTransitions in Care
“Marketplace”
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We “discovered” design specs, by looking atwhat’s already working at UPHS
Build in psycho-social interventions
Contact with the follow-up program while stillin the hospital to establish the relationship
Hyper-vigilance during the first few days
Identifycandidatepatientsas earlyaspossible
Interdisciplinary (electronic) plan of carefollows patient after discharge
Manage medications along the continuum
Bi-directional followup
Connect patient withprovider within two weeks
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5
10
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Interdisciplinary care planning from the beginning
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Hospital StayPreadmission Follow-up ProgramAdmission Discharge Medical
“Landing”
Link patient education before, during, and after hospitalization3
Design Specs for Transitions Follow-up Programs
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Learning from ourselves — lessons learned
An organization learns bestwhen it learns from itself
Pockets of innovation arealready emerging inside almostevery organization — if it knowshow to look and listen
These innovations are thebuilding blocks of culturechange. Your organization’sculture is a “renewableresource.”
Learning from yourself creates “pull” for the changesyou want to make. People like to look at themselves in the mirror.
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Knitting with hard wire
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“Knitting with hard wire” — By that we mean putting inplace a scaffold of supports for the new ways of working
Physiciancommitment
Nursing staffinfrastructure
Alignedmetrics &incentives
Budgeting Leadershipdevelopment
Other everyday“machinery” ofaccountability
Makingthe case
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Unit leadership alone won’t do it. We negotiated thestaffing infrastructure to help the unit succeed
Providesleverage forthe nursingrole
10 patientsper CertifiedNursingAssistant
1:10 CNARatio
Allows theunit to focuson qualityagenda
5 patients perRN
1:5 RN Ratio
Staff andpatienteducationmake theother rolesmore effective
Handles the“air trafficcontrol” thatfrees theNurse Leaderto partner withPhysicianLeader
Providesstrategic viewand continuityon off-shifts
At least .5FTE per unit
One per unit.Rotationalassignment.
One per uniton off shift.Units share onweekends.
ClinicalNurse
Specialist/Educator
ChargeNurse
withoutPatient Care
Duties
AssistantNurse Mgr onOff Shift andWeekends
What
Why
Nursing Ratios and Leverage
Nursing staff infrastructure
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No one believed we could attract enoughPhysician Leaders, but here’s what we did
Uncovered physicians already playing the role
Looked for natural affinities and career goals
Located up-and-coming physicians who were flatteredto be tapped for leadership
Asked the nurses who they wanted
Put “medical quarterbacks” on surgical floors
Focused on hospitalists where that made sense
We’re going for the tipping point where momentum andexpectations begin to feed on themselves.
Physician commitment
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We started building a new alliance with thefinancial side of the house
The 7:00 am breakfast meetingwith the health system CFO
We don’t want Finance to set themargins for the hospitals withoutfirst getting input from theQuality strategy. We want todo that at a system level.
Can we count on you?
“
”— UPHS CMO & CLO
Budgeting
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We’re getting out ahead of the budget cycleand speaking with a united clinical voice
First step — set margins foreach hospital. Hospitals arelocked in.
Discussion of system-widequality initiatives beforemargins are set.
Hospitals (separately)submit budgets.
Negotiation — acrosshospitals and with Finance —occurs after budgets aresubmitted.
CMOs and CNOs submit a jointbudget for system-wide qualityinitiatives they all agreed on.
Negotiation occurs beforebudgets are submitted.
Budgeting
We’re making our job AND theCFO’s job easier.
The old way The new way
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With the economic downturn, we’re looking forcreative ways to fund what we need
Budgeting
Alternative 24/7coverage strategies
Reallocating transferfunds to physicianstipends
Gain-sharingarrangementswith payers
New uses ofHospitalists
Unit clinical leadershipAccountability
Interdisciplinary roundingCoordination of care
Reduce hospital-acquiredinfections
Reduce medication errors
Reduce unnecessaryvariations in practice
Transition planning Medication management
Transitions in care
Priority ActionsFour Imperatives
UPHS Blueprint forQuality and Patient Safety
UPHS’ overarching quality goal is to reduce mortalityand reduce 30-day re-admissions.
1.Post-acute carereferrals
2.Use of hospice3.Med rec on discharge4.Readmission rate for
TCM follow-up program
Transitions in Care — FY’10 Targets
12. Interdisciplinaryrounding
13. Nurse/physiciancollaboration(NDNQI)
14. Patient satisfaction(HCAHPS)
Coordination of Care — FY’10 Targets
5. DVTs & PEs6. BSIs7. Falls with injury8. Pressure ulcers9. VAPs10.SCIP11.UTIs
Reduce Variations in Practice — FY’10 Targets
“Choice within a framework” — we developed targetsand worked with each UBCL to pick theirs
Aligned metrics & incentives
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We negotiated to get a Transitions metric in everysenior leader’s incentive plan
Unit clinical leadershipAccountability
Interdisciplinary roundingCoordination of care
Reduce hospital-acquiredinfections
Reduce medication errors
Reduce variations inpractice
Transition planning Medication mgmt
Transitions incare
Priority ActionsFour Imperatives
UPHS Blueprint forQuality and Patient Safety
UPHS’ overarching quality goal is to reducemortality and reduce 30-day re-admissions.
Aligned metrics & Incentives
Focusing theattention ofthe system
Every UBCL andevery seniorleader at UPHShas aTransitions inCare targetthis year.
