are responsible for everything in an organization,
especially what goes wrong.”
(Paul O’Neill, former
US Secretary of the Treasury, and CEO of Alcoa).
The climate established by an organization's leaders is
a powerful driver of quality. Our approach focuses on leadership
practices that influence health care quality, with the ultimate
objective of achieving system-wide results across the entire
organization, rather than “doing quality projects.” These
are the kinds of specific questions we address:
- We are doing great quality projects, but they don't seem
to be spreading fast enough throughout the organization.
How do we move from "doing CQI" to a complete
transformation of the way we work, throughout the enterprise?
- How can we really engage our physicians in clinical quality
- Quality improvement gets a lot of nice words at meetings
and in annual reports, but when times are tough, we seem
to invest less in quality, rather than more. How can we
make quality our core strategy?
- Our “dashboard” for quality and safety was
supposed to make it easier to monitor our progress,
but instead it seems to be confusing to everyone. What
be on our dashboard, and how should we use it?
- Our CFO is skeptical about our claims that quality improvement
can help the bottom line. If he’s right,
what are we doing wrong? Can you help us work with
our payers to
improve the business case for quality?
overall approach to these difficult problems is based on
the classical quality
theory of W. Edwards Deming. Our leadership
development and organizational transformation
work is grounded in complex adaptive systems
theory, and in the broad framework laid out
in the Institute of Medicine’s Crossing
the Quality Chasm. Finally, we are convinced
that the central focus of health care must
be on the quality of the “healing relationships” that
are developed between patients and their
physicians and nurses, and that “touch
time” is an essential element in the
development of those vitally important relationships.
Examples of our approach, as applied to specific
challenges, can be seen in the links below.
- Leading the Transformation: In response
to numerous requests from health care executives,
we have developed an overall framework for
the quality transformation of health care,
A Theory of Leadership for the Transformation
of Health Care Organizations.
- Leadership Leverage Points for Measured
System-Level Improvement: The history
of quality improvement in health care has
been one of "science projects"--interesting
efforts to apply quality theory to health
care problems, but not strategically linked,
with enough scale and pace to move whole
system measures such as mortality rate, cost
per capita, and other important measures
of effectiveness, safety, efficiency, and
other quality dimensions. The leadership
group at IHI has developed a framework for
how leaders can plan to improve system-level
measures--to "Move the Big Dots." This
approach, which has proved to be immensely
helpful in framing the work of leaders,
is laid out in this short white paper:
Leadership Leverage Points for System
Level Improvement in Health Care.
and Quality: Hospital
and Healthcare System Boards are becoming
of their responsibility for quality
and safety. But many board members—especially those
who are not clinically trained—are
uncertain about how to oversee clinical quality.
This paper lays out what the best boards
do to lead quality and safety, and more importantly, how they do it—by
establishing Will to improve, driving
changes, and maintaining Constancy
of Purpose over the long haul.
Physicians in Quality: One of the most frequently-asked questions is "How can we engage our doctors in our quality and safety agenda?" And since health reform, that question has broadened to something like "How do we engage with our doctors in becoming more clinically integrated, and accountable to our community?" My approach to this question is laid out in two white papers, one of which focuses fairly specifically on engaging with doctors in quality initiatives, and the other on true clinical integration. In both papers, you will see that we prefer to turn the questions around. The quality challenge, in our view, is "How can the organization engage in the doctors' quality agenda?" And in the case of clinical integration and ACOs, the real issue is not getting the doctors clinically integrated with the organization: it's getting doctors to clinically integrate with each other. Both papers outline useful, practical frameworks, and form the basis for our consulting and teaching work with medical staff leaders in a wide variety of healthcare settings. To get a better idea of how our approach translates into keynotes and presentations, please view an example presentation on the subject of clinical integration, accountable care organizations, and other reform-related current issues.
Many aspects of our approach to physicians as leaders of improvement and the professional challenge of clinical autonomy have remained constant for years, and are laid out in these classic papers in the Annals of Internal Medicine.
- Every system is perfectly designed to produce
the results it achieves.
- Every patient comes first.
- Practice clinical science as a team, so that you can practice
the art of medicine as an individual.
- Remove everything that steals "touch time" from
doctors, nurses, and patients.
- Organize your work the way it gets done, not the way you
got your diplomas.
- Make the right thing the easy thing to do.
- If you really want it done right, regularly, get a nurse
- If your doctors and nurses are feeling joy and pride in
their work, you're on the right track. If not, think
- Health care organizations must be led from hundreds of
places, not solely from the corner office.
- Sometimes it's easier to change people than it is to change