Discuss how accountability and standardization produced lasting results for each of the case studies. What alternative strategies may these organizations have employed to achieve the same results?

Sustaining Improvement

 

AN IHI RESOURCE

 

20 University Road, Cambridge, MA 02138 • ihi.org

 

How to Cite This Paper: Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge,

 

Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)

 

WHITE PAPER

 

AUTHORS:

 

Richard Scoville, PhD: Improvement Advisor and IHI Faculty

 

Kevin Little, PhD: Principal, Informing Ecological Design, LLC,

 

and IHI Faculty

 

Jeff Rakover, MPP: Research Associate, IHI

 

Katharine Luther, RN, MPM: Vice President, IHI

 

Kedar Mate, MD: Chief Innovation and Education Officer, IHI

 

Acknowledgements:

 

The authors wish to thank the many reviewers who generously contributed their time and good judgment. Don Goldmann,

 

IHI Chief Medical and Scientific Officer, provided formative guidance on our earliest drafts. Maureen Bisognano, IHI

 

President Emerita and Senior Fellow, reminded us that it’s the stories that bring the theory to life. Pierre Barker, IHI Senior

 

Vice President, helped clarify our understanding of the Juran Trilogy. Comments by IHI staff Andrea Kabcenell, Dave

 

Williams, and Christina Gunther-Murphy, Rohit Ramaswamy of the University of North Carolina at Chapel Hill, and Steve

 

Meuthing of Cincinnati Children’s Hospital Medical Center pointed out needed clarifications. Clareen Weincek, President of

 

the American Association of Critical Care Nurses, provided frontline nursing perspective. IHI editors Jane Roessner and Val

 

Weber provided valuable ideas to improve the structure and expression. Of course, the authors assume full responsibility

 

for any errors or misrepresentations. In the spirit of “all teach, all learn,” we welcome readers’ reactions, corrections, and

 

suggestions.

 

The Institute for Healthcare Improvement (IHI) is a leading innovator in health and health care improvement worldwide. For more than 25 years, we have

 

partnered with a growing community of visionaries, leaders, and frontline practitioners around the globe to spark bold, inventive ways to improve the

 

health of individuals and populations. Together, we build the will for change, seek out innovative models of care, and spread proven best practices. To

 

advance our mission, IHI is dedicated to optimizing health care delivery systems, driving the Triple Aim for populations, realizing person- and family-

 

centered care, and building improvement capability. We have developed IHI’s white papers as one means for advancing our mission. The ideas and

 

findings in these white papers represent innovative work by IHI and organizations with whom we collaborate. Our white papers are designed to share the

 

problems IHI is working to address, the ideas we are developing and testing to help organizations make breakthrough improvements, and early results

 

where they exist.

 

Copyright © 2016 Institute for Healthcare Improvement. All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the

 

contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in

 

any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement.

 

Institute for Healthcare Improvement • ihi.org 3

 

Contents

 

Executive Summary 4

 

Background 4

 

Theoretical Context: “Doing the Work, Improving the Work” 6

 

A High-Performance Management System 9

 

Key Drivers of High-Performance Management at the Front Line 11

 

Implementing a High-Performance Management System: Lessons from the Field 16

 

Conclusion 19

 

Appendix A: Case Examples of Standard Work Implementation in Health Care 20

 

Appendix B: Examples of How Informant Organizations Execute Drivers of Quality Control 29

 

References 32

 

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Executive Summary

 

This white paper presents a framework that health care organizations can use to sustain

 

improvements in the safety, effectiveness, and efficiency of patient care. The key to sustaining

 

improvement is to focus on the daily work of frontline managers, supported by a high-performance

 

management system that prescribes standard tasks and responsibilities for managers at all levels

 

of the organization. To inform this work, we reviewed selected literature and interviewed leading

 

organizations. The result presented here is a description of high-performance management in

 

theory and practice, along with recommendations for organizations interested in pursuing these

 

methods:

 

 A theoretical context for high-performance management, grounded in the Juran

 

Trilogy (Quality Planning, Quality Control, and Quality Improvement) and selected current

 

literature;

 

 An organizational framework for a high-performance management system

 

(HPMS), illustrating standard work for each tier of management and the integrated

 

organizational hierarchy that reinforces, supports, and improves work at all levels;

 

 A driver diagram that summarizes our theory of the key factors for

 

implementing a HPMS through standardized management tasks, pervasive Quality

 

Control (as defined by Juran to mean monitoring the system and making necessary

 

adjustments to ensure stability over time), coordinated Quality Improvement, and

 

development of a culture of candid transparency that encourages and sustains these activities;

 

 Case examples that describe three health care organizations’ approaches to testing and

 

implementing management standard work; and

 

 Appendices containing additional guidance for organizations seeking to implement these

 

practices.

 

Background

 

Leading health care organizations are coming to recognize that sustaining improvement is

 

essential. Typically, they have spent years building improvement capability and applying it

 

throughout the organization. But too often, hard-won improvements are lost as attention shifts to

 

other priorities and staff revert to the “old way” of doing things.

 

Having achieved high levels of clinical quality and safety, organizations with reputations for

 

clinical excellence are increasingly focused on sustaining improvement — ensuring that, following

 

improvement, care and support processes continue to perform at the new levels of quality and

 

safety. In the research that informs this white paper, we set out to understand the systems for

 

sustaining improvement developed by ten outstanding health care systems — and to synthesize

 

them into a framework that other health care organizations can use to ensure that improvements

 

are sustained over time.

 

Two main schools of thought were especially influential in framing our investigation: Joseph

 

Juran’s “Trilogy”1 for quality management (i.e., Quality Planning, Quality Control, and Quality

 

Improvement); and Lean management, articulated by David Mann,2 Steven Spear,3 and others.

 

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Our study of ten high-performance health care systems revealed a common focus on explicitly

 

organized frontline management — daily work for unit leaders — that guides day-to-day

 

provision of excellent patient care by all frontline staff. In this white paper, we refer to such regular

 

daily work using the Lean term “standard work”: the routine daily care and support tasks enacted

 

in nursing units, ICUs, ORs, ERs, or clinics where patient and provider meet and care is sought

 

and delivered. We also learned about specific coordinated practices at higher levels of

 

management — an integrated “management system architecture” — that enable effective Quality

 

Planning and reinforce, support, and improve work at the front line.

 

Using Juran’s terminology and definitions,1 our primary focus in this paper is not on Quality

 

Improvement, but on Quality Control — and by Quality Control, we expressly are not referring to

 

the regulatory systems of inspection and accreditation that play a vital role in standardizing quality

 

across the health care industry; nor do we mean the kind of micromanagement practiced by some

 

leaders. Of course, the astute reader will recognize that Quality Control and Quality Improvement

 

are not separable activities, but integrated elements of a high-performance management system

 

(HPMS).

 

Our investigation revealed a view of management work as disciplined standard work, analogous to

 

the protocol-driven work of frontline caregivers, integrated vertically and horizontally by means of

 

frequent team-based communication and ubiquitous, graphically displayed process measurement

 

(often in the form of Shewhart control charts). Process abnormalities (special causes) trigger

 

frontline adjustments or surface issues that are escalated to formal improvement initiatives.

 

Continuous frontline attention to quality and a culture that focuses on problem analysis (versus

 

personal blame) provide the foundation for Quality Planning, Quality Control, and Quality

 

Improvement. Formal, negotiated Quality Planning relies on candid, energetic staff participation,

 

and aligns frontline improvements with the organization’s strategic intent. In a HPMS that

 

incorporates standard work, managers serve primarily as coordinators and coaches in order to

 

build staff capacity and expertise for improving quality.

 

While leadership commitment at the most senior levels (e.g., C-suite, boards of directors, vice

 

presidents, chairs and chiefs of departments and divisions) is necessary to cultivate and lead

 

improvement throughout an organization, frontline clinical leaders — those who most directly

 

impact the patient experience of care — need complementary guidance in the form of a system of

 

practical direction and support. Senior leadership commitment is needed to achieve fully

 

integrated, consistently excellent performance; yet smaller, incremental steps within service

 

delivery units can also build will and set the stage for whole system change.

 

Many of IHI’s strategic partners have developed world-class improvement infrastructures and are

 

now exploring the methods and benefits of managing standard work. This white paper seeks to

 

understand their efforts, learn from their experiences, and suggest a way forward for organizations

 

that are now starting down this path.

