Certification as a Level-1 Center for Children s Surgery: A Journey in Transformational Change

Transcription

1 Certification as a Level-1 Center for Children s Surgery: A Journey in Transformational Change Alexander C. Allori, MD, MPH Duke Children s Hospital Durham, NC

2 Disclosures The author has no relationships, financial or otherwise, that would result in a conflict of interest related to the content of this presentation.

3 Duke University Health System: Duke University Hospital Duke Regional Hospital Duke Raleigh Hospital Ambulatory Surgery Center Dozens of clinics Duke University Hospital: ~1200 inpatient beds ~50 ORs Duke Children s Hospital: Hospital-in-hospital structure ~200 inpatient beds 8 dedicated pediatric ORs

4 Durham, NC

5 August 2014 September 2014 October 2014 November 2014 January 2015 Draft guidelines released by ACS Internal briefing & Task Force established Internal self-assessment according to draft ACS guidelines ACS releases second draft of guidelines & Pilot program announced Internal executive summary prepared based on initial Task Force work & Institutional support obtained

6 Diligent and frantic preparations by Task Force January 2015 March 2015 April 2015 July 2015 Internal executive summary prepared based on initial Task Force work & Institutional support obtained ACS releases the formal pre-review questionnaire (PRQ) ACS site visit ACS returns the site-visit report listing deficiencies and weaknesses Waiting

7 July 2015 August 2015 October 2015 November 2015 January 2016 April 2016 ACS returns the site-visit report listing deficiencies and weaknesses Offline discussions with various people connected with the ACS NSQIP Peds SCR hired and trained Necessary support and permissions obtained from hospital hierarchy Task Force restructured as Guiding Coalition ACS releases official version of guidelines, with significant changes (but does not include a changelog!) Response to criticisms submitted to ACS Admin Director for Q&S hired Near-total organizational and functional re-design

8 Selected Major Accomplishments (truly, too numerous to list) Leadership: MDCS MDCA Formal liaisons to each discipline Q&S Personnel: Program Manager (CSPM) Admin Director Q&S Med Director Q&S Surgery / Champion NSQIP-Peds Anesthesia / Champion WakeUpSafe Pediatrics / Champion SPS NSQIP Pediatric SCR Data Engineer (Performance Services) Functional structure: Core Q&S Team (Operations) Meeting Quality Oversight Committee Meeting Multidisciplinary Peer-Review Conference (MPRC) NSQIP-Pediatric weekly review OR/Periop Committee Meeting Core Safety Team Meeting RCAs / LFDs Report-Out structure: Children s Surgery Faculty Meeting Nurse Manager & Med Dir Meeting Children s Hospital Leadership Meeting

9 Selected Major Accomplishments (truly, too numerous to list) Accomplishments to date: Consolidation of Q&S data silos Centralization of QI oversight 24/7 coverage of PED Guidelines for pediatric consultations Pediatric backup call schedules Overhauled pediatric credentialing/privileging process

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12 Preparation for focused site visit April 2016 June 2016 July 2016 August 2016 October 2016 November 2016 Response to criticisms submitted to ACS Letter received from ACS indicating areas still needing improvement Waiting with total radio silence Letter from ACS detailing areas for focused site review Focused site visit Program Manager (CSPM) hired ACS grants approval for Level-1 status, contingent on certain provisions & Our final response to ACS with required documentation of provisions being met Level-1 Certification goes into effect

13 Level-1

14 Lessons Learned

15 Be organized: Lesson #1 Have a project management framework Use a task management system Use a system-based model for QI

16 Theoretical Frameworks Process-based management Lean (value-based) Theory of constraints Six Sigma Total quality management (TQM) Agile Scrum Kanban

17 Lesson #2 Create the long-term vision Formulate a strategy map for getting there Align all goals and processes Take the necessary time

18 The change process goes through a series of phases that, in total, usually require a considerable length of time. John P. Kotter Kotter JP. Leading change. HBR, 1995 Mar-Apr:59-67.

