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10/20/2016

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Welcome back, warm up, questions from Day 1Improvement Coach Professional Development Program

Workshop 2, Day 2

October 26, 2016

Karen Baldoza

Coaching to Learn: The Key to Improvement CoachingPhyllis Virgil

Improvement Coach Professional Development Program

Wave 2, Workshop 2

October 26, 2016Day 2

Created by Phyllis M. Virgil

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Session Objectives

• Review the basic building blocks of connecting and

coaching to learn.

• Practice key skills associated with the art of coaching

questioning, exploration, understanding, and the ability

to elicit insight (3 rounds of paired coaching)

• Obtain insight on one key issue or problem you are

currently working on.

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Session agenda

Topic Min

Introduction 5

Meet, Greet and Gathering Skills (5, 5/5) 15

Questioning, Exploration and Inquiry Skills (10, 10/10) 30

Skills for Understanding and Insight (10, 5/5) 20

Reflection and Wrap-up 15

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Coaching to Learn

Requires:Choosing the right attitude,

and sending the right signals.

In order to get people to talk,

and keep them talking.

So we can gather the story,

to elicit their insights

and offer our own.

Adapted from Boothman, Levine and Gladwell by Phyllis M. Virgil

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First Things…

Write down one key problem or difficult situation that is complex in nature, currently unresolved and weighing on your mind.

Can be any issue (project related or not, professional or personal), which you are willing to openly share and to work on...

Source: Phyllis M. Virgil, Coach Training

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When Coaching Others:

First Attend to the Person

Then to the Problem

Content Design: Phyllis M. Virgil, Coach Training

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Recognize the Importance of Trust

People must trust you, before they will hear you.

Content Design: Phyllis M. Virgil, Coach Training

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Building the Cycle of TrustPractice Open Communication

COMMUNICATION

Open

Closed

Trust

Collaboration

MistrustFear

Competition

Learning

No Learning

@Phyllis M. Virgil

Adapted from The Fifth Discipline by Peter Senge

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The coaching kick off...

When connecting as a coach we need to:

• Choose the right attitude

• Send the right signals

• Get people talking

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Adapted from How to Connect in Healthcare in 90 Seconds or Less by Nicolas Boothman by Phyllis M. Virgil

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Choose the Right Attitude

• Attitudes are infectious.

• Drive behavior.

• Open not closed.

• Can make or break a coaching session.

• Be genuine.

• Charming not alarming.

• Mend moodiness before meeting.


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Send the Right Signals

• Recognize the importance of nonverbal

communication

• The three must’s of body language:

1. Look them in the

2. Warm smile

3. Point your towards them

• Coordinate (synchronize) posture and tone


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Get People Talking

Begin with an open statement:

• Comment on location or occasion

Follow by an open ended question

• What / Why / How

Avoid closed questions:

• Are You? / Have You / Do You?

• (can soften with respect or a smile)


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Round One Practice (10 minutes)

Choose a partner -- someone close by who you would like to get to know better.

ID roles Coach/Client (birthday closest to today = client)

Go thru steps: • Choose the right attitude• Send the right signals• Get them talking

Work on problem/issue you wrote down...

Coach works to connect to person and their problem, no solutions only understanding

5 minute round then switch roles coach/client


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Keep them Talking � By providing feedback:

• Eye contact

• Open body language

• An occasional nod of the head

• Short words of encouragement

� By throwing the ball back in their court:

• Follow-up questions – tell, explain, describe

• Appeal to senses – how does that sound, what do you see, how did you feel....

• Active listening paired with reflective feedback


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Gather the Story

• Recognize the importance of story

• Contains seeds of insight

• Treat it as a treasure

• Have a genuine concern

• Feedback to reflect back

• Take a spirit of inquiry

• Probe to discover meaning

• Practice the art of listening

Adapted From: Getting to Resolution: Turning Conflict into Collaboration by Stewart Levine, by Phyllis M. Virgil

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Be an Intuitive Listener

Open

Perceptive

Unpresuming


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Practice the Art of Questioning

To help your client:

• Find Clarity

• Explore Emotions

• Develop Strategies

• Take Action

Source: Coaching with a Full Deck by Dr. Anne Power

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Coaching With a Full Deck

The card questions are organized as follows:

Finding Clarity – Diamonds

Exploring Emotions – Hearts

Developing Strategy – Clubs

Taking Action - Spades

Start by seeing if there is a suit that captures the problem or issue.

