Evidence-Based Leadership: The Chassis for High Reliability
by Craig Deao, MHA, Studer Group senior leader and national speaker, and Lyn Ketelsen, RN, MBA, Chief Patient Experience Officer for HCA Healthcare
If you flew on an airplane in the last year, did you check your bag? Data tells us that there is a 99.4 percent chance those bags will end up at their intended destination. Yet, many travelers don’t want to take that risk.
That is what a Four Sigma process feels like. While 99.4 percent sounds pretty good, our experience tells us it’s just not that reliable. And yet, in healthcare, we frequently accept a higher percentage of medication errors and hospital-acquired infections!
A Few Words about Six Sigma
Six Sigma—an improvement methodology—is an excellent way to determine relative levels of quality. When we say something is at a Six Sigma level of performance, we mean it’s “best in class.” A number of industries have actually achieved this, where they are 99.9996 percent reliable. In other words, they experience just 3.4 defects per million. These include a few manufacturing facilities, nuclear power, and airline safety.
Isn’t it interesting, though, that organizations with the same people and same resources can produce highly reliable results in one area (e.g., airline safety) and relatively untrustworthy results in another (e.g., baggage at destination)? Think about your own organization: Are there areas that are achieving world-class performance, while just a few steps down the hall other areas aren’t even performing as well as last year?
Six Sigma is also helpful to compare very different types of outcomes. Take basketball, for example: The odds that an NBA star will seek a shot from the free throw line is close to a Two Sigma process. And if we compare that to healthcare, the odds that a patient will leave without a hospital-acquired infection are just slightly better than that!
Still, the odds that a patient will leave with a hospital-acquired condition are much higher than the odds that Shaquille O’Neal will personally sink that ball, since he has the worst performance record in NBA history for free throw shots…about 52 percent. But Shaquille is still among the best .001 percent of individuals who have ever played basketball. So individual performance varies widely, even among the very best.
It turns out that 99 percent of hospitals succeed at meeting the CMS standard to give heart attack patients aspirin at discharge when not contraindicated, which sounds good at first, until we think about how little we trust our 99 percent reliable baggage handling experience! When we look at hospital performance with respect to the patient experience—more specifically the percentage of patients who say staff always explained medications before giving them—there’s a 37 percent defect rate: that’s a Two Sigma process.
High Reliability and The Patient Experience
In healthcare, when we think of quality and clinical examples, hospital-acquired conditions or patient safety tend to come to mind. At Studer Group, we find the very best organizations also think about them as service defects. While many hospitals achieve excellent results on clinical processes of care, patients rate the quality of their care (as measured by CAHPS patient experience surveys) as mediocre, with high deviation from one hospital to the next.
CAHPS surveys ask patients about frequency of behaviors—never, sometimes, usually, always—not satisfaction. In fact, in high reliability, we often talk about “deference to expertise” or ensuring the person closest to the problem makes the decision. Aren’t patients really the ultimate experts on the experience of their care? That’s why CAHPS is more than just a score; it’s the voice of the patient. A culture of Always is a culture of high reliability.
Evidence-Based Leadership provides the execution framework to align goals, behaviors, and processes—to not only realize but to sustain high reliability at all levels of the organization—because leaders have the skills to execute both nimbly and consistently.
Let’s take an example: Imagine a hospital that already uses the Evidence-Based Leadership framework, but just learned that they have a major opportunity to improve patient perception of care. Two of their high-volume med-surg units (important drivers of overall performance) are below the national average of 66 percent on the HCAHPS question: “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?” The first thing they would do is adjust leader goals to create alignment, urgency and accountability around improvement here.
First, Align Goals
The CNO’s goal to improve overall HCAHPS performance might be moved from a weight of 15 to 25 percent of her total evaluation to increase her focus in this area. The nurse leaders of the two med-surg units might get a new goal—weighted at 30 percent of total evaluation to demonstrate urgency—around improving performance on this medication side effects question. The individual who supervises the med-surg leader would then work with them to identify a 90-day action plan of strategies and tactics to drive improvement. A review of current performance and next steps would become a standing agenda item at the monthly meeting with their leader.
Of course, accountability requires training. Our commitment to leadership development must be strong to ensure leaders have the skills they need to avoid frustration and high turnover. In this example, it will be important that the individual they report to assesses whether these two med-surg nurse leaders have the knowledge, skills, and ability to drive performance.
Both of these leaders would be attending the organization’s quarterly Leadership Development Institute (LDI), where the curriculum is designed to improve the skills and abilities of leaders to achieve the stated objectives.
Since leader rounding on patients is a highly effective tactic to validate whether nurses are consistently informing patients about potential medication side effects, the organization might teach that tactic at its upcoming LDI. The two med-surg nurse leaders would have an accountability linkage item (because linkage is an expectation of execution, e.g., “achieve 90 percent or greater compliance with nurse leader rounding on every patient every day”) from the LDI so their leader can assess their performance and skill set for performance to these expectations.
At monthly supervisory meetings, skill development with nurse leader rounding on patients would be monitored qualitatively and quantitatively, in addition to assessment of their staff’s performance against specific best practices they had been taught to execute. (Are they always informing patients about potential medication side effects when rounding? Supervisors would embrace a “preoccupation with failure” to look for defect opportunities by drilling down with “Why?” to get to the root cause of any barriers.)
Next, Align Behavior
Since this organization has already implemented AIDET® as a “Must Haves®,” it will step up its validation on nurses’ Explanation component. (For example: “Mr. Jones, I’ve got the medication for your blood pressure. I just want you to know I’ve taken care of many patients and I’d like to spend a few moments to share some really important information on potential side effects of this medication. We’ll be watching for them while you are here, but I also want to ensure you can take good care of yourself once you are at home.”) The nurse would also use the teach-back method to confirm the patient understands (e.g., “Mr. Jones, can you repeat back to me what you heard me say and which things are important for us to be watching for?”)
Once the goals have been set, the tools have been identified, and the skills have been taught and validated, this organization will want to recognize those staff and leaders who are consistently executing and achieving goals. Likewise, when leaders identify gaps in performance, they won’t hesitate to take the appropriate corrective action.
Finally, Align Processes
Lastly, the organization will want to ensure it has aligned processes in place that do not create barriers to consistency. For example, if a computer system makes it difficult for nurses to sign off on a medication because it doesn’t offer pop-ups that identify medication side effects and require hand-written documentation; instead, the organization may want to identify an alternative technology solution to streamline this process. Or, pre-printed handouts for patients on each medication could be used for verbal reinforcement.
Purpose, Worthwhile Work, and Making A Difference
If we acknowledge the legitimacy of the tenants of high-reliability organizations—sensitive to operations, reluctance to oversimplify, preoccupation with failure, deference to expertise, and resiliency—then we understand they require an operational framework that supports a culture for minute-by-minute commitment toward outcomes like zero defects. Evidence-Based Leadership is that culture. After all, we are not as fortunate as airline baggage handlers. For them, a lost bag simply means a frustrated customer. In healthcare, we leave a patient and family who have been harmed. Zero defects must be our commitment.