IHI Framework for Leadership Improvement

A Framework for Leadership of Improvement 1

A Framework for Leadership of Improvement

February 2006

In Crossing the Quality Chasm, the Institute of Medicine (IOM) has set forth a vision of a 21st century health care system that performs dramatically better than current benchmarks.1 The IOM envisions a care delivery system that delivers theoretically ideal care, across six dimensions of quality, for all conditions. The contrast between this vision and the present reality is stunning. Even the best of our current health care organizations approach the ideal in one or two quality dimensions, for one or two conditions, only some of the time. Such a dramatic change in health care delivery systems will not be brought about by a simple project-by-project approach, using the same organizational structures that have produced the current levels of performance. Rather, this transformation will require rebuilding our leadership systems to focus the organization on improvement. It is our purpose in this document to outline a framework for a system of leadership that could successfully accomplish the IOM challenge of delivering ideal care. This framework for leadership of improvement can be useful in several ways:

• As an organizing structure to understand how the various work activities of health care leaders contribute to the broad aim of transformation and improvement of the care system.

• As an ongoing learning tool, to be contributed to and modified by participants in Institute for Healthcare Improvement (IHI) networks, projects, and initiatives

• As an aid for health care leaders to assess and improve their organizations • As a guide for the design of leadership development programs in health care

organizations A Framework for Leadership of Improvement We propose the following basic framework for building a leadership system capable of meeting the IOM challenge (see Figure 1)... The primary function of leaders in health care is to influence their “followers” to develop behaviors, habits, processes, and technologies that result in dramatically improved performance. This influence can be thought of as a combination of “Push” (making the status quo uncomfortable) and “Pull” (making the future attractive). The influence comes about through a variety of five leadership activities, as described below.

A Framework for Leadership of Improvement 2

Figure 1. A Framework for Leadership of Improvement

1. Establish the Mission, Vision, and Strategy: Use the organization’s mission, vision, and strategy as a relentless drumbeat to communicate the direction of the organization to all stakeholders while maintaining constancy of purpose. It will be critical to obtain and maintain the long-term support of the governing board if constancy of purpose is to be achieved. 2. Build the Foundation for an Effective Leadership System: The extraordinary aims of the IOM vision will require extraordinary leaders, as well as an extraordinary level of alignment and teamwork among those leaders. The framework requires the care system to choose and align a leadership team capable of this transformational task. That team, in turn, must reframe operating values, develop a broad cadre of leaders throughout the organization, and establish exceptional levels of improvement capability. 3. Build Will: The challenges of the IOM Dimension described above will engender significant resistance, hesitance, and second-guessing. The leadership framework requires leaders to prepare the organization for change; generate discomfort with the status quo; make the vision of the future attractive; and create and sustain the commitment for improvement in all areas of the organization. 4. Generate Ideas: The IOM challenge of delivering ideal care will not occur using the same thinking that led to the present state. Knowledge management systems must be designed to listen to patients and other stakeholders and turn their communications into ideas for change. In addition to investing in internal research and development, leaders will also need to find new ideas by reading and scanning widely to learn from other industries and disciplines outside of health care. .

Making the status quo uncomfortable Making the future attractive

Leadership for Improvement

Will Ideas Execution

Foundation

Set Direction: Mission, Vision and Strategy

PULL PUSH

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5. Execute Change: Ultimately, nothing will occur without solid execution of needed changes. The organization undergoing transformation will need to have in place a solid model for testing, adapting, and implementing new ideas in the systems of care. This will require the organization to possess exceptional capacity for improvement, project management skills, and highly disciplined methods for design and redesign of the structures, processes and services needed to implement, sustain, and spread the good ideas. Building the System The leadership framework is presented in different ways and at different levels of detail in an effort to provide a variety of ways of understanding the leadership role in organizational transformation. Figure 2 adds more detail about the 26 specific components for each five key activities of the framework. Figure 2. A More Detailed View of a Framework for Leadership of Improvement

PULL

PUSH

1. Set Direction: Mission, Vision and Strategy

Make the status quo uncomfortable

Make the future attractive

3. Build Will • Plan for Improvement • Set Aims/Allocate Resources • Measure System

Performance • Provide Encouragement • Make Financial Linkages • Learn Subject Matter • Work on the Larger System

5. Execute Change • Use Model for Improvement

for Design and Redesign • Review and Guide Key

Initiatives • Spread Ideas • Communicate Results • Sustain Improved Levels of Performance

4. Generate Ideas • Read and Scan Widely, Learn from

Other Industries and Disciplines • Benchmark to Find Ideas • Listen to Customers • Invest in Research and Development • Manage Knowledge • Understand the Organization as a