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Quality-related outcomes at UPHS are movingin the right direction
MORTALITY
STAFFSATISFACTION
MALPRACTICE
PATIENTSATISFACTION
PEERRECOGNITION
INFECTIONS LENGTH OF STAY
P4Pis on track
Making the case
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First BSI Campaign
2nd BSI Campaign
BioPatch Pilot
BioPatch UseExpanded
TheraDoc
BSI Definition Changes
CLC 2000 Removed
BSI Task Force
Value Capture
New Dressing
Many efforts over time to reduce bloodstream infections.How to know if the UBCLs were making a difference?
Making the case
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We did a study to separate out the impact of the firstpilot UBCLs on reducing bloodstream infections
Making the case
We controlledfor the effectof otherinterventions(Biopatch,TheraDoc, newdressing).
And found thatUBCLs reducebloodstreaminfections andsave costs.
Net impact of five pilot UBCLsover nine months (Q3’08 - Q1’09)
33 BSIs avoided
670 hospital days avoided
$477,200 supply cost savings(direct variable supply costs adjusted forage, gender, insurance type and DRG)
$330,000 incrementalinvestment (physician stipends,assistant nurse mgrs)
Total net savings for five unitsover nine months: $147,200
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Figure/ groundLeadership development
From one perspective,we’re working toimprove Quality onthe units.
From another perspective,we’re developing theCMOs, CNOs, andUBCLs as leaders.
Succeeding at the work builds leadership skills.Leadership skills make it possible to succeed at the work.
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We expected to hand off “mentoring” eventually, butdiscovered we wanted to keep our ears to the ground
CMO/CNOAlliance
Unit BasedClinicalLeadership
CMO/CNO pairs continue to meetmonthly with their UBCL teams —to strategize, troubleshoot,and plan ahead.
Leadership development
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The UBCLs have to learn to be leaders who canget work done through others
Leadership development
Everybody wants apiece of the UBCLs
Penn Medicine LeadershipForum — traditionallyreserved for senior leaders— is focused this yearon the UBCLs
It’s organized as“action learning,” toapply the leadership skills toa Transitions-in-Care projecton each unit.
Dilemmas of success Next steps
The health system keepssaying, “Give it to theUBCLs.”
Many groups are trying toget the UBCLs’attention —pharmacists, dischargeplanners, nurseeducators, post-acutecare providers, …
Teaching the UBCLs to beleaders who can get workdone through others
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Staffing & projectmanagement for theCMO/CNO Alliance
Other structures — big and small — that make itpossible for people to take responsibility
Communication withUPHS senior leadersembedded into theirregular meetings —to signal that our issuesare central to the work ofthe institution
Reallocated an FTE toestablish an overallproject manager forthe UBCLs
Clinical tools &resources forimprovement targets
Tools and templates formanaging improvementprojects and running theweekly ops meetings
Everyday “machinery” of accountability
Support for schedulingmeetings — a “small”barrier that can loomvery large
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Knitting with hard wire — lessons learned
To change people’sbehavior, you have tochange their everydaywork practices
To change work practices,you have to put in placesupports andinfrastructures — bothbig and small
The supporting infrastructures create “pull” forthe changes you want to make. They attract people to thenew ways of working and make them easier, not harder.
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Q&A — We welcome your questions, thoughts,& experiences
A new take onaccountability
A new take oninnovation
Playing with other people’s cards
Learning from ourselves
Knitting with hard wire
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The “Campaign” approach tochange
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There’s good social sciencebehind what we’re doing
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CFAR’s Campaign Approach to Change
Direction andMomentum
SweepingPeople In
Consolidatingthe Gains
The quiet phase —create “facts onthe ground”before you gobroadly public
Broaden thecampaign andcreate capacitiesand infrastructures
Institutionalizethe changesand turn theCampaign backinto themainstream
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Results. Early gainsand a strongfoundation for broaderchanges.
Results. Spread ofnew behaviors and thesupports to sustainthem.
Results. Change thatsticks and the skills tochange again as the futuredemands it.
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“Pull” is stronger than “push”
If we create pull,others will do thework of change for us.
New behaviors can’tbe legislated. They begin toshow up when an organizationknows how to create pull forthem.
A Campaign creates“pull” for new behaviors.
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Your organization’s culture is a renewable resource
A useful definition of culture:“The way we do thingsaround here.”
New behaviors are the buildingblocks of an organization’sculture. Each behavior by itselfmay be small, but togetherthey can move theorganization’s culture.
The raw material for aculture change is almostalways already emerging in theorganization.
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A Campaign is top down AND bottom up
Top down, by itself,lacks theresilience andcreativity ofgrass-rootsefforts.
Bottom up, by itself,lacks focus,alignment andthe commitmentof mainstreamleaders who cangive resources.
A Campaign taps thecreativity andcommitment ofthe wholesystem.
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The leadership skills you’ll need may seemcounterintuitive
Trying to “motivate” or“empower” others
Discovering and freeing upenergy and passion
Pushing people to change Creating pull for the changes
Telling and selling Listening and amplifying
Thinking your way tonew actions
Acting your way tonew thinking
NOT … INSTEAD …
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A few resources — Campaign Approach to Change
Hirschhorn, Larry and Linda May. “The CampaignApproach to Change.” Change, Vol. 32, No. 3,May-June, 2000.
Hirschhorn, Larry, “Campaigning for Change,”Harvard Business Review, July, 2002.
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To be in touch
Victoria Rich, PhD, FAAN, [email protected]
PJ Brennan, [email protected]
Elizabeth Riley-Wasserman, [email protected]
Linda May, [email protected]
Larry Hirschhorn, [email protected]