 

Representatives of the following organizations informed our work: Intermountain Healthcare

 

(Utah); ThedaCare (Wisconsin); Virginia Mason Health System (Washington); Essentia Health

 

(Minnesota); Greater Baltimore Medical Center (Maryland); Children’s Mercy Hospital (Missouri);

 

Saskatoon Health Region (Canada); Saskatchewan Health Quality Council (Canada); Denver

 

Health (Colorado); and Cincinnati Children’s Hospital Medical Center (Ohio).

 

These organizations were selected based on their reputation for clinical excellence and

 

implementation of standardized management approaches (e.g., Lean, Juran, IHI’s approach to

 

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Quality Improvement) that characterize recognized world-class enterprises both within and

 

outside of health care.4

 

Three case examples, drawn from interviews with informant organizations, illustrate in depth the

 

implementation of a HPMS by three leading North American health systems (see Appendix A). Our

 

investigations for this white paper focused on management systems in acute care settings; but the

 

principles of high-performance management can be applied in any care setting, just as they have

 

been deployed in diverse enterprises outside of health care. We expect to explore such variations in

 

future research.

 

Theoretical Context: “Doing the Work,

 

Improving the Work”

 

Excellence in care delivery demands systems capable of reliably supporting the clinical skills of

 

physicians, nurses, and staff — and in such systems, everyone has two interdependent roles: doing

 

the work and improving the work. Several key theoretical concepts underpin the high-performance

 

management system described in this white paper.

 

Health Care as a System

 

W. Edwards Deming described a “system” as a set of interdependent components — structures,

 

people, and processes — working together toward a common purpose.5 A health care organization

 

is a complex, adaptive system animated by hundreds or thousands of providers, administrators,

 

patients, and support staff. For the organization to deliver on the promise expressed in its mission

 

statement — for every patient, every time — requires that everyone in the system knows what to do

 

and why, how and when to do it, and how to adjust when necessary to maintain fidelity with the

 

organization’s mission and values.

 

As demonstrated by our informant organizations, standardizing routine tasks at the front line of

 

care creates an orderly, predictable work environment — thereby reducing the fumbles and

 

ambiguities that take staff away from the patient’s side, and that lead to “unintended variation”

 

that endangers patient safety and impedes the effectiveness and efficiency of care.6 Standard

 

frontline work provides a stable “platform” on which clinicians can most effectively exercise their

 

clinical skills, and on which systematic, integrated improvement initiatives can be conducted and

 

their results sustained.7

 

As Deming proposed, management is responsible for establishing and maintaining such a system.5

 

The coordination and alignment of diverse parts to the purposeful whole is the essential function of

 

a high-performance management system.

 

The Juran Trilogy

 

The Juran Trilogy1 consists of three key quality-related functions for managers: Quality Planning,

 

Quality Control, and Quality Improvement. Together these functions constitute an active,

 

integrated system for pervasive organizational attention to customers’ (i.e., patients’) needs, the

 

design and delivery of products and services consistent with the best technical specifications to

 

consistently meet those needs, and the ongoing management and continuous improvement of the

 

systems of production.

 

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 Quality Planning (QP): Quality Planning begins with a comprehensive understanding of

 

customer needs. In health care, the Triple Aim provides a framework for conceptualizing the

 

needs of patients: experience of care, health, and cost of care. Other stakeholders, including

 

physicians, staff, payers, regulators, and the community at large, place additional demands on

 

care systems. QP thus comprises processes for understanding patient experience; the

 

establishment of evidence-based protocols; the design of physical space, technology, and

 

specific care routines to ensure that the best available technical knowledge gets translated

 

into standard practice; the establishment of a sustaining and rewarding work environment;

 

and much more. QP also includes the design and operation of systems of management, such

 

as the HPMS described in this paper, as well as an infrastructure to identify gaps in

 

performance and commission improvement projects to close the gaps. This white paper can

 

be used as guidance for Quality Planning to establish frontline Quality Control, based on the

 

HPMS.

 

 Quality Control (QC): Quality Control focuses on operations: monitoring the system of

 

production for stability, detecting emerging process problems (special causes), and taking

 

steps to address them. QC is based on measurement of performance; processes are

 

continually examined (via statistical methods, technology, or direct observation) for

 

conformance with current quality expectations (goals). When gaps are detected between

 

expected and observed performance, frontline staff undertake problem-solving methods such

 

as root cause analysis to identify the source of the problem and devise a remedy. If the current

 

process is not capable of meeting customer needs and the needed changes are beyond the

 

scope of the frontline unit, a QI initiative is planned to redesign the process. Quality Control

 

fundamentally is about ensuring that a process remains stable (“in control”) over time — that

 

is, its performance remains within the upper and lower control limits. QC is usually

 

performed by those closest to the process.

 

 Quality Improvement (QI): In a QI initiative, a designated team of managers and staff

 

with relevant expertise, with technical assistance from dedicated QI specialists, analyzes the

 

current process, identifies the symptoms and causes of poor quality, and frames a theory of

 

what is required to improve the process. The team uses a variety of methods and tools to

 

develop, test, and implement changes, and if needed redesigns the relevant processes.4

 

Following successful improvement, QC is then used to monitor the redesigned process to

 

ensure it performs at a new level (with new upper and lower control limits), with new work

 

specifications, improved results, and reduced variation.

 

Figure 1 shows QC and QI as interlocking loops of activity. Quality Control involves the routine

 

enactment of standard tasks, monitoring quality, and making routine adjustments and local

 

improvements. (Note that the “Adjust” step in the QC loop may involve frontline application of the

 

Model for Improvement, with its own nested Plan-Do-Study-Act, or PDSA, cycles to test and refine

 

changes that will lead to improvement.) When problems arise that are beyond the scope of the

 

local team, or that point to the need for improvements in process capability (for example, when a

 

new clinical protocol is introduced that fundamentally changes processes of care or patient

 

expectations, or when the problem requires interdepartmental coordination), the problem is

 

escalated to a higher-level QI initiative to redesign the process, or to Quality Planning functions to

 

fundamentally revise the production system.

 

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Figure 1. The Relationship of Quality Improvement and Quality Control

 

It is important to distinguish Juran’s conception of Quality Control as an integral component of

 

everyday work and management from the common misperception that QC is the same as quality

 

assurance or inspection. It’s well worth consulting Juran’s Quality Handbook1 on this point:

 

“Quality control and quality assurance have much in common. Each evaluates

 

performance. Each compares performance to goals. Each acts on the difference. However

 

they also differ from each other. Quality control has as its primary purpose to maintain

 

control. Performance is evaluated during operations, and performance is compared to

 

goals during operations. The resulting information is received and used by the operating

 

forces. Quality assurance’s main purpose is to verify that control is being maintained.

 

Performance is evaluated after operations, and the resulting information is provided to

 

both the operating forces and others who have a need to know.” (p. 4.3)

 

Accreditation is one particular form of quality assurance in health care and is performed by

 

external regulators or standards bodies. While important, quality assurance and accreditation are

 

not the focus of this white paper. Similarly, Quality Control should not be confused with the form

 

of “control” exercised by some managers who periodically respond to summary reports with

 

directives for staff to respond to problems that may not be current, or for which the manager lacks

 

complete information. A variant is “tampering” — making changes to a process, based on a limited

 

understanding of the principles of common cause and special cause variation.6

 

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Other Important Sources from the Literature

 

Our review of selected literature surfaced a number of descriptions of high-performance

 

management systems that are substantially consistent with the Juran Trilogy, although with

 

differing terminology and methods. We reviewed key sources from the Lean tradition including

 

Mann,2 Spear,3 and Toussaint.8 Ando and colleagues document formal standard practices for

 

“Daily Management” on behalf of the Japanese Society for Quality Control.9 Nolan reports on IHI’s

 

work to develop “a framework for execution of strategic initiatives aimed at producing system-level

 

results.”10 Case studies from the automotive industry provide insights regarding myriad issues

 

involved in implementation of a HPMS.11,12 Previous IHI work provides specific guidance for

 

organizing frontline standard work to surface process problems requiring QC adjustments or QI

 

interventions.13

 

A High-Performance Management System

 

Figure 2 presents an architectural overview of a high-performance management system, organized

 

into QC and QI functions and tasks across representative levels of a typical health care

 

organization. (Note that the authors discussed at length the merits of flipping the vertical

 

dimension of this figure to show patients at the top, to indicate their position at the focus of the

 

organization’s purpose, with management tiers arrayed below to signify their role as supporters

 

and facilitators of QC and QI. Ultimately, we decided on the figure as it now appears because we

 

recognize the traditional “ups” and “downs” of organizational hierarchies, and we felt that a change

 

would be confusing to readers.)