Stay within that suit.

Organized in terms of complexity # low to high

If the problem or issues cuts across all suits then shuffle the deck and pick at random

Source: Coaching with a Full Deck by Dr. Anne Power, [email protected]

Linson leave source in large type

So folks can get e-mail, last time

A number wanted to purchase the

Coaching cards, so inserted e-mail here

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Round Two Practice (20 minutes)

Continue your coaching conversation:

• Choose the right attitude

• Send the right signals

• Get them talking, and

• Keep them talking

• Gather the story

Use coaching cards to stimulate questions

Coach ONLY asks questions (no advice, direction, or judgment)

10 minute round then switch roles coach/client (I will call time)

Adapted from Boothman, Levine, Gladwell, Power by Phyllis M. Virgil

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Continue the Exploration

Take a Spirit of Inquiry & Attitude of Discovery

• Genuine desire to understand

• Suspend your judgments. assumptions and conclusions

• Search behind statements and positions

• Dig deeper, play detective

• Probe to discover meaning


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Elicit Insights (not answers)

� Be present

� In the moment

� Forget your preconceptions

� Be a blank slate

� Feel way to findings

� Ask for permission

� Trust and test your intuition

� Maintain detachment

� Elicit and offer insight

Adapted from Blink - The Power of Thinking Without Thinking by Malcolm Gladwell by Phyllis M. Virgilo

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Use The Power of Blink

Blink: The Power of Thinking Without Thinking,

by Malcolm Gladwell

� Rapid cognition operates very effectively:

1. First meet a person/situation

2. Times of crisis and quick decisions making

3. Complex situations…

� Silent mental valet

� Occurs in an instant

� Skill that can be developed

Source: Blink - The Power of Thinking Without Thinking by Malcolm Gladwell

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Round Three Practice (10-20 minutes)

Continue your coaching conversation: • Choose the right attitude• Send the right signals• Get them talking

• Keep them talking

• Gather the story • Continue the exploration• Elicit their insights, offer yours

5 minute coaching round then switch roles client/coach

Adapted from Boothman, Levine, Gladwell, by Phyllis M. Virgil

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Coaching to learn requires a shift...

From: “How do I get

this person, this

team to do xyz?”

To: “How do I help this person or team discover

their own way and their

own solutions

Source: Jane Taylor

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This means an effective Coach…

�Asks questions

�Stimulates the imagination

�Challenges ways of thinking

�Validates and supports

�Shows patience and compassion

�Helps their client discover their own solutions, develop their own plans and put them into action

Source: Jane Taylor

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A Final Thought

There is nothing as rewarding as watching your client

(team/leader) wake up to their own insights and

answers...

Conversation with John S. Dowd

on the art of coaching

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Reflections

� What insights did you get from this exercise?

� What hit you most powerfully about your coaches help?

� What might you take home or do differently now?


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Appreciate, Adjourn

� What words of gratitude would you like to share

with your coach?


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Appendices

A. Coaching Skill Sets

B. Coaching Tips

C. How can a coach help?

D. Why this Matters

E. Emotional Intelligence (EI)

F. Approaches to Improvement

G. The Importance of Story

H. Elicit Definition

I. Additional Resources

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Personal CompetenceSelf-Awareness; emotional awareness

accurate self assessmentself-confidence

Self-Regulation: self controltrustworthinessconscientiousnessadaptabilityinnovation

Self-Motivation: achievement drivecommitmentinitiativeoptimism

Social CompetenceSocial Awareness: empathy; serviced

developing othersleveraging diversitypolitical awareness

Social Skills: influence communicationleadershipchange catalystconflict managementbuilding bondscollaboration and cooperationteam capabilities

Appendix ACoaching Skill Sets

• Evaluate yourself in light of these characteristics.

• Which areas do you do well?

• Which areas do you need to work on?

Adapted From: Daniel Goleman, Emotional Intelligence, 1995.

Appendix B

Coaching Tips

√ Articulate: succinctly describe what is going on; share observations without judgment

√ Clarify: Here’s what I’m hearing. . . . Is that right?