19 Strategy Searching Doing Modifying Learning Kotter JP. Accelerate. HBR, 2012 Nov:46-58.

20 Skipping steps creates only the illusion of speed and never produces a satisfying result. Critical mistakes in any of the phases can have a devastating impact, slowing momentum and negating hard-won gains. John P. Kotter Kotter JP. Leading change. HBR, 1995 Mar-Apr:59-67.

21 Lesson #3 Learn from business examples.

22 Eight Steps toward Transformation 1. Establishing a sense of urgency 2. Forming a powerful guiding coalition 3. Creating a vision 4. Communicating the vision for buy-in 5. Empowering others to act on the vision 6. Planning for and creating short-term wins 7. Never letting up 8. Incorporating changes into the culture Kotter JP. Leading change. HBR, 1995 Mar-Apr: Kotter JP. Accelerate. HBR, 2012 Nov:46-58.

23 Lesson #4 A guiding coalition and network are far superior than traditional task forces.

24 The hierarchical structures and organizational processes we have used for decades are no longer up to the task of winning in this faster-moving world. In fact, they can actually thwart attempts to compete in a marketplace where discontinuities are more frequent and innovators must always be ready to face new problems. John P. Kotter Kotter JP. Accelerate. HBR, 2012 Nov:46-58.

25 We cannot ignore the daily demands of running a company, which traditional hierarchies and managerial processes do very well. What they do not do well is identify the most important hazards and opportunities early enough, formulate creative strategic initiatives nimbly enough, and implement them fast enough. John P. Kotter Kotter JP. Accelerate. HBR, 2012 Nov:46-58.

26 The solution is a second operating system, devoted to the design and implementation of strategy, that uses an agile, networklike structure and a very different set of processes. John P. Kotter Kotter JP. Accelerate. HBR, 2012 Nov:46-58.

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28 The strategy network meshes with the hierarchy as an equal. It is not a super task force that reports to some level in the hierarchy. It is seamlessly connected to and coordinated with the hierarchy in a number of ways, chiefly through the people who populate both systems. John P. Kotter Kotter JP. Accelerate. HBR, 2012 Nov:46-58.

29 Advantages of the Network + Guiding Coalition Many change agents, not just the usual few appointees A want-to and get-to (not just have-to) mindset Head and heart Much more leadership (not just management) Two systems, one organization

30 Lesson #5 Recognize that transformational change is just that: change. Change is slow. Change hurts. Demonstrate respect through all phases of the project.

31 Respect the Volunteer Army The volunteer army is not a bunch of grunts carrying out orders from the brass. Its members are change leaders who bring energy, commitment, and enthusiasm. John P. Kotter Kotter JP. Accelerate. HBR, 2012 Nov:46-58.

32 There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. Niccolò Macchiavelli Il Principe (The Prince) 1513 Portrait of Niccolò Machiavelli Santi di Tito Ca. 1530

33 The Journey Create urgency around the need for change Share the future vision Understand the present state: Understand what motivates others Accommodate how others process change Tailor messages to suit individual needs Clarify what others need to stop doing Determine resources Implement early changes Demonstrate the change Evaluate the change

34 Methods for Managing Conflict & Resistance Method How When + Pros + Cons Education Communicate the desired changes and reasons for them Participation Involve potential resisters in designing and implementing change Facilitation Provide skills training and emotional support Negotiation Offer incentives for making the change Coercion Fire or transfer those who can t or won t change Employees lack information about the change s implications Change initiators lack sufficient information to design the change People resist because they fear they can t make the needed adjustments People will lose out in the change and have considerable power to resist Speed is essential and change initiators possess considerable power Once persuaded, people often help implement the change People feel more committed to making the change happen No other approach works as well with adjustment problems It s a relatively easy way to defuse major resistence It works quickly and can overcome any kind of resistance Time-consuming if lots of people are involved Time-consuming, and employees may design inappropriate change Can be timeconsuming and expensive; can still fail Can be expensive and open managers to the possibility of blackmail Can spark intense resentment toward change initiators (or the cause for change) Kotter JP and Schlesinger LA. Choosing strategies for change. HBR, 2008 July.

35 Downstream Side Effects of Change Stakeholder engagement Knowledge transfer Training and support for change Manage change risks and issues Managing role changes Realize business benefits

36 Questions?

37 Contact Information Alexander C. Allori, MD, MPH