 

In the HPMS, Tier 1 Quality Control (operations management) focuses on guiding the direct

 

provision of care. For example, huddles conducted by a unit manager at shift changes focus on

 

immediate process management: ensuring that all job roles are assigned, identifying patients at

 

risk or in need of special attention, and anticipating needs that will arise in the upcoming hours.

 

During the shift, the unit manager ensures staff adherence to standard work, monitors care

 

processes, takes corrective action to avoid errors, pitches in to help where needed, and coaches

 

frontline staff on work skills, problem identification, and improvement methods. Operational

 

issues beyond the control of the unit escalate upward, for response by the appropriate

 

management tier, for whom triaging and acting on escalated issues is part of their regular Quality

 

Control work. Daily updating and review of operational data, including sentinel events, by every

 

tier ensures that responses to problems are prompt; delays at any level pose risks to the

 

organization’s purpose and reputation. (See Appendix A for additional examples that elaborate on

 

such huddles.)

 

For Quality Improvement projects initiated to address problems that are surfaced during QP, Tier 1

 

managers, initially relying on support from organizational QI specialists, surface and scope local

 

opportunities for improvement (often special cause variation identified in routine QC activities, but

 

also including minor common cause issues),13 prioritize them, coach staff on QI methods, monitor

 

progress, and engage frontline staff in testing and implementing process changes. The unit

 

manager and unit team are responsible (with QI specialist help) for translating key organizational

 

metrics related to strategy and mission into unit-level measures. Over time, as frontline and Tier 1

 

personnel become adept at QI, the need for specialist assistance lessens.

 

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Figure 2. Architecture of a High-Performance Management System

 

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Moving up the management hierarchy, higher tiers identify, prioritize, and respond to

 

improvement opportunities with increasing scope. At Tier 3, and to some extent at Tier 2, Quality

 

Improvement gives way to Quality Planning: initiating, guiding, and monitoring system design and

 

improvement at the organizational level. Information — about the current state of operations and

 

the status of QI projects — flows upward at successively aggregated levels of granularity.14,15 For QC

 

issues, the flow of information is immediate: issues that might seriously impact patient safety

 

should reach Tier 3 within hours, if not minutes.

 

Measures of current operational status are aligned with organizational purpose, on multiple quality

 

dimensions.16 Operational guidance and alignment of QI with organizational purpose flow

 

downward toward the front line. Integration of unit-level QI projects with overall organization-

 

wide strategic Quality Improvement efforts can be achieved through an annual QP process of

 

“catchball” negotiations between tiers (where ideas and information flow back and forth between

 

tiers), beginning with Tier 3 strategic priorities, as at Virginia Mason Health System (see Appendix

 

A). Tier 3 and Tier 2 negotiate Tier 2 priorities, initiatives, and goals, and the process is repeated

 

downward to unit-level improvement projects, with unit-level goals and metrics aligned with the

 

overall organizational strategy.

 

Key Drivers of High-Performance

 

Management at the Front Line

 

What does it take to implement a high-performance management system? Through our literature

 

review and interviews, we identified three primary drivers of a sustainable HPMS at the front line,

 

as shown in the driver diagram in Figure 3. It’s important to note that one reviewer of this white

 

paper rightly pointed out that the drivers represented in this diagram may require substantial

 

modifications in low-resource contexts, where infrastructure, government policies, funding,

 

resource availability, existing quality management practices, and cultural norms may prioritize a

 

different set of interventions.

 

The driver diagram targets key processes, structures, and cultural norms that our research

 

identified as necessary factors for the establishment and maintenance of a high-performance

 

management system at the front line. Primary drivers P1 and P2 are aligned with the Juran

 

Trilogy: P1 focuses on management for Quality Control, P2 on Quality Improvement. Primary

 

driver P3 highlights management practices for establishing the culture that sustains consistent

 

execution of Quality Planning, Quality Control, and Quality Improvement activities. Quality

 

Planning (QP) is not explicitly called out in this driver diagram, but permeates all of the functions

 

represented; in effect, the diagram is a roadmap for Quality Planning. Appendix B provides

 

examples of how seven of our informant organizations implemented the P1 drivers for Quality

 

Control.

 

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Figure 3. Driver Diagram: High-Performance Management System at the Front Line

 

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Primary Driver P1: Drive Quality Control

 

The high-performance management system is organized to anticipate and detect defects,

 

maintain stable operations, and respond to abnormalities.

 

We identified six secondary drivers (S1–S6) of Quality Control. (See Appendix B for examples of

 

specific ideas for implementing the six secondary drivers, based on our informant interviews.)

 

 S1: Standardization: Processes exist to help define and disseminate standard

 

work (what to do and how to do it).

 

Managers at all levels should have well-defined daily, weekly, monthly, quarterly, and annual

 

tasks (i.e., standard work). The Tier 1 unit manager must have a clear sense of the reliability

 

of these tasks at all times, regardless of how they are represented (e.g., on a daily checklist,

 

huddle board, or huddle agenda). Several informant organizations developed such standard

 

work. For instance, Intermountain Healthcare developed detailed documented standard work

 

for charge nurses, frontline staff, and Tier 1 unit managers, supported by checklists,

 

education, and an internal website.

 

 S2: Accountability: A process is in place to review execution of standard work.

 

The organization needs systems to continuously monitor whether staff are doing the work

 

according to agreed-upon standards. This is crucial to maintaining QC of the process,

 

understanding what staff training needs may exist, or identifying processes that do not work

 

well. Managers use this information as the basis for analysis and improvement of the work

 

unit; evaluation of individual staff performance for promotion or separation is secondary.

 

Virginia Mason Health System, for example, developed a comprehensive tool to track

 

manager standard work, self-reported up to the next management level on a quarterly basis.

 

 S3: Visual Management: Process performance information is continuously

 

available to synchronize staff attention and guide current activities.

 

Staff on the unit need current information — both quantitative and qualitative — about

 

process performance to coordinate and guide their work. Most often, clinical units track key

 

data using visual metric boards, displayed publicly or semi-publicly, that show key process

 

indicators which in turn align with system-wide strategic goals. These visual data displays are

 

typically accompanied by a daily communication process, such as a team huddle, to ensure

 

that all staff understand the current context, issues, problems, and priorities for their work.

 

Several of our informant organizations developed daily management boards to structure such

 

team huddles. For example, Greater Baltimore Medical Center uses huddle boards with

 

standard metrics organized according to four strategic aims: better health, better health care,

 

less waste, and joy in work.

 

 S4: Problem Solving: Methods are available for surfacing and addressing

 

problems that are solvable at the front line, and for developing improvement

 

capability.

 

Unit managers and frontline staff should be able to apply improvement methods and tools

 

such as the Lean A3 method17 or the Model for Improvement18 to address process anomalies

 

as they arise. Structured methods for identifying problems, diagnosing problems (e.g., flow

 

diagrams, root cause analysis, cause-and-effect diagrams), and testing changes (Plan-Do-

 

Study-Act cycles) are essential, but they must be used in a true spirit of inquiry by managers

 

and staff who maintain a “preoccupation with failure.”19 Frontline unit managers and staff

 

employ these methods and tools routinely, with QI specialists to provide support as needed.

 

Higher-tier managers recognize and celebrate candid problem analysis and effective

 

remedies. The “See-Solve” model articulated by Resar and colleagues provides a detailed,

 

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tested method for engaging frontline staff in problem identification and scoping.13 Among our

 

informants, Virginia Mason expects unit managers to master such methods (including the 5

 

Whys, fishbone diagrams, and affinity diagrams), coach staff in these techniques, and lead

 

problem-solving efforts via rapid improvement events (also known as kaizen events, a Lean

 

term translated as “continuous improvement” or “beneficial change”).

 

 S5: Escalation: Frontline staff scope issues and escalate those that require

 

management action to resolve.

 

Addressing process abnormalities may require system adjustments that are beyond the

 

control of frontline staff and unit managers, such as when a sentinel event requires an

 

immediate management response, or when new clinical evidence, system changes, or

 

recurring exceptions point to needed updates in process design (e.g., new care protocols,

 

changes in IT systems, or whenever the current process design is incapable of delivering

 

acceptable results). In many cases, the root causes of a problem involve multiple units or

 

departments, so improvement requires a coordinated initiative.