√ Acknowledge: strengths and weaknesses

√ Show curiosity: “I wonder . . .” leads to discovery

√ Help team gather information: What topics will you include in the report? What data would help us understand more?

√ Help team develop accountability: What will you do? When will you do it? And, how will we know?

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Appendix C

How can a coach help?

� Coach helps the team or leader identify issues, barriers, struggles, areas

to understand, test and improve

� Once identified - these issues are the focus of team meetings and follow up

� Listen first —don’t offer own valuable experience, when need to - ask permission

� Ask penetrating questions

� Reflect back and then ask, “is this the case?”� Avoid the temptation to:

� Share your story - unless you are asked

� Give advice - unless you are advising

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Appendix DEmotional Intelligence- Why it Matters

� 50% of work satisfaction is determined by the relationship a worker has with… his/her boss.

�Emotional Intelligence (EI) is a prerequisite for effective leadership across disciplines.

�EI requires a high level of self-mastery and people skills; ability to put yourself into the positions of others.


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• Signals of Lower EI• All or nothing thinking

• Overgeneralization

• Excessive worrying

• Worrying as magical thinking

• Disqualifying the position

• Jumping to negative conclusions

• “Should” statements

• Labeling & mislabeling

• Personalization

• Stonewalling

• Criticism; contempt

Appendix EEmotional Intelligence (EI)

• Develop EI by:• Take time for mindfulness

• Be “present

• Recognize and name emotions

• ID the causes of feelings

• Differentiate having the emotion and doing something about it

• Learn optimism to challenge distortion - Martin Seligman

• Learn distraction techniques

• Listen to voice of experience

• Develop Listening skills


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Consultant Mentor Coach

• ‘Expert’ view• Tells you what to do

• Developmental view• Mentor shows

• Results view• Coach asks

questions

• Looks backwards on the data to make conclusions

• Where are you right now?

• No firm action plan

• Forward looking only

• Client does the work based on the ‘expert’ advice

• Client observes• Discusses issues

and topics• Process is

developmental

• Client acts and reflects

• Action orientation• PDSA testing• Coach holds client

accountable

Source: Jane Taylor

Appendix F

Approaches to Improvement

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Appendix G

The Importance of Story

When we haven’t the time to Listen to each other’s story, we seek out experts to teach us how to live… The less time we spend together at the kitchen table, the more how to books appear… Because we have stopped listening to each other, we may even have forgotten how to listen, and stopped learning how to recognize meaning.

Levine, Getting to Resolution

Levine, Getting to Resolution

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Appendix H

Elicit Definition

• evoke or draw out (a response, answer, or fact) from someone in reaction to one's own actions or questions.

• draw forth (something that is latent or potential) into existence.

• synonyms: obtain, draw out, extract, bring out, evoke, call forth, bring forth, induce, prompt, generate, engender, trigger, provoke;

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Appendix I

Additional References

� Immunity to Change. Robert Kegan, Lisa Lahey.

� Emotional Intelligence. Daniel Goldman

� Social Intelligence. Daniel Goldman

� Learned Optimism. Martin Seligman

� Co-active Coaching. Laura Whitworth, Karen Kimsey-House

� Executive Coaching with Backbone & Heart. Mary Beth O’Neill

� Robert Putnam’s dissertation (Harvard)

� Action Inquiry: The Secret of Timely and Transforming. William Torbert

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Break

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Developing Change Ideas: Change PackagesWilliam Peters

Improvement Coach Professional Development Program

Wave 2, Workshop 2


Question 3 of the Model for Improvement

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

PlanAct

DoStudy

Source: Associates for Process Improvement

Here we are looking at a set of changes “pre-packaged” for ease of

use and rapid effectiveness:

CHANGE PACKAGES

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Question 3 of the Model for Improvement

• A collection of good ideas ready for use

• Tests of change, known to bring about improvement

• Proved ideas

• Based in research (might include level of evidence)

• Clinical guidelines

• Experience

• Usually organized around a

model or framework

• Where do they come from?

W h a t a re w e try ing toa cc o m plish?

H ow w ill w e k n o w th a t ac ha n g e is an im p rov e m e n t?

