Part 1: Organizational Approaches to Execution — Inside and Outside of Health Care
The best at …, the leader in …, the national model for …, highest quality health care, improve the health of the community, leave no one behind — the aspirations of health care organizations are high, as expressed in their mission and vision statements that invariably contain some of these words and phrases. Quality improvement in health care has progressed. Many clinics, practices, hospitals, or other organizations can get results from projects such as reduction of medication errors, reduction of mortality from acute myocardial infarction, improvement in management of a particular chronic disease, or reduction of delays in discharge from a hospital. These projects often are initiated by internal champions such as a surgeon motivated to lead an effort to lower surgical site infections, a nurse interested in management of anticoagulants, or a pharmacist passionate about medication safety. External forces also give rise to projects — for example, national patient safety goals, core measures, or the 100,000 Lives Campaign. This plethora of ignition sources predictably results in a long list of worthwhile projects and measures, each of which makes sense on its own. However, the collection of projects is less likely to make sense as a coordinated whole aligned with the strategic direction of the organization.
A simple framework for strategic improvement work is Will-Ideas-Execution. Achieving results at the system or organizational level requires will at all levels, but especially the will of top management to make a new way of working attractive and the status quo uncomfortable. The new system will require new ideas about how work gets done, how relationships are built, and how patients participate in their care. Some of these ideas may come from sources internal to the organization, but many will come from outside. Processes to scan widely within and outside the organization’s industry will be needed to find ideas robust enough to form the basis of a new system that performs at unprecedented levels. No single initiative or set of unaligned projects will likely be enough to produce system-level results. Therefore, the development of a system for execution of a portfolio of projects aligned with strategy that produces and sustains results is a vital component.
The will of participants in the 100,000 Lives Campaign and the will, creativity, and perseverance of the participants in the five years of the Pursuing Perfection initiative led IHI to conclude that execution is currently the weak link in the three-component chain of Will-Ideas-Execution. As a result of this conclusion, the IHI launched a research-and-development project to gather data on the approaches used by organizations inside and outside of health care. IHI conducted interviews with leaders from Caterpillar, Milliken, DuPont, Baldrige winner OMI, and SRF from India, one of the few winners of the Deming Prize outside of Japan. In addition, through its programs and alliances IHI had opportunities to observe, interview, and learn from many organizations in health care, including the Ascension System, the Bellin Health System, HealthPartners, OSF, the health system of Jonkoping County in Sweden, and Cincinnati Children’s Hospital Medical Center. This report contains a synthesis of the data that we gathered. Based on this synthesis we propose a method of execution aimed at producing transformation through achieving unprecedented and sustained results at the system level.
Themes and Differences
Several common themes emerged from the organizations that we interviewed or observed. Each of the organizations was using their investment in improvement to accomplish the strategic goals of the organization. The projects and initiatives were supporting strategic priorities. Since the investment in people’s time and investments of capital were substantial, each of the organizations had formal oversight systems operated by managers and executives. Monthly reviews of a project by those most accountable for its success and quarterly reviews of the portfolio by senior executives were common occurrences. SRF in India supplemented these reviews by using a lean concept of “making the system visible.” They attempt to make the results and progress of key initiatives transparent by readily accessible charts, illustrations, or stories. A surprisingly strong theme of transparency, combined with intrinsic desire to serve patients or customers and produce business results, emerged as an important source of motivation.
Focus and the courage to say what will not be done this year echoed throughout the interviews: “Less is more.” “The less we do each year, the faster the results at the system level come.” “We hate to see performance below our standards, but we will do less if we try to do it all.” Although the number of projects was small, the ambition of the aims was not.
Projects were connected to strategy in two ways. Some organizations, in particular SRF, emerged from strategic planning with not more than two breakthrough goals at the individual business level. Each of the goals was accompanied by three “means,” or “drivers.” These drivers became goals for managers in the system. The managers used the same logic to establish their own set of drivers. This cascading definition of goals and drivers made explicit the logic or theory of how the system-level results were to be achieved. From this logic chain, organizations chose a set of projects by means of a negotiation process. Those familiar with the Japanese approach to strategic improvement will recognize this approach to setting priorities as hoshin planning and the negotiation referred to as “catch ball.” A related but different approach to selecting projects used by many organizations was to request nominations for projects related to strategic priorities such as safety, international expansion, community health, patient or customer experience, new service lines, or cost reduction. The list under each strategic priority was then pared down and connected into a coherent whole.
Each of the industrial companies chose projects individually in each of their businesses. (A “business” is usually defined by a group of like customers or markets.) Several of the companies had corporate themes that became inputs to the planning of all the businesses. For example, at Caterpillar each business was encouraged to consider the theme of environmental sustainability when choosing their portfolio. The corporation also supported organization-wide initiatives related to sustainability. Service lines in the health care organizations or divisions in a teaching facility served a similar purpose.
Some of the companies also spread good ideas and methods around the company. Some demanded some standardization of processes, such as pricing or new product development, among the largely autonomous businesses. In the health care systems, for example, Ascension, the hospitals in the system served geographically diverse populations but provided similar services. The same could be said of HealthPartners or Bellin, which have multiple clinics or hospitals that serve patients in a region.
Several differences between the industrial and health care organizations emerged. The most significant difference was in the investment of people’s time to run the projects in the portfolio. In most cases, the projects were run by someone assigned full time. This provided a reliable day-to-day driver of the effort. If the project was big enough, one or more persons might also be full time. One of the industrial leaders expressed skepticism that a busy person could carve out 20 to 50 percent of their time reliably to devote to longer-term payoffs, while daily emergencies were arising. However, this was precisely how many health care organizations were deploying their resources. An important difference between the sectors may explain this difference in approaches. In the industrial companies, being selected as a project leader was considered favorable for one’s career. Many were managers, and gaining experience and recognition leading a highly visible project often led to career advancement after the project was completed. In health care, however, the career of a doctor or nurse who takes leave from clinical work to lead a project might not be enhanced if their aim is to return to clinical work. For health care leaders, this is a deployment issue that will need to be addressed.
A Framework for Execution
Based on these observations and our experience at IHI with advancing the improvement of quality of health care, we propose the framework for execution shown in Figure 1 below. Of course, the framework will need to be adapted to local circumstances, but we are confident that it contains the components of an execution system capable of producing system-level results.
Figure 1. A Framework for Execution
An organization that is able to consistently improve system-level performance will have developed capabilities in three areas:
- The ability to consistently deliver on breakthrough aims aligned with strategic priorities by coordinating a portfolio of projects and the associated human and capital investments;
- Ubiquitous local management and supervision of activities aimed at stabilizing local performance, supporting or sustaining breakthrough aims, and providing an environment that promotes joy in work; and
- Continual development of a sufficient number of employees who are capable of leading initiatives to produce system-level results and managers and supervisors capable of quality-based management in their local areas.
Related stories in this series:
Part 2: Achieving Breakthrough Performance: Setting Goals and Developing a Portfolio of Projects
Part 3: Achieving Breakthrough Performance: Deploying Resources and Providing Oversight
Part 4: System-Level Impact of Local Improvement
01/15/2007