 

Thus a well-functioning management system includes clear criteria to distinguish issues that

 

should be escalated to higher management tiers, which then resolve the issue directly or

 

commission an interdepartmental improvement project (a Quality Planning function). At

 

ThedaCare, for example, if a patient care problem arises that a frontline staff member cannot

 

solve within 15 minutes, the staff member escalates the problem to the next-level unit

 

manager, and on up the hierarchy as needed. A sufficiently complex and/or acute problem

 

can reach the CEO within 90 minutes.8

 

 S6: Integration: Goals, standard work, and QI project aims are integrated across

 

organizational levels and coordinated among units and departments.

 

To continuously reinforce and support proper care and the aims of local improvement

 

activities, priorities and metrics must be vertically aligned at all levels of leadership in the

 

organization and horizontally consistent across divisions, departments, and units. The

 

standard work of frontline staff and leaders is critical for ensuring that patient care practices

 

are consistent with organization-wide standards, goals, and strategy. Greater Baltimore

 

Medical Center’s HPMS has benefited from strong executive support, including daily C-suite

 

workplace walks and regular, data-fueled huddles for executives.

 

Primary Driver P2: Manage Quality Improvement

 

The high-performance management system coordinates projects to improve process capability.

 

In addition to secondary drivers S4: Problem Solving, S5: Escalation, and S6: Integration (drivers

 

for both QC and QI), we identified three secondary drivers that support unit managers in

 

effectively managing frontline Quality Improvement efforts.

 

 S7: Prioritization: Processes are established to help prioritize frontline

 

improvement projects based on organizational goals.

 

At any given time, clinical units will have many different improvement initiatives they might

 

implement, but to pursue them all would be wasteful and ultimately counterproductive.20

 

Quality Planning in a HPMS helps establish clear procedures and criteria to prioritize unit-

 

level improvements that are of greatest importance to both the goals of the unit and those of

 

the organization. At Virginia Mason, service lines such as orthopedics maintain “Kaizen

 

Plans,” which include all improvement efforts currently underway. Service line leaders meet

 

monthly to ensure that improvement priorities are correct and adjust them as necessary. To

 

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avoid fragmented, duplicative efforts, the service line only undertakes large-scale

 

improvement efforts that are consistent with this plan.

 

 S8: Assimilation: Improvement projects are integrated into daily work.

 

As suggested in the high-performance management system architecture (see Figure 2 above),

 

initiating and directing Quality Improvement projects is a core component of standard work

 

at all levels of the organization. Due to their daily involvement in patient care, Tier 1 unit

 

managers are responsible for leading the testing and implementation of process changes at

 

the unit level. Job descriptions, and senior managers’ expectations, encourage active frontline

 

staff and manager participation in QI work such as team meetings, rapid improvement

 

events, PDSA testing, data collection, and data review. Staff are explicitly allocated the time

 

required to participate in these activities. For example, at Children’s Mercy Hospital,

 

conducting PDSAs is included as part of frontline clinical leaders’ regular standard work,

 

along with attendance at QI project reviews.

 

 S9: Implementation: Frontline teams have support to move from QI back to QC,

 

integrating the results of QI projects into standard processes.

 

Many QI projects do not yield sustainable improvement because the changes needed in

 

support systems such as labs, purchasing, human relations, mechanical systems, or IT are

 

never implemented. A HPMS has an established means to coordinate improvements across

 

departments (see S6: Integration) and to incorporate the results of improvement projects into

 

standard work at the front line. At ThedaCare8 and Intermountain, management engineers

 

work closely with frontline clinical managers to support improvement and help with the

 

development and adjustment of standard work.

 

Primary Driver P3: Establish a Culture of High-Performance Management

 

The high-performance management system cultivates a positive trust relationship that

 

encourages and sustains frontline staff engagement in Quality Control and Quality Improvement.

 

 S10: Policy, S11: Feedback, S12: Transparency, S13: Trust

 

This primary driver refers to the social and ethical milieu in which people go about their daily

 

tasks and comprises four secondary drivers: policy, feedback, transparency, and trust.

 

Although not the focus of this paper, these factors are absolutely essential to establish and

 

maintain the deep, mutual sense of trust that pervades a high-performance management

 

system. Such a culture provides the transparent atmosphere in which process problems can

 

be quickly surfaced, understood, and addressed by frontline staff.12,21

 

A high-performance management system requires that managers trust staff to conscientiously

 

embrace necessary standard practices, appropriately adjust processes in response to everyday

 

problems, and candidly identify problems that represent opportunities for improvement.

 

Conversely, a HPMS also requires staff to trust managers to take a “systems view”: to provide

 

the skills training and operational support systems needed for excellent performance, seek

 

the true root causes of problems instead of blaming individuals, take prompt action to

 

address systemic problems, and uphold the dignity of workers as an essential value for the

 

organization. Aligned human resources (HR) policies, regular feedback to frontline staff

 

about patient outcomes, and an objective, analytical response to problems are key drivers of

 

this critical positive trust relationship.

 

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In our interviews with informant organizations, we were most impressed by the rigor with which

 

these organizations implemented management standard work (e.g., checklists) and their

 

appreciation of the importance of its consistent completion — not only for ensuring reliable care,

 

but as a means of building trust. The regular daily rhythm of huddles conducted in a spirit of open,

 

blame-free inquiry with predictable follow-up and results enabled staff to gain trust in the

 

management system.

 

Implementing a High-Performance

 

Management System: Lessons from the Field

 

Together, the high-performance management system architecture (see Figure 2) and driver

 

diagram (see Figure 3) describe the “changes” — structures, processes, and cultural norms —

 

needed to establish and maintain a high-performance management system. The case examples in

 

Appendix A offer a rich set of ideas and lessons from health care organizations that have

 

implemented standard work as part of their efforts to implement a HPMS. This section of the white

 

paper offers recommendations, in the spirit of PDSA, for putting these changes into practice — not

 

as a guaranteed path to a HPMS, but as a set of ideas to be tested and adapted by those who wish to

 

pursue the journey.

 

The Model for Improvement provides a framework for structuring an initiative to test these

 

changes. At a whole system level, the plan to implement a HPMS initiative might look something

 

like this:

 

 Aim: Improve patient outcomes and process performance based on system-wide

 

implementation of a high-performance management system

 

 Measures:

 

o Measures of patient outcomes, cost of care, and staff satisfaction aligned with system

 

mission

 

o Measures of clinical process reliability, efficiency, safety, timeliness, patient centeredness,

 

and equity aligned with outcome goals

 

o Measures of HPMS adoption: state of implementation of each secondary driver by unit,

 

pace of unit implementation, qualitative data from leader observation, etc.

 

o Balancing measures (e.g., joy in work)

 

 Changes: Described in the high-performance management system architecture (Figure 2),

 

driver diagram (Figure 3), and organizational case examples (Appendix A)

 

 Empirical Learning: Based on a plan to test changes on a small (pilot) scale, then

 

implement changes throughout the system with appropriate adaptations

 

Recommendations for Implementing Management Standard Work

 

Standard work is required of managers at all levels (Tiers 1, 2, and 3), referred to here as

 

“management standard work” (MSW). For example, while Tier 1 leaders are responsible for

 

identifying unit-level process measures, collecting the required data, and maintaining visuals for

 

huddles, Tier 2 and Tier 3 leaders determine the measures needed to monitor the standard work

 

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system and are responsible for acquiring the needed data (via huddles and direct observation, and

 

with the help of improvement specialists). Spreading changes and sustaining performance

 

improvement requires Tier 1 and Tier 2 managers to practice their own standard work, including

 

coordination with other departments or service lines. Leaders at all tiers (including especially C-

 

suite leaders) need to demonstrate their active engagement in standard work and improvement,

 

and not just delegate changes to QI specialists or frontline units.

 

Prior work by the IHI Innovation team suggests a testable strategy for developing Tier 1

 

management standard work (MSW), as part of the HPMS, that is consistent with models in use at

 

Thedacare8 and elsewhere:

 

 Frontline staff at the unit level design, test, and implement detailed standard work with the

 

support of QI specialists. Frontline staff focus on tracking process problems identified at the

 

unit level and actions to resolve them, including conducting root cause analysis of problems

 

and frequent testing of changes to improve processes.

 

 QI specialists coordinate standard work and improvement initiatives across units and

 

departments, and serve as coaches to unit-level teams. Specialists work closely with the unit

 

leader to establish and improve Tier 1 management practices (e.g., team huddles and visual

 

displays of data about process performance), surface and scope problems requiring QI

 

projects, provide data analysis, help with QI methods, facilitate rapid improvement events,

 

and oversee implementation and spread of effective changes.