W h a t c h an g e c an w e m ak e th a tw ill re su lt in im p ro v e m e n t?

M o del fo r Im provem ent

P lanA ct

D oS tud y

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The lifecycle of testing changes44

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How we come up with changes45

Packaging Effective Changes

Change Package- Change 1 - Change 2 - Change 3- Change 4- Change x …

How we come up with changes, cont’d

• It is the ideas that lead to improvement that are singled out to be incorporated into a “Change Package”

• Changes that lead to improvement after implementation are the kind of changes we need to think about spreading!

• Rapid Response Teams, or Early Warning Systems, I’ve seen as some of the most effective

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Some well known change packages

• RRT, or Rapid Response Teams

• QEWS, or “Qatar Early Warning System”

• VAP, or Ventilated Associated Pneumonia

• CLABSI, or Central Line Associated Bloodborn…

• Pressure Ulcer Prevention Bundle

• VTE High Risk Bundle

• Any one have one they know about?

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Example 1: The Package48

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Example 1: The Breakdown49

Example 1: Let’s dive in one50

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Example 1: Detail51

Example 1: Measurement Detail52

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Example 2: The Package53

Example 2: The Breakdown54

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Example 2: Let’s dive in one55

Example 2: Detail56

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Example 2: Measurement Detail57

Summary

• Not a “one size fits all” mentality

• Only package and spread proven ideas

• Your team could be forming one now? Anyone?

• Typical parts of a change package:– Driver Diagram detailing change package overview

– Table detailing each of the individual parts

– Table operationally defining the measures needed

• The completed product should be able to be implemented by a 3rd party with limited input, it’s almost a “standalone” product

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Breakouts

Lunch

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The Visual Display of DataWilliam Peters

Improvement Coach Professional Development

ProgramWave 2, Workshop 2


Why graphical displays of data?

Data Set 1 Data Set 2 Data Set 3 Data Set 4

X Y X Y X Y X Y

10.00 8.04 10.00 9.14 10.00 7.46 8.00 6.58

8.00 6.95 8.00 8.14 8.00 6.77 8.00 5.76

13.00 7.58 13.00 8.74 13.00 12.74 8.00 7.71

9.00 8.81 9.00 8.77 9.00 7.11 8.00 8.84

11.00 8.33 11.00 9.26 11.00 7.81 8.00 8.47

14.00 9.96 14.00 8.10 14.00 8.84 8.00 7.04

6.00 7.24 6.00 6.13 6.00 6.08 8.00 5.25

4.00 4.26 4.00 3.10 4.00 5.39 19.00 12.50

12.00 10.84 12.00 9.13 12.00 8.15 8.00 5.56

7.00 4.82 7.00 7.26 7.00 6.42 8.00 7.91

5.00 5.68 5.00 4.74 5.00 5.73 8.00 6.89

Average

9.0

Average

7.5

Average

9.0

Average

7.5

Average

9.0

Average

7.5

Average

9.0

Average

7.5

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Statistical summary of four data sets

• Each data set has 11 data points for variables X and Y

• Each data set has the same averages for the Xs (9.0) for the and Ys (7.5)

• Each data set has the same correlation coefficient for X and Y (r = .86)

• Each data set has the same least squares regression equation ( Y = 3.0 + .5X with r2 = .667 and the standard error = 1.24)

So, do you conclude that the four data sets are the same

or different?

They all produce the same results.

Look at the scatterplots produced by these four data sets on the next page.

What conclusions do you make now?

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Scatter plots of Anscombe’s four data sets

Scatterplot for Data Set 1

0

5

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X values

Y v

alu

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X values

Y v

lau

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Scatterplot for data Set 4

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Five basic types of data display

Plot data over time

Plot data showing a distribution

Plot data showing relationships

Plot data as locations

Plot data showing multiple measures

What graphic tools are associated with each type of data display listed above?

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• Overall Objective of a chart or graph: To communicate information about the issue of interest while minimizing the amount of ink and white space on the chart!