System

A Framework for Leadership of Improvement

2. Establish the Foundation • Personal Preparation • Choose and Align the Senior

Team

• Build Relationships • Develop Future

Leaders

• Reframe Operating Values • Build Improvement Capability

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While the detailed view of the leadership framework lists the specific components that leaders of improvement must engage in, it fails to depict the critical linkages between these detailed activities. Ultimately it is the integration of these components to work together as a system that will accomplish the IOM challenge of delivering ideal care. . Figure 3 depicts the 26 leadership components as key processes that link together to form a system of improvement. This representation of the leadership framework as a system of interrelated processes more accurately reflects how the framework can be used within an organization. As leaders build this system of improvement it is critical to work on the linkages between processes, as well as the specific improvement processes themselves. Figure 3. The Leadership Framework as an Integrated System

Changing the old and communicating the direction

Building a System of Leadership for Improvement PULLPUSH

Planning for

Transformation Measuring

System Perform-

ance

Strategic Benchmarking

Setting Aims/ Allocating Resources

Making Financial Linkages

Learning Subject Matter

Listening to Customers

Understanding the Organization as a System

Set Direction: Mission, Vision and Strategy

Communicating Results

Reviewing and Guiding

Key Initiatives

Using a Model for

Improvement to

Design and Redesign

Spreading Ideas

Reframing Operating Values

Personal Preparation

Building Improvement Capability

Building Cooperative Relationships

Choosing and Aligning the Senior Team

Investing in Research & Development

Providing Encouragement

Sustaining Improved Levels of Performance

Wide Reading and scanning, learning from other industries and disciplines

Knowledge Management

Working on the Larger System

Developing Future Leaders

The Activities of Leaders of Improvement The purpose of the leadership framework is to produce a shared mission, vision, and values, along with the necessary will, ideas and organizational processes to accomplish the IOM challenge of delivering ideal care. The 26 specific component of the framework are organized

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into the categories of setting direction, building the foundation, creating will, generating ideas, and executing change. For simplicity, the component processes are described below at the organizational level, but can readily be translated to the other levels (divisions, departments, hospitals in a system, etc). Although it is useful to describe these activities one by one, they clearly form a system of leadership, and so it is somewhat artificial to parse them into separate individual items. It is how they are woven together in any particular organization by its leaders that make an effective system of leadership for improvement.

1. Set Direction: Establish Mission, Vision, and Strategy • Develop written statements of purpose of the organization, including consideration of

mission, values, vision, and strategic objectives that incorporate quality as a core strategy. • Communicate this purpose to all stakeholders. • Relate the work of different parts of the organization to the purpose. Use these purpose

statements to guide and focus business planning. • Use the vision to form strategies and align improvement activities • Align any organization incentives with the purpose. • Build education and employee development programs around the purpose. • Visibly use the purpose statements to make key organizational decisions.

2. Establish the Foundation for an Effective Leadership System

Reframe Operating Values • Define the desired culture through a set of principles, beliefs, values, tenets, or doctrine

that describes how the organization should conduct itself while accomplishing its mission.

• Incorporate quality as a strategy and the new health care environmental rules: o Use all the science we know as a profession. o Patients are the center of care and get all the control they want. o Think and act to optimize the system. o Cooperate and collaborate.

• Introduce and explain all change within the context of these operating values. • Address critical issues that may be related to the understanding and acceptance of the

stated values. • Change policies that are not consistent with the operating values. • Use the statement of operating values as the foundation for policy and statements about

safety, environment, ethics, quality, etc. • Model these operating values in all leadership and management activities. • Get feedback on the performance of the senior leadership team relative to the values.

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Develop Future Leaders • Create a process for identifying future leaders of the organization. • Create a formal development process that includes mentoring and rotation of

assignments. • Provide the opportunities for future leaders to participate in formal improvement

initiatives. • Schedule all leaders to participate in leadership development curriculum. • Consider support of the organization values as well as performance and results when

evaluating employees and medical staff for leadership positions.

Choose and Align the Senior Team • Strive to have the senior leaders of the organization work together as a high performance

team. • Modify the composition of the leadership team, if necessary, to embody the desired

operating values. • Develop a senior leadership team with the right balance of skills, healthy relationships,

and deep personal commitment to achievement of the organization’s purpose.

Build Relationships • Consciously build effective relationships among the employees and other key

stakeholders in the organization • Use the values statement and other components of the purpose to create commonality

among groups in the organization. • Integrate the medical staff with the leadership team. • Encourage the leadership team to participate in community activities. • Share information openly across all departments. • Support with key suppliers (staff, equipment, supplies, pharmaceuticals, payers, etc.) on

improvement initiatives.

Build Improvement Capability • Target development of improvement capability to all members of the senior team.

Consider: sponsorship of improvement initiatives, one, connecting to leaders outside the organization, external courses, new employee training, site visits, peer mentoring.

