Part 3: Achieving Breakthrough Performance: Deploying Resources and Providing Oversight
A proposed system for achieving breakthrough levels of performance contains four components:
- Setting Breakthrough Performance Goals
- Developing a Portfolio of Projects to Support the Goals
- Deploying Resources to the Projects That Are Appropriate for the Aim
- Establishing an Oversight and Learning System to Increase the Chance of Producing the Intended Results
The second article in this series outlined an approach to the first two components of the system. In this article, we consider the third and fourth elements: deploying resources and providing oversight.
3. Deploying Resources to the Projects That Are Appropriate for the Aim
The organizations that we interviewed took the process of deploying resources to the improvement projects in the portfolio very seriously. Assigning the project leader was given special consideration. In one case, the Vice President of Human Resources did an assessment of the skills needed to lead each project; candidates from the organization who matched these skills became candidates for project leader. Leaders were selected from this group after assessing the interest of the individual and negotiating with their line manager. Project leaders were often relieved of other duties to work full time on the project. Sometimes the leader came from a staff dedicated to improvement. In organizations that were following a Six Sigma approach, these people were called “Black Belts” or “Master Black Belts.” Other organizations selected leaders from among their operations management personnel and relieved them of their other line responsibilities.
Although this level of staffing may seem excessive or unaffordable, when pressed on this point, each of the organizations that followed this approach responded that the projects were large system projects demanding lots of time, were vital to the organization, and were expected to pay a substantial financial or strategic return. They added that the pace of the improvement project was a deliberate choice (i.e., "how much by when”) and that the organization could choose to increase the pace without increasing resources by focusing the leader’s efforts. For example, consider a person leading two projects scheduled for one year and devoting 25 percent of his or her time to each. Each project takes one year to produce results. Consider another allocation of time: The same person allocates 50 percent of his or her time to a six-month project, finishes it, and goes on to a second project of six months’ duration. The project leader has not increased his/her time allocation, but instead of producing results from two projects in an average of 12 months, he has produced results from the same two projects in an average of nine months. (The first project delivered results in six months and the second project in 12 months).
The day-to-day leader sets the pace. Others on the team are also “multitasking.” This focus of the leader and the project accrues productivity benefits to others besides the team leader and produces the increased throughput of results.
The basic structure for improvement project teams was quite similar among all organizations. The team leader was responsible for the day-to-day progress and pace. Each team was assigned an executive sponsor to keep the team connected to organizational strategy, to coordinate the efforts with other projects, and to increase the chances of success. Teams also had one or more technical experts (i.e., a person who knows the clinical subject matter intimately and who understands the processes of care, and an expert on improvement methods) depending on the needs of the project.
Of course, for many organizations the issue is not how much of someone’s time to allocate to a project. The issue is finding and developing people in the organization capable of integrating a portfolio of projects or leading one of those projects. The high-performing organizations that we talked with made it a strategic priority to continually increase the pool of persons with these skills and attributes:
- Curiosity: To achieve results at the system level requires system-level change. No easy answers are available. A successful leader of large-scale execution must be open to finding and translating ideas from within health care and from other industries.
- Capability to move between conceptual thinking and execution: Integrating a portfolio of projects and learning about what is producing system-level results takes conceptual thinking. It also takes disciplined project management skills. Leaders that are effective at execution can do both.
- Quantitative skills: Effective improvement almost always requires measurement. The measurement and learning challenge increases as the size and ambition of the portfolio increase.
- Ability to work well with all levels of the workforce and professional disciplines: To achieve system-level results requires contributions from all levels of the organization.
- Confidence to link with senior executives: Senior executives play a vital role in ensuring that the aims are achieved. Leaders of execution will require cooperative interaction with executives as peers.
- Ability to be a good communicator: When the organization sets system-level aims and makes fundamental changes to accomplish them, people in the organization will want to know “What are we going to do?” and “Why are we doing it?” One successful executive said that he was not through until he communicated his message “eight times, eight ways.”
Organizations that we interviewed also had plans for the development of individuals within the organization that included the following:
- Increasing responsibility for larger and more complex projects;
- Attending seminars and other formal training;
- Participating in multi-organization efforts such as an IHI Breakthrough Series Collaborative;
- Making presentations at conferences; and
- Writing papers for peer-reviewed journal publication.
Despite the many different approaches to development, there is a clear consensus that training and development of leaders of improvement should be based on real projects and improvement efforts.