• Chart titles

• 1st line of title: Organization• 2nd line of title: name of the specific measure (e.g., Inpatient Falls Rate)

• 3rd line of title: date of data sequence shown on the chart (e.g., 2016/01 – 2016/12)

• Clearly label the X and Y axes (clear wording as well as appropriate font size)

• Scale the Y axis to allow for future data points and don’t rely on auto scaling

• Avoid vertical and horizontal grid lines on charts, especially on control charts (sometimes grid lines help for reference on scatter diagrams but grid lines need to be lighter than other

axes)

• When presenting percent or rate charts it is helpful to show the numerators and

denominators in a data table on the top or bottom of the chart

• If you are going to show the raw data on each point on the chart make sure that it does not

make the chart confusing and too busy

• If a control chart is being made make sure to identify the type of chart, CL and UCL/LCL

• Annotate the charts to show changes and when they were implemented

• Partition the control chart (i.e., freeze the control limits) to show changes

Checklist for Making Good Graphics

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Edward R. Tufte

• “The Leonardo da Vinci of

data” –New York Times

• Professor Emeritus at Yale

• Author and publisher of

7 books

• Received 40 awards for

content and design

• Provides practical design principles for graphical excellence

“The least ink to present the greatest amount of information in the smallest space.”

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Prince George Regional Hospital

Surgury and IMU Arrests

Surgery

IM U

Total

XYZ

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Time on Diversion

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Example: CMS/HQA Core Measures

(Perfect Care Bundles – all aspects of a bundle must be met in order to receive credit)

Better than or Equal to State Average

Worse than State Average

Legend

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#1: Reported “Patient/Visitor/Other” Incidents

4th Quarter - October 1, 2005 – December 31, 2005 Total Incidents = 2301st Quarter – January 1, 2006 - March 31, 2006 Total incident = 331

0

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4th Q 2005 46 49 32 9 17

1st Q 2006 69 56 40 32 8

Fall Delay in Treatment Pollicy ProcessHospital Acquired Pressure

UlcersEquipment Failure

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Tufte’s classic works

The Visual Display of Quantitative Information. Graphics Press, Cheshire, CT, 1983.

Envisioning Information. Graphics Press, Cheshire, CT, 1990.

Visual Explanations. Graphics Press, Cheshire, CT, 1997.

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This graphic shows six variables simultaneously: the size of the army, its location on a two-

dimensional surface, direction of the army’s movement, and temperature on various dates during

the retreat from Moscow.

422,000 men started the journey to Moscow

10,000 men made it back to Poland

From: The Visual Display of Quantitative Information by E. Tufte, Graphic Press, Cheshire, CT, 1983, page 40.

IH: 23-4

Tufte (page 40)

concludes that this map “may well be

the best statistical

graphic ever

drawn.”

Charles Joseph Minard’s dramatic account of Napoleon's Russian

campaign of 1812 (drawn in 1861)

100,000 men arrived in

Moscow

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In September of 1854 Dr. John Snow used a dot (or location) map to plot the location of deaths due to

cholera in central London. The red dots indicate the location of water

pumps. The black bars indicate the

total number of deaths in the area. Snow observed that the deaths due to cholera occurred primarily around

the Broad Street water pump. He had the handle of the contaminated

pump removed thus ending the cholera epidemic that claimed over

500 lives.

Broad Street neighborhood

From: Visual and Statistical Thinking: Displays of Evidence for Making Decisions by E. Tufte, Graphic Press, Cheshire,

CT, 1997.

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Graphical Excellence Summarized

� Substance and integrity• Provide important information, never mislead by way we scale,

sample, frequency

� Statistics

� Design principles• use the least ink to present the greatest amount of

information in the smallest space

� First and foremost: visual displays of data (i.e. run chart) are there to learn from, not talk about!

� On run charts, include the op-def and a SME interpretation

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Practical strategies for managing successful improvement projectsImprovement Coach Professional Development Program

Workshop 2, Day 2

October 26, 2016

Karen Baldoza

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Session objectives

• Compare and contrast project management and improvement project management

• Summarize six principles for more effective management of improvement projects to accelerate your efforts

• Identify a few tools, including aspects of coaching, that will help your teams better manage improvement projects