 

 Unit managers (Tier 1) supervise this work in collaboration with the QI specialist. Over

 

time, the role of the specialist wanes as the unit manager gains skill and confidence with the

 

daily exercise of QC and QI, and the HPMS itself.

 

The guidance presented here is focused on Tier 1, but full, sustained implementation of a HPMS

 

ultimately requires wholehearted support from Tiers 2 and 3, with managers and leaders engaged

 

as active, hands-on participants. IHI’s experience with helping health care leaders inspire and

 

manage system-wide change provides specific recommendations — mental models, behaviors, and

 

areas of focus — that can support the implementation of a HPMS.22

 

Not all managers will find these changes palatable. A successful HPMS initiative may require

 

reassignment of roles, as Intermountain discovered, and some staff turnover is to be expected. Our

 

informant organizations offered four useful lessons for implementing MSW, as described below,

 

that may inform other organizations’ efforts.

 

1. Choose a pilot unit within your organization.

 

Most organizations introduce MSW by testing it on a small scale in one pilot unit (e.g., ThedaCare’s

 

“model cell”8). The pilot unit is carefully selected to maximize insights and build momentum for

 

change. As with any improvement project, introducing changes to an existing process or system

 

will be more successful when the target system is operating in a stable, predictable fashion.

 

The pilot unit should have the following characteristics:

 

 Staff turnover is low. High turnover makes it difficult to implement the sustained staff

 

training and education necessary for a standard work initiative.

 

 Tier 1 unit managers understand what is expected, know what the change will look

 

like when implemented, and embrace the rationale for standard work.

 

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Unit managers serve as key champions for any successful standard work initiative. Without

 

their buy-in and support, the initiative will likely fail.

 

 Good management practices are in place. Examples include effective budget

 

management and a stable staff schedule. In addition, look for areas with relatively stable

 

processes; a manager with an already chaotic daily schedule will be unable to focus attention

 

on the change.

 

 A respected local “champion” stands ready to build excitement for change, encourage

 

participation, coach the team, and celebrate success.

 

Although in principle the HPMS applies to work at all levels in a health care organization, several

 

informant organizations observed that pilot units that resemble an “assembly line” or “production

 

line” are stronger candidates for introducing MSW than units in which processes are less

 

predictable. For example, a surgical unit, or radiology, or sterilization services might serve as better

 

candidates for the pilot unit than a medical unit. Virginia Mason found it more challenging to

 

implement MSW outside of such “assembly-line-like” units, despite an organization-wide

 

commitment to the new management system. Potential adopters of MSW might consider choosing

 

a pilot unit with standard processes already established, then spreading to other areas.

 

Early on, Saskatoon Health Region implemented MSW in support services such as human

 

resources and housekeeping, with the prediction that “early win” improvements in such centralized

 

functions would raise interest and buy-in across the organization. For example, efficiencies gained

 

through standard work in human resources and housekeeping could free frontline unit managers

 

and clinical staff of unnecessary paperwork and emails, allowing for more time spent at the patient

 

bedside.

 

2. Start at the level of immediate supervision of point of care.

 

Many organizations looking to implement MSW may turn initially to the unit manager, an

 

administrator. However, several informant organizations stressed that in their systems, the true

 

frontline clinical leader is not the nurse manager, but rather the charge nurse.

 

An initial step, well-illustrated by Intermountain’s experience, is to clarify and standardize the role

 

and work of the charge nurse. In the absence of clearly defined roles, unit managers might feel

 

obligated to perform standard work intended for charge nurses (e.g., basic coaching of frontline

 

staff, leading frontline huddles, or rounding on patients). This sets up the nurse manager for

 

failure in any attempt to do standard work appropriate to his or her own level.

 

3. Start with modest goals to secure early wins.

 

The initial pilot unit goals should be achievable within a relatively short period of time. For

 

example, conducting a daily huddle to monitor medication administration, supported by a visual

 

management board with simple metrics, could be tested and implemented over a period of three or

 

four weeks, then elaborated on based on further testing. Complex goals that require significant

 

interdepartmental teamwork — like medication reconciliation or staff onboarding — will likely be

 

poor choices for initial testing. Several informants stressed the importance of “early wins” to boost

 

staff engagement. For example, Greater Baltimore Medical Center introduces managers into their

 

MSW system by first asking them to select one manageable metric to track, which aligns with the

 

organization’s overall strategic framework.

 

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4. Create a sense of urgency and trust.

 

Above all, successful implementation of a HPMS depends on the continuing commitment of

 

frontline staff who directly understand its benefits. Interventions that reduce chaos and workload

 

and are perceived to be valuable by the people asked to use new methods are “more likely to be

 

sustainably adopted, more likely to achieve their intended outcomes and encounter less ongoing

 

resistance.”23 Hence, a new HPMS initiative can gain a sense of urgency by targeting acute

 

problems that are widely recognized by staff. Over time, observable success on acknowledged

 

problems in the pilot unit can build widespread support for the initiative.

 

Three of our informant organizations followed this strategy. Denver Health focused its efforts to

 

create standard work in medical units on two top organizational goals: reducing patient falls and

 

improving patient experience scores. Saskatoon Health Region focused much of its initial effort on

 

scaling a province-wide safety protocol. Intermountain Healthcare implemented standard work in

 

the context of its Transforming Care at the Bedside program.

 

We have already discussed the importance of daily activities such as huddles for building trust; in

 

the longer term, it is essential to align career incentives such as promotions and performance

 

reviews with HPMS tasks to sustain buy-in and support for the new management structure. At

 

ThedaCare, high-potential professionals are assigned full-time to a Central Improvement Team for

 

a period of time, to deepen their understanding of Lean methods and to help “reshape the career

 

expectations of managers and executives” so that advancement is contingent on participation in

 

continuous improvement.8

 

Conclusion

 

Sustaining frontline standard work remains a challenge even for organizations implementing

 

comprehensive performance management and improvement systems — whether inspired by Lean

 

or other improvement approaches. Many of our informant organizations were just beginning to

 

explore high-performance management systems, with only a few organizations at a more advanced

 

(yet still early) stage of implementation.

 

Health systems wishing to sustain the gains of more episodic, tool-based, or otherwise narrow

 

approaches to Quality Improvement have found the development of more robust management

 

systems an unavoidable step in their pursuit of higher performance — particularly in achieving

 

sustained, quantified improvements in outcomes. Without a high-performance management

 

system that includes a clear focus on developing standard work and using Quality Control to

 

monitor and adjust the system as needed, even the best-intentioned and best-structured

 

improvement programs are likely to fall short in their efforts to effect top performance in the

 

longer term.

 

By focusing first on implementing standard work with frontline clinical units and managers, such

 

as a charge nurse or team lead, organizations can build a solid “bottom-up” foundation for Quality

 

Control and Quality Improvement that then supports more robust high-performance management

 

at the system level.

 

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Appendix A: Case Examples of Standard

 

Work Implementation in Health Care

 

Case Example 1: Intermountain Healthcare (Salt Lake City, Utah)

 

Summary

 

Intermountain Healthcare carried out a pilot project between 2012 and 2014 that illustrates two

 

key drivers of a high-performance management system (HPMS): S1: Standardization and S2:

 

Accountability (see Figure 3). With a focus on standardizing and extending the role of the frontline

 

charge nurse, the pilot unit — a 25-bed inpatient medical nursing unit — used task documentation,

 

scripted huddles at shift change, and regular monitoring and coaching by charge nurses to

 

structure and maintain frontline care processes. These changes resulted in increased nurse time for

 

direct patient care, improved patient and staff satisfaction, and increased compliance with Centers

 

for Medicare & Medicaid Services (CMS) core measures. That the pilot improvements were not

 

spread system-wide was also instructive.

 

Background

 

Although Intermountain Healthcare began implementing Lean management principles in 2009,

 

the organization had not seen sustained improvement in outcomes. After visiting other leading

 

health systems, Intermountain leaders realized they needed to focus on standard work for frontline

 

managers. They implemented several key elements of a HPMS, including standard work for

 

frontline leaders and other unit roles, through a robust test of change with one pilot site. The pilot

 

was a success; Intermountain saw significant gains in both efficiency and staff satisfaction. The

 

case illustrates how a health system can begin to build a HPMS from the ground up, focusing first

 

on frontline management (in this example, the charge nurse role) in a single pilot site.

 

Identifying the Initial Focus for the New Management System

 

Beginning in 2011, the medical leadership group’s Lean committee selected a 25-bed inpatient

 

medical nursing unit as a pilot site. The unit was simultaneously introducing the principles of

 

Transforming Care at the Bedside (TCAB, an IHI-led initiative funded by the Robert Wood

 

Johnson Foundation). Leaders felt implementing standard work and other improvements to their

 

management system could help facilitate this effort.