• Develop a strategy for the role of managers and supervisors in improvement initiatives. • Integrate development of improvement skills with the overall HR development plan. • Use participation on improvement teams as part of the development of all employees. • Develop internal capability in all aspects of the science of improvement.

Prepare Personally • Make a conscious decision whether or not to invest personal reputation and energy into

leading the effort to address the IOM challenge of delivering ideal care. • Master the core competencies of a leadership development program. • Ask for feedback and coaching to improve individual effectiveness. • Create a personal improvement plan and align personal goals with the organization’s

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vision. • Serve as a mentor for potential leaders.

3. Build Will Plan for Improvement

• Translate the organization’s purpose to action by developing a credible set of strategies, plans, and budgets that will drive organization success.

• Integrate planning for improvement into strategic and business planning processes to create an effective system for planning.

• Summarize inputs from research, feedback, benchmarking, marketing, the external environment, and new ideas.

• Based on these inputs, develop (or update) strategic objectives that could best accelerate the performance of the organization.

• Develop a priority list of the processes and services to design or redesign. • Establish improvement charters to address the high priority processes and services and

allocate resources. Set Aims and Allocate Resources

• Deploy the organization’s plan for improvement by chartering and staffing improvement initiatives.

• Establish aims to accomplish the improvements that can be resourced and managed. • Create charters to describe the scope of improvement initiatives based on the

improvement plan. • Include goals for initiatives that reflect the best performing systems in each are of care. • Expect all staff to participate in improvement activities. • Appoint members of the medical staff to support improvement initiatives and provide

release time. • Provide sponsors for the key improvement initiatives.

Measure System Performance • Guided by your mission and business strategies, establish the key measures of

performance of the system. • Balance the measures from the perspectives of customers, finance, operations, and

employees. • Display these measures as run charts in management reports and public documents. • Learn how the organization is executing its strategy and how it functions as a system

through study of these measures. • Align division and department measures with system performance measures. • Expect individuals and teams to use system performance measures in their improvement

work.

Provide Encouragement • Change negative statements into positive ones.

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• Routinely show appreciation for effort and results. • Accept people where they are and work with their strengths. • Treat people at all levels of the organization with respect. • Work to ensure that important interactions (e.g., board meetings) add rather than subtract

energy from the individual or the improvement team. • Use project designs that build in encouragement and reinforcement:

o Divide large projects into smaller ones (e.g. projects designed to cut the performance gap in half, rather than completely close the gap.).

o Assign tasks that are slightly beyond current capabilities and show confidence in the team or individual.

o Promote learning from Plan, Do, Study, Act testing on a small scale.

Make Financial Linkages The broad aim of improving value of any product or service can be divided into three sub aims suggested by Noriaki Kano:

1. Eliminate quality problems that arise because expectations of customers are not met 2. Reduce costs significantly while maintaining or improving quality 3. Expand customers’ expectations by providing products and services that they perceive as

unusually high in value In health care category 1 aims include decreasing adverse events, delays, and billing errors. Aims in category 1 are the ones that are frequently pursued in improvement efforts in health care. Many health care organizations are becoming skilled at acknowledging and finding quality problems, measuring their frequency, and engaging doctors, nurses, and other clinicians in reducing these defects. It is less clear how to determine whether the reduction of these defects provides a financial gain for the organization in the short run. What has been referred to as “the business case for quality” often is a search for a side effect of reduction of costs resulting from the reduction of defects. Category 2 aims seem to be less prevalent in health care. The prevailing culture among clinicians often results in conflict when executives propose category 2 aims. Even when the aims are pursued, improvement teams usually produce potential savings, for example less wasted time, rather than actual cost savings, less overtime wages. Converting potential cost savings into actual cost savings requires processes that executives and financial expects must operate. Deliberate intention to establish aims in category 2 will support our overall portfolio of work. An aim of reducing 1-3% of total organizational expenses is a level of performance which comes from benchmarking organizations inside and outside of health care which consistently reduce costs through redesign. Category 3 aims can be achieved by more convenient services such as email correspondence with doctors, shared internet health records, or very convenient access to care. Traditionally category three aims have been achieved by medical breakthroughs such as drugs for AIDS or laser eye surgery. In a system of health care that is not population based the gains in revenue

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associated with achieving category 3 aims are often associated with increased costs for some other part of the system or for society. Organizations Linking Financial improvement with their quality portfolio will:

• Adopt a balanced strategy using each of the Kano’s categories of improvement • Establish clear accountability within the leadership team for quality and the bottom line. • Assign financial specialists to partner with the improvement leader to plan and track

financial impact • Ensure that no major improvement is made without an analysis of the impact on the

patient and the business, and make sure that predictions are reviewed by clinical and financial staff

• Define a reinvestment strategy: clinical , ser vice and systems, great work environment, IT/HR, bottom line

• Communicate how financial performance is related to the fulfillment of improvement aims

Learn Subject Matter • Personally learn the subject matter that is driving key change initiatives, including

understanding of the principles and science of flow, safety, and reliability, and patient- centered care.