• Apply two of these principles to strengthen your team’s improvement work

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Session agenda

Topic Time

Overview 5 minutes

1 – Frontload the work

2 – Create and keep pace3 – Make it easy

Exercise

20 minutes

4 – Build a big tent5 – Focus on learning, not perfection

Exercise

15 minutes

6 – Build a portfolio of projects 5 minutes

Wrap up 5 minutes

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\

PROJECT

MANAGEMENT

QUALITY

IMPROVEMENT

MANAGING

IMPROVEMENT

PROJECTS

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Managing Quality Improvement Projects Is Different

Difference Implication

Improvement project is rarely a full-time job for team leader or team

• Link improvement to day-to-day work• Build into existing work and meetings • Keep improvement front and center• Team may not be formally trained in methods• Create and keep the pace

How is known, but what (i.e., actions) depend on learning

• Deliverable is a completed charter and progress towards your aim, rather than a concrete document or product

• Need frequent touch points to assess learning and map work

Progress is harder to see due to delays between activity and

movement in your data

• Create ways to see progress before data reflects it• Manage team to keep energy high

• Document process of learning• Requires a sound theory for change

Encourage failure, not mitigate against it

• Celebrate early failures• Encourage honest reflection and unexpected outcomes

• Step-down to learn quickly• Test at the scale appropriate to the risk

Everything is a moving target and a learning process

• Everything is in pencil• Keep theory front and center AND don’t be afraid to change it• Perfect is the enemy of the good

Project is never actually done (always more to improve or

sustain) and pace is faster

• Frontload the work• Select an end point (vs. end point being a deliverable)

• Focus on sustainability at the outset

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Pre-requisites

• Strong foundation in quality improvement methods

• Multi-disciplinary team

• Project selection process to identify meaningful improvement opportunities

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Six practical strategies

1. Frontload the work

2. Create and keep pace

3. Make it easy

4. Build a big tent

5. Focus on learning, not perfection

6. Build a portfolio of projects

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Frontload the work83

Time

Am

ount of

Work

Progress

curve

“If I had an hour to solve a problem I'd spend 55 minutes thinking about

the problem and 5 minutes thinking about solutions.”

- Albert Einstein

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First six weeks 85

Frontload the work: Practical tips

• Block time at the beginning:– Your calendar to manage the upfront work

– Your executive sponsor meeting (more in the beginning)

– Team meetings and retreat

• Hold a full-day kaizen event, process mapping session, or team retreat to kick-off the work:– Build the team

– Deeply study the process

– Finalize the aim, your theory to achieve the aim, measures, and changes to test

• Communication with team (expectations, opportunities to show progress):– Share “work curve” and “progress curve” with team

– Use a checklist of tasks to show the team progress before you start testing

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Example checklist to “see” progress87

Frontload the work: Practical tips (continued)

• Build the team:– Build team-building activities into the initial meetings, such as giving

individuals an opportunity to share why this work is important or what skills they hope to build

– Allow time for discussion and disagreement; successful teams leverage the various team member’s different views of the system

– Spend time with your sponsor at the beginning of the project to ensure you agree on scope, aim, constraints, and how you’ll work together

• Set deadlines:– Set a date where if the set-up activities are not completed, you’ll

pause the project

– Create a “set-up” phase that is time-limited (e.g., 30 days)

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It’s never too late…to frontload the work

• Revisit any of the set-up activities that need attention

• Ask the team to do observation or interviews to get a team unstuck

• Set-up standing meetings or check-ins (team, sponsor)

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Frontload the Work: Project Set-up Checklist

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Create and keep pace

Predict, create, and keep pace

• Set a start and end date:– Stick to the end date

– Re-charter a team if needed

• Use work planning to help identify the pace of improvement:– Unlike traditional work plans, what you do in the future will

evolve

– Can predict where you’ll be (e.g., testing vs. implementing)

– Predict milestones and expected trajectory

– Always look to pick-up the pace (measures, PDSA)

• Use visuals to communicate and keep pace• Meet frequently – use huddles

• Create 30, 60, 90-day plan for the end of the project

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47

Gantt chart for PDSA cycle ramps

Change IdeaMay June July

4 11 18 25 1 8 15 22 29 6 13 20 27

Include: • Questions/predictions• Who, what, where,

when, how• How will you know?

93

Gantt chart for PDSA cycle ramps -EXAMPLE

Change IdeaMay June

4 11 18 25 1

Proactive Prioritization

Begin week by planning priorities Will identifying my

priorities each week

help me accomplish

critical tasks on time?