 

As part of TCAB, management engineers identified suboptimal use of charge nurses, and poor role

 

definition of charge nurses, as root causes of several problems on the unit such as inconsistent

 

supervision of supply cart restocking. Given this challenge, and the focus on developing a new

 

management system, charge nurses served as an initial focus for the efforts to develop the HPMS.

 

Focusing on Charge Nurses

 

“Charge nurse” had traditionally been an honorific position, usually based on seniority; many

 

charge nurses were not interested in new skills and responsibilities. As an initial step to address

 

the challenge, management engineers facilitated a retreat for charge nurses, with a focus on

 

defining major roles and responsibilities.

 

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When the retreat and subsequent coaching failed to result in the hoped-for gains, unit leaders took

 

a dramatic step. They reduced the number of charge nurse positions and the nurse manager

 

rewrote the charge nurse job description, reposted the job, and invited nurses on the unit to apply.

 

This resulted in 30 percent staff turnover.

 

Next, the nurse manager, the assistant manager, a director, and a supporting management

 

engineer held a retreat with the new charge nurses to develop a model for charge nurse standard

 

work. At the same time, the unit leadership team created standard work for all the other roles on

 

the unit, including techs, clerks, frontline nurses, manager, assistant manager, director, and

 

patient educator.

 

The entire pilot unit staff received training on standard work — an opportunity to affirm the new

 

status of the charge nurse, and to direct staff to listen to charge nurse directions. During roll-out of

 

the project, the nurse manager and hospital nursing director met with management engineers

 

weekly to discuss the development and roll-out of the standard work program. By spring of 2013,

 

the pilot unit roll-out was complete. Ultimately, the timing of the pilot project did not mesh with

 

top-management priorities, and the project lapsed.

 

Standardization: Developing Standard Work for Each Role on the Unit

 

Unit leadership created standards for a range of activities (such as admission, discharge,

 

medication administration, and other major clinical and operational processes) and for all key

 

roles, starting with the charge nurse. In their documentation of standard work, unit leaders

 

clarified key items for each element: timing (how often?); details (what steps are involved?); and

 

rationale (how does this item connect to organizational strategic goals and patient care goals?).

 

For example, leading huddles was a key item of charge nurse standard work. The standard work

 

document specified that the huddle should take place at the beginning of each shift. Leading a

 

huddle involved several standard steps: calling the team to huddle; reviewing the huddle

 

sheet/agenda; acknowledging staff for successes; and completing an action register to improve key

 

metrics. The rationale section cited several goals, including sustaining staff engagement and

 

satisfaction, and improving patient engagement. The unit documented standard work in hard copy

 

(assembled into binders, stored on the unit) and electronically in the unit’s intranet system.

 

Accountability

 

Monitoring staff completion of standard work was another key element in the unit’s system,

 

essential to the system’s success. As part of their standard work, charge nurses were required to

 

conduct three assessments per day of whether or not frontline staff executed their standard tasks.

 

The charge nurses could select which items of standard work were examined.

 

In general, these observations occurred anonymously. For example, the charge nurse might stand

 

outside a patient room while a nurse conducted rounding. The charge nurse listened and

 

determined whether the frontline nurse executed all required steps documented in the nurse’s

 

standard work. When the nurse left the room, the charge nurse had an opportunity to coach the

 

nurse on any steps missed and provide positive feedback for steps conducted well. Charge nurses

 

and other leaders also provided recognition regularly at staff meetings and huddles.

 

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The charge nurse recorded these checks in a log, kept by the nurse manager. This log served to

 

inform improvement activities. For example, the log revealed that nursing assistants did not

 

conduct pain management properly. After further inquiry, the nurse manager learned that the

 

nursing assistants had not received training in pain management. The leadership team created the

 

training and resolved the issue.

 

The unit’s management system included several other aspects that speak to the drivers of Quality

 

Control, such as huddle boards (S3: Visual Management); stressing the PDSA technique of

 

problem solving (S4: Problem Solving); and ensuring staff are aware of appropriate go-to people

 

for problems they cannot immediately solve (S5: Escalation).

 

Results Point to a Promising Approach

 

Intermountain’s standard work for charge nurses yielded exceptional results. By the end of 2014,

 

the pilot unit achieved the following:

 

 An increase in time at the bedside, from 37 percent to 55 percent;

 

 A dramatic increase in HCAHPS scores: The unit went from being consistently in the bottom

 

five among 45 units tracked system-wide to being among the top three units consistently;

 

 Increased employee engagement (tracked via Gallup), from a mean of 4.16 in 2012 to 4.62 by

 

the end of 2014; and

 

 Consistent 100 percent compliance with CMS core metrics over several consecutive months.

 

While the development and introduction of standard work took some time — through the staff

 

retreats and training described above — ultimately, it resulted in increased efficiency and staff and

 

patient satisfaction. Intermountain hopes to ultimately scale up this model for standard work to

 

other units and sites. Many of our informant organizations cited the importance of executive buy-

 

in and engagement as key next steps in promoting scale-up of this work.

 

Case Example 2: Saskatoon Health Region (Saskatchewan, Canada)

 

Summary

 

Saskatoon Health Region (SHR) focused on patient safety, a high-priority quality issue, as the

 

opportunity to develop elements of a HPMS. Standard work for frontline managers focused

 

initially on a scripted algorithm, called “SAFER” (Stop, Assess, Fix, Escalate, Report), as the

 

required response to safety-related incidents. Daily data-driven huddles focused on operational

 

issues and key metrics aligned with organizational safety goals. Key factors in these efforts were

 

support and encouragement for frontline problem solving and escalation of more complex

 

problems. SHR found it important to look more broadly at the manager’s daily work in order to

 

reduce waste and ensure that practices like safety-oriented huddles were sustained.

 

Background

 

Saskatoon Health Region is the largest health system in Saskatchewan, Canada. Instead of focusing

 

their HPMS pilot on a specific job role (such as charge nurses, as in the Intermountain example),

 

SHR initially implemented the core functions of MSW around improvements in patient safety, a

 

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system-wide concern at the time. As of this writing, they are focused on spreading elements of the

 

HPMS more widely.

 

Using Safety as a Foundation

 

SHR has received significant support from the Saskatchewan Health Quality Council (SHQC), a

 

province-wide group that is working to scale protocols and standard work to advance a provincial

 

safety initiative to reduce harm to zero for patients and staff by 2020. At the heart of this province-

 

wide safety initiative are explicit frontline protocols based on a common heuristic called “SAFER”:

 

 Stop: Stop if staff see anything unsafe.

 

 Assess: Assess the situation. Ask for support from other staff, supervisors, or leaders.

 

 Fix: Fix the unsafe situation if they can.

 

 Escalate: If they cannot fix the situation, escalate the concern to the next person in the chain

 

of command.

 

 Report: Report unsafe situations, environments, and practices, including “near misses” and

 

incidents resulting in harm to patients or staff.

 

Saskatoon introduced important elements of the high-performance management system around

 

safety through Plan-Do-Study-Act cycles (PDSAs) in 2013 and 2014. Leaders developed the outline

 

for the HPMS around safety through a province-wide visioning session followed by a 3P

 

(Production Preparation Process) event that encourages innovation and collaboration among key

 

stakeholders early in a product or process redesign, and provides a structure for low-cost

 

experimentation of the redesign. They focused first on creating huddle boards (visual

 

management), then instituted huddles, followed by implementation of the accountability system

 

that includes escalating huddles up the organizational hierarchy. The organization had a strong

 

foundation in Lean methods, given province-wide efforts to adopt Lean in health care starting in

 

2010. Those efforts included formal training of senior leaders and managers in Lean tools.

 

Standardization

 

Beginning in 2014, SQHC quality specialists and consultants helped unit leaders design standard

 

work aligned with the SAFER protocol in response to potential safety incidents. For example, the

 

unit director on call has a sequenced set of tasks, with detailed task definitions and approximate

 

“task cycle times,” when safety incidents occur. Initially, the director on call contacts the

 

designated frontline staff person, who briefs the director about the incident using the SBAR

 

(Situation-Background-Assessment-Recommendation) format. This briefing generally takes at

 

most 10 minutes. The director assesses whether he or she needs to respond to the situation in

 

person. SHQC designed standard work around the SAFER protocol for charge nurses, frontline

 

staff (nurses and physicians), unit managers, and executives.