• Personally study, and in some cases master, new design principles for major organizational improvement initiatives.

Work on the Larger System

• Manage the connections between your organization and the broader health care system. • Focus system performance measures on the population of the entire community the

organization serves, and not just on the organization’s patients. • Become involved in setting health care policy through participation on committees in

government and professional organizations. • Bring payers, purchasers, and regulators into the organization to meet directly with the

board of directors and staff. • Share all of the organization’s performance data on cost and quality with staff, the board,

and the community. • Obtain board commitment to quality as the strategy, and maintain board attention on

overseeing the work of transformation. • Use the media to make visible, public statements of the organization’s intent to transform

to dramatically higher levels of performance. • Recruit board members who will challenge and push the organization on quality and

value performance. • Create external systems that enhance the business case for quality. • Use public measurements of performance to create internal pressure for improvement. • Work with payers and regulators to establish payment and regulatory models that drive

the transformation rather than inhibit it.

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4. Generate Ideas

Read and Scan Widely, Learning from Other Industries and Disciplines • Find great prototypes, either inside or outside of health care that can be adapted. • Send individuals to attend meetings and conferences and expect them to bring back ideas

for change. • Schedule group visits for leaders to other industries outside of health care at least once

per year. • Formalize organizational surveillance of scientific developments that can lead to ideas for

change.

Benchmark to Find Good Ideas • Identify best practice industries and organizations for issues similar to those your

organization is facing. • Study performance data to learn the best performing organizations in each are of health

care. • Encourage individuals to visit other organizations to look for great ideas for change. • Assign champions to new ideas to develop them into improvement initiatives within the

organization. • Assign the responsibility for “finding new ideas” to an individual or group.

Listen to Customers (patients) • Identify the current and future patients of the organization and group them into

appropriate segments (such as disease types, payers, geography, etc.). • Develop a system to gather information about patients’ needs, satisfaction, and loyalty in

each segment. • Develop systems to gather information connected to the organization’s purpose from

suppliers, employees, and the marketplace. • Communicate this information to all parts of the organization at appropriate times • Analyze information from patients to guide planning and improvement efforts.

Invest in Research and Development • Allocate resources for research and development. • Connect the research agenda to the organization’s strategic objectives. • Report on R&D results in the planning process each year.

Manage Knowledge • Maintain a system (i.e., knowledge warehouses) to organize the ideas for improvement

the organization possesses. • Emphasize knowledge sharing in the culture of the organization. • Develop systems to capture and disseminate tacit knowledge from individuals.

Understand the Organization as a System • Understand the major processes and services in the organization.

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• Prepare system maps to show how these processes link together to form a system. • Use these system maps and other aids to learn how the organization functions as a

system. • Develop a deep understanding of the system to guide planning and improvement

initiatives. • Use understanding of the system and its dynamics to organize information and

knowledge.

5. Execute Change

Use an Improvement Model for Design and Redesign • Select a standard approach (an “improvement model”) to execute change in the

organization. • Train all employees and other stakeholders in the model and basic methods for

improvement. • Encourage use of the model for everyday improvements as well as major design and

redesign efforts. • Redesign status reports to be consistent with the model for improvement.

Review and Guide Key Initiatives • Frequently review progress of major change initiatives and improvement projects in

senior operations meetings. • Maintain knowledge of all important projects and meet with improvement teams at

regular intervals. • Remove obstacles for improvement teams and provide recognition of their work. • Acknowledge that failures that occur as part of tests of new ideas are expected and

accepted, as long as learning results from them. • Study the activities of the team to learn about the key processes in the organization and

the key forces driving the system. • Redirect and redeploy resources as improvements are made.

Spread Ideas • Formalize processes to support the transfer of ideas for change throughout the

organization. • Understand the social networks in the organization and identify opinion leaders that can

help spread changes. • For targeted ideas, name a “spread champion” and provide him or her with resources and

authority to implement the ideas. • For key spread initiatives, create a matrix of the components of targeted changes to track

the rate and extent of spread throughout the organization.

Communicate Results • Hold meetings across departments to share improvement activities and exchange ideas.

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• Develop formal communication processes to gather and share information and results

from improvement initiatives. • Share performance data with all staff. • Create verbal descriptions on graphs of key system performance measures to describe the

impact of improvement initiatives. • Communicate openly to the larger community about your results and progress.

Sustain Improved Levels of Performance • When improvements are made, also make it difficult to revert to old processes. • Establish and document standard processes to accommodate the improvements and

support the spread of improvements throughout the organization. • Incorporate new measures of performance into the organization’s system performance

measures. • Update organization audits to include review of the new process standards. • Incorporate the changes into job descriptions and new employee training.

References: 1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.