W, W, W, W, H

Number of priorities

accomplished

Will need to do

something daily too

– add listing

tomorrow‘s priorities

Make

electro

nic –

put in

calend

ar

Implement

List tomorrow’s top priorities at end of previous day Will identifying my

priorities each day

help me accomplish

critical tasks on

time?

W, W, W, W, H

Number of priorities

accomplished

Will

need

to ID

and

addres

s

barrier

s

Regular Mental and Physical Breaks

Plan two 10-15 minute breaks each work day

Minimize Interruptions

Block off work time in calendar during more

productive hours

Will holding time

in my calendar

help accomplish

critical tasks?

Will need to use

quite room

Try just two days

a week

Check email twice/day

94

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48

Work plan template

Task By

When?

Description Status* Who? Notes

* Status is: Not Started, Started, Underway, Complete

95

Work plan template - EXAMPLE

* Status is: Not Started, Started, Underway, Complete

TopicTask ID Date Added Task By when Description

Status (Start,

Underway,

Done)

Who? Notes

Charter (Aim) 1.1 2/5/2014 Draft PRO Deployment Charter 2/5/2014based on meeting

discussionD KL/IHI

method: cross out when done, see at

a glance finished work

Charter (Aim) 1.2 2/5/2014 Get feedback on draft Soon

Kimberlee will look

over draft 1.0 and

discuss with team

KD shared with Dr. Smith 2/12

Physician and

Staff

Education

2.1 ########Review clinical pathway with clinical staff,

showing how PROs fit in

Patient

Education3.1 ########

Review educational materials and revise

to include information about PROs: why

important, how used, schedule

3/31/2014

Patient

Education3.2 ########

Align written material (handouts) with web

information and verbal communication

Should staff discuss "key points"?

How will we align the verbal

communication with paper and

electronic info?

96

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49

Predicted Date Description of Level

1 – Program Defined January 23. 2015 Work plan with deliverables and expected outcomes defined

for phase I and phase II

2 – Activity but no

changes in practice May 1, 2015

June 30, 2015

In phase I pilot sites, teams have co-designed Always Events

and run at least three PDSA cycles

In phase II pilot sites, pilot sites selected and completed pre-

work

3 – Modest Improvement September 30,

2015

All three pilot sites will have designed a reliable process with

85% process reliability and baseline data on patient experience

50% of participants in the Always Events® Learning Community

will have tested and co-designed an Always Event® and have

begun to improve reliability of implementation

4 – Significant Progress December 31,

2015

80% of participants in the Always Events® Learning Community

will have reliably implemented Always Events® on specified

pilot units

10% improvement in patient experience in both pilot sites and

10 additional teams

5 – Outstanding Success March 31, 2016 50% of participants in the Always Events® Learning Community

will have tested, implemented and sustained strategies for 5x

scale-up

25% improvement in patient experience in both pilot sites and

10 additional teams

97

98

Project

Progress Score

Predicted

Date /

Actual Date

Operational Definition

0.5 - Intent to

participate

Project has been identified, but the charter* has not been completed nor team

formed.

1.0 - Charter

and team

established

A charter has been completed and reviewed. Individuals or teams have been

assigned, but no work has been accomplished.

1.5 - Planning

for the project

has begun

Organization of project structure has begun (e.g., identified what resources or

other support will likely be needed, identified where we will focus first, gathered

tools/materials, developed a meeting schedule).

2.0 - Activity,

but no changes

Initial cycles for team learning have begun (e.g., project planning, measurement,

data collection, obtaining baseline data, study of processes, surveys, etc.). At

least one project measure has been defined and plans made to collect data to

demonstrate improvement. Team has described how much improvement they

expect by February 29, 2016.

2.5 - Changes

tested, but no

improvement

One or more PDSA cycles for testing changes have begun. Cycles must meet at

minimum the 4 + Prediction** criteria for a PDSA. Data for at least one project

measure is displayed in a graph or table with target included.

3.0 - Modest

improvement

Successful tests of change have been completed for at least three changes.

Some small scale implementation has been done. Anecdotal evidence of

improvement exists. Expected results are 20% complete. See Note 1 below.

3.5 -

Improvement

Testing and implementation continue