 

Accountability

 

Directors’ quarterly gemba (“workplace”) walks in their units facilitate accountability. During

 

these walks directors observe firsthand how the units function, review updates to the huddle

 

boards, and the like. Further, frontline staff standard work supports management standard work.

 

SHR maintains a safety “call line” that anyone can use to report safety issues — including patients,

 

families, staff, physicians, and community members. Each day, directors huddle with the vice

 

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president and CEO to discuss safety issues. A safety expert participates in the huddle to log all

 

safety incidents reported via the call line; this helps ensure accountability. During the executive

 

huddle, directors are expected to report all serious and critical safety incidents. If the safety expert

 

reports an incident on a director’s unit that the director did not know about, it becomes clear that

 

the director has not followed through with MSW (which includes attention to all incidents of harm

 

or near misses).

 

Visual Management

 

Individual units at SHR have huddle boards that predate the safety initiative, originating from

 

their Lean performance improvement efforts. Units generally maintain two separate huddle

 

boards: one focused on day-to-day operational considerations (e.g., bed capacity and demand,

 

staffing), and the other focused on key performance measures that cascade up to organizational

 

goals for quality, safety, delivery, and cost.

 

Problem Solving

 

SHR uses numerous problem-solving methods and frameworks as part of its safety work. The use

 

of SBAR to analyze incidents is one example. In general, frontline staff surface problems and use a

 

Plan-Do-Check-Act approach with small tests of change. Frontline supervisors also use and coach

 

with the 5 Whys approach.

 

Escalation

 

To help facilitate problem solving with respect to safety, SHR’s leadership distinguishes among

 

three levels of safety challenges: critical incidents, with mandatory reporting to senior executives;

 

serious challenges that can be addressed first by directors on call; and other incidents, which did

 

not result in harm, and are within the jurisdiction of unit managers.

 

Cascading huddles at each level of management serve as a clear mechanism for problem escalation.

 

Daily at 7:30 AM, managers huddle with their staff, with a focus on discussing any safety issues. At

 

8:15 AM, directors huddle with unit managers, who surface any safety issues and can request that

 

directors help remove any relevant barriers to resolving such issues. Finally, directors participate

 

in the executive huddle later in the morning, and the executive can again remove any barriers to

 

resolving safety issues. Following the executive huddle, the CEO and the vice presidents meet to

 

discuss any action items, such as response to critical incidents.

 

The SAFER protocol itself also clearly delineates an agreed-upon escalation protocol; if a staff

 

member cannot resolve a safety-related problem directly, the protocol calls on staff to escalate the

 

issue to the next available staff member in the “chain of command” (e.g., a frontline manager).

 

Integration

 

Saskatoon Health Region’s approach has been successful in part because of strong executive

 

support and engagement — with their safety initiative, their Lean efforts, and the development of

 

MSW. Executives have their own MSW designed around safety. In addition to regular executive

 

gemba walks, Saskatoon has developed a framework to support executive coaching of staff when a

 

safety incident occurs. This framework, which encourages open-ended questions and a non-

 

confrontational tone, helps executive leaders model standard work for others, and hence

 

strengthen the MSW system overall.

 

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SHQC performance improvement staff helped SHR staff design simulations for executives to

 

facilitate their use of these guidelines. They videotape executives responding to a simulated safety

 

incident, and then coach them through the response.

 

Designing a Broader System for Management Standard Work

 

SHR has seen impressive results from this work, including improvements in cycle time for safety

 

incident responses and improvements in scores on safety culture surveys. Staff now have standard

 

work when a safety incident arises; they know exactly what to do. Being able to call a dedicated line

 

in response to a safety incident rather than fill out an online form has resulted in an average four-

 

minute savings per incident for physicians and nurses. The hospital in which the model was most

 

fully implemented saw many benefits, including more than 6,000 hours of staff time per year

 

saved by reducing safety incident reporting time; 255 hours saved per year in eliminated duplicate

 

reporting; and $281,000 saved, representing the value of labor gained due to increased

 

productivity.

 

At the same time, leaders at SHR realized that managers did not have the time they needed to

 

move from implementing a robust system of control for safety to also incorporating improvement.

 

Safety incidents would arise and be managed through standard work. Managers and others would

 

conduct root cause analysis to understand the underlying problem. But, given too many demands

 

on a manager’s day, the problem would often resurface because there was inadequate time to

 

redesign processes and “error-proof” the work.

 

This realization led to broader efforts to spread the elements of the HPMS beyond their initial

 

safety-focused application. For example, introducing elements of the HPMS to areas like human

 

resources has meant that frontline clinical managers no longer need to worry about doing work

 

best suited to other departments; those departments now work more efficiently. To stimulate

 

development of the HPMS elements more broadly for managers across health care system

 

departments, SHR leaders convened a rapid improvement workshop with managers and directors

 

who volunteered to participate, facilitated by a Kaizen fellow. Participants agreed on a broad

 

framework to organize all MSW for managers, with three key elements:

 

 Grow your people;

 

 Improve your processes; and

 

 Know your business.

 

Participants created a daily status sheet, with provocative questions to help them anticipate

 

challenges throughout the workshop. They also received tips on how to modify daily huddles to

 

make them more interactive.

 

Analyzing the Frontline Leader’s Day to Create Momentum

 

To maintain momentum following the workshop, the Kaizen Promotion Office structured a time

 

study to better understand how frontline clinical managers spend their time. A Kaizen fellow

 

developed a time diary, asking 11 managers to record how they spent their time over two weeks,

 

using 13 different categories (e.g., administrative work, safety efforts, hiring).

 

The fellow found that managers on average spent 45 percent of their time on administrative

 

activities and meetings, and only 3 percent on activities related to the three core elements

 

identified in the workshop. She is now using this data to help motivate managers to move forward

 

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in their efforts to create MSW, and to help them structure their standardized daily tasks. These

 

efforts move SHR closer to realizing the components of the HPMS on a broader scale, including a

 

focus on the drivers of both Quality Control and Quality Improvement.

 

Case Example 3: Virginia Mason Health System (Seattle, Washington)

 

Summary

 

Virginia Mason Health System is a longstanding leader in Lean approaches to health care. With

 

unflagging senior leadership commitment and ample resources to support staff learning, they have

 

created a vertically and horizontally aligned management system that uses standard work at all

 

levels to maintain consistent attention to operational issues and mount effective responses to

 

emerging problems. This work has resulted in many innovative practices to improve the reliability,

 

efficiency, and effectiveness of clinical care. Virginia Mason’s work, now implemented at scale,

 

offers highly visible working examples of tools and strategies useful for implementing a HPMS.

 

Background

 

Like Intermountain, Virginia Mason Health System began its journey toward developing a HPMS

 

starting from long experience with Quality Improvement. After 15 years of sustained support from

 

its executive team led by CEO Gary Kaplan, it is now world famous for the Virginia Mason

 

Production System (VMPS), which has enabled them to reengineer many care and support

 

processes based on Lean principles. Inspired by the Toyota Production System, VMPS prescribes

 

continuously monitoring care, driving out waste through regular Rapid Process Improvement

 

(kaizen) events and workshops.

 

Following Toyota principles, Virginia Mason implemented its new management system using

 

VMPS. The management system is anchored in explicit statements of purpose, called compacts:

 

one each for physicians, management, and the board of directors. These in effect constitute the

 

institutional values and personal expectations for all Virginia Mason personnel. Virginia Mason

 

initially introduced its management system in a small set of value streams, selected in line with

 

their annual strategic planning process.

 

While many aspects of the VMPS speak to the secondary drivers of the HPMS, three key drivers are

 

highlighted here that other health systems may find helpful in developing their own HPMS: a set of

 

standardized tasks for frontline leaders (S1); a tool to support both learning and accountability

 

(S2); and integration of work and purpose across organizational levels (S6).

 

Standardization

 

The development of Virginia Mason’s system has prioritized frontline leaders’ work. According to

 

one system leader: “This is where things really happen in an organization… If you don’t engage and

 

get the alignment of middle management, you’re not going to get anywhere.”24

 

As part of the Virginia Mason Production System, frontline leaders have several key

 

responsibilities, which become part of their standard work: they must know the status of planned

 

work, know if frontline staff follow standard work, and understand the upstream and downstream

 

impact of work at the front line.