In addition to allocating the time of the leader and other team members, the allocation of other organizational resources to the portfolio of projects was a priority. These resources included:
- Capital for projects, such as information technology, construction, or new equipment;
- Priority for requests to information technology services;
- Priority for other support services such as finance or human resources; and
- Assignment of analysts or quality improvement specialists to assist the team.
Pitfall
Assigning a project leader to a project, but allocating less than 40 percent of that person’s time to the project.
Suggestions
- Do a thoughtful assessment of return on investment to reaffirm the importance of the project and build consensus for the allocation of time.
- Shorten the length of the project because of the increased allocation of time for the project leader.
- Be clear about what the person will stop doing to make time for the duties of project leader.
- Monitor the time spent on the project to prevent the erosion of project leader’s time and attention from the project.
4. Establishing an Oversight and Learning System to Increase the Chance of Producing the Intended Results
Each of the organizations that we interviewed had well-developed executive review processes. These reviews occurred at least monthly with the executive sponsor of the project, and quarterly with an executive team that was responsible for execution of the strategic plan and the associated improvement initiatives. The best reviews seemed to function as high-level problem-solving sessions, with an unwavering commitment to make the project and the team successful. The purposes of the review included many of the following:
- To provide encouragement and recognition of the project teams;
- To learn whether the project was on track, or was likely to fall short of the aim;
- To develop action plans for getting projects back on track; and
- To decide whether the project should be modified in some way or stopped.
At Bellin Health System (Green Bay, Wisconsin, USA), for example, each of the projects was on a 120-day cycle. At the end of each cycle, the portfolio of projects was rebalanced depending on whether or not the aim had been accomplished and the remaining opportunity for improvement. This rebalance was done at a full-day retreat of the management team.
A good executive review of improvement projects requires a good process for review, with the following steps:
- Review of the context: The project is nested in a portfolio of projects connected to a breakthrough aim or strategic imperative. Make this context clear and use it as needed for the rest of the review.
- Efficient review of progress: Many of the organizations that we interviewed emphasized the importance of good preparation by the team leader of the “story” of the project. Elements of the story included the aim of the project, annotated time series for two to three important measures, the major system changes, and the degree of belief — high, medium, low — that the aim would be achieved. One can develop skills for communicating this information effectively by adapting techniques from abstracts for peer-reviewed journals supplemented by time series graphs, storyboards, sidebars in magazine articles, or illustrative graphics from newspaper articles. The SBAR (Situation, Background, Assessment, Recommendation) method is associated with efficient and effective communication and can also serve as a template for the team’s presentation. This review of progress should take no more than 25 percent of the time allotted for the overall review.
- Agreement on barriers and emerging issues: If the project is not achieving the intended results, reach agreement on why:
- Lack of organizational will?
- Absence of strong enough ideas for improvement?
- Failure to execute changes?
- Unanticipated external forces?
- Action plan: During the discussion of barriers and issues, some solutions may surface and require action by one of the executives or require a new approach that can be carried out by the team without executive action. The review team may recognize that some of the assumptions on which the project was based were flawed. This may prompt a more fundamental rethinking of the project aim and how the project fits in the portfolio of projects. A written action plan should be the outcome. Time constraints may prevent the development of the action plan at the review, but at least some guidance on the plan and an assignment of responsibility for creating the action plan is required.
- Summary of new knowledge: The review process is an ideal time to review the new knowledge that is emerging from the execution of the project. The executives and the team learn their way to new performance. Projects may have unexpected connections or reinforce each other in ways that were not anticipated. Effective review processes provide means of documenting and spreading this learning.
Pitfall
Many project reviews turn into presentations by the team with lots of slides. The presentation consumes almost all the time for the review. The executives have a difficult time separating important issues from unnecessary details, and consequently the team does not get the help they need.
Suggestions
- The review team is clear about their role in ensuring the success of the project.
- The team is prepared to summarize on one page or in five slides the progress to date and the issues they need help with. This briefing takes less than 25 percent of the total time for the review.
- Action plans are created and assignments made.
Next: Part 4 in the series, System-Level Impact of Local Improvement
Related stories in this series:
Part 1: Organizational Approaches to Execution — Inside and Outside of Health Care
Part 2: Achieving Breakthrough Performance: Setting Goals and Developing a Portfolio of Projects
Part 4: System-Level Impact of Local Improvement
02/12/2007