 

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In addition, the leadership system includes standardized tasks for frontline leaders. Leaders are

 

expected to use visual management, maintaining a “reporting wall” (known as “PeopleLink wall”),

 

which includes goals and the status in achieving those goals. They huddle at least weekly with their

 

teams to review the status in achieving the goals, and use these meetings as an opportunity for

 

coaching. In addition, on a daily and weekly basis, frontline leaders review financial performance,

 

conduct manual and electronic “sweeps” of the workspace, and provide coaching to frontline staff.

 

Accountability

 

Huddles offer an opportunity for managers to review staff understanding of and compliance with

 

standard work. Frontline managers also submit quarterly reports to the central Kaizen Promotion

 

Office, which allows them an opportunity to reflect on their unit’s progress in achieving the aims of

 

high-performance management across a number of dimensions. The tool helps them assess

 

progress in implementing visual management, huddles, root cause problem solving, review of team

 

standard work, solicitation and tracking of improvement ideas from staff, and their own standard

 

work overall.

 

This tool serves not only as an accountability mechanism, but also as a resource for learning; it

 

includes numerous links to examples of tools that frontline managers throughout Virginia Mason

 

have used to meet the aims of the Virginia Mason Production System.

 

Integration

 

Virginia Mason’s orthopedic service line is a vivid example of integration in a high-performance

 

management system. Prior to the new system, inpatient units and ambulatory care struggled with

 

misaligned demand. Physician offices did a poor job of coordinating with scheduled surgery blocks

 

in the OR. The OR in turn did a poor job of sending patients to the inpatient floors in a timely

 

manner. In order to maintain attention to the problem and its evolving remedy, service line

 

management regularly initiate weekly huddles that include unit managers from the OR, physician

 

offices, and nursing. The huddles provide a forum for direct cross-department coordination; they

 

are consistently and eagerly attended. Together, these department managers can respond to

 

fluctuating circumstances, target specific problems, and sponsor initiatives to improve them.

 

Adjustments to improve workflow are part of standard work. Under this standard work, the

 

orthopedic service line now functions as a more cohesive whole, better able to consistently satisfy

 

the expectations of staff and patients. Staff engagement is high because the system is directed at

 

solving recognized problems and because the value it provides is widely acknowledged.

 

Virginia Mason’s success in scaling the Virginia Mason Production System would not have been

 

possible without major, sustained executive support and leadership. Beyond support, the

 

organization’s top leaders are active participants in the management system, regularly performing

 

their own MSW. Every Tuesday, the executive team meets at 7:00 AM for a huddle to review

 

current improvement projects. Three presenters give brief reports and receive feedback from the

 

executive team, including physician leaders, C-suite executives, and value stream administrative

 

leaders. This continuous feedback drives integration across the organization. It offers an

 

opportunity for constructive criticism and for leaders to remove barriers where necessary.

 

Outstanding Outcomes

 

A high-performance management system focused on middle managers and frontline leaders serves

 

as one crucial element of the Virginia Mason Production System — one that ties many other

 

elements together and ensures sustained progress. Virginia Mason has achieved significant

 

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progress as a result, including improvements in time spent by nurses at the bedside, consistent

 

margin improvements,24 and some of the highest quality and safety ratings in the country. Virginia

 

Mason has among the lowest rates of complications like central line infections and surgical site

 

infections in the US. Leaders at Virginia Mason remark that perhaps the most notable change that

 

has resulted from their development of a HPMS is a dramatic reduction in turnaround time for

 

routine problems that staff now themselves solve with greater ease, with fewer barriers.

 

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Appendix B: Examples of How Informant Organizations

 

Execute Drivers of Quality Control

 

This table outlines the ways in which seven of our informant organizations operationalized a high-performance management

 

system at the front line — the drivers of Quality Control (noted in the left-most column in the table below, and depicted in

 

Figure 3 above).

 

Abbreviations: QC: Quality Control; SW: Standard Work; PDSA: Plan-Do-Study-Act; HPMS: High-Performance

 

Management System

 

Drivers of QC

 

Virginia Mason Health System

 

ThedaCare Intermountain Healthcare

 

Greater Baltimore Medical Center

 

Children’s Mercy Hospital

 

Saskatoon Health Region

 

Denver Health

 

S 1 :

 

S ta

 

n d

 

a rd

 

iz a ti

 

o n

 

SW at all levels of management for numerous departments/units

 

SW at all levels of management for numerous departments/units

 

Standardized activities at RN, charge RN, manager, and director levels for pilot unit; many processes and roles have SW organization-wide

 

SW at all levels of management for numerous departments/units (nursing units, ORs, environmental services, transport, and others)

 

Limited scope; unit managers in radiology have SW, including observations of critical processes; SW in development for perioperative care and ambulatory clinics

 

Early stages (i.e., in process of developing comprehensive SW for front line); SW in place for frontline leaders in support areas (e.g., HR); SW for safety exists for numerous roles

 

Many processes standardized across units; in early stages of developing leader SW around high- priority areas such as fall prevention, pain control

 

S 2 :

 

A c c o

 

u n

 

ta b

 

il it

 

y

 

Quarterly assessment tool captures essential elements of standardization in a unit; turned in to next-level manager

 

Spot checks daily/weekly

 

For pilot, 2 to 3 spot checks per week as part of charge nurse SW; checks captured in log

 

Spot checks of staff SW

 

Weekly report card for SW and manager SW submitted to next- level unit manager; director reviews all manager SW weekly and documents follow- up with each individual

 

Directors complete “audit sheet” in response to safety incidents, which they submit to dedicated safety staff; details SW steps

 

Spot checks on SW (e.g., for fall risks) at multiple levels

 

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Drivers of QC

 

Virginia Mason Health System

 

ThedaCare Intermountain Healthcare

 

Greater Baltimore Medical Center

 

Children’s Mercy Hospital

 

Saskatoon Health Region

 

Denver Health S

 

3 :

 

V is

 

u a l

 

M a n

 

a g

 

e m

 

e n

 

t

 

Huddle boards Huddle boards Huddle boards Huddle boards

 

Huddle boards, K Cards (picture to represent ideal state of an environment)

 

Two huddle boards per unit (one operational and focused on items like staff shortage or mitigation, the other quality oriented and focused on items like complications)

 

Huddle boards in development with measures aligned with executive- level goals and strategic aims

 

S 4 :

 

P ro

 

b le

 

m S

 

o lv

 

in g

 

Multiple methods (5 Whys, PDSA, etc.)

 

A3 problem solving, other methods

 

PDSA, rapid improvement workshops

 

Multiple methods (5 Whys, PDSA, etc.)

 

PDSA, A3, Rapid Improvement Events; STP (“Situation, Target, Proposal”— staff submit and unit managers review weekly)

 

Use PDSAs and small tests of change; 5 Whys; safety issues presented in SBAR format to facilitate problem solving (Situation, Background, Assessment, Recommendation)

 

PDSAs, root cause analysis

 

S 5 :

 

E s c a la

 

ti o

 

n

 

Escalation integrated into SW (e.g., protocols to escalate problems to others when the usual person responsible is not available); dedicated protocol for escalating safety issues through Patient Safety Alert System

 

Time-based: If patient care problem cannot be solved in 15 minutes, escalate to next level

 

For pilot unit: Escalation integrated into SW (e.g., protocols to escalate problems to others when the usual person responsible is not available); escalation built into SW in many areas

 

Daily executive- level workplace walks facilitate problem escalation

 

Daily Safety Update (hospital- wide) facilitates problem escalation; quick hits and big issues listed on huddle board, escalated from daily huddles; use of abnormality trackers supports problem identification

 

Time-based escalation criterion for safety issues; cascading daily huddles offer means to escalate critical or serious safety incidents

 

Cascading huddles facilitate problem escalation (daily huddles at frontline staff level; weekly huddles among RN managers)

 

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Drivers of QC

 

Virginia Mason Health System

 

ThedaCare Intermountain Healthcare

 

Greater Baltimore Medical Center

 

Children’s Mercy Hospital

 

Saskatoon Health Region

 

Denver Health

 

S 6 :

 

In te

 

g ra

 

ti o

 

n

 

Strong support and engagement; executive-level huddles; cascading SW up through executive level

 

“True North”; visual management organized around organizational priorities at all levels

 

HPMS in process of spread

 

Strong executive support; C-suite gemba walks;

 

executive Lean daily management board; visual management measures aligned with enterprise strategic goals

 

Strong executive support; executive- initiated 5S workshops help establish early interest

 

Strong executive support, both at the health system level and at the province/policy level; “bottom-up” development of SW, starting with safety focus and with support areas (e.g., HR)

 

Strong executive support; measures on visual boards at all levels aligned with board-level strategic goals; C- suite monthly gemba walks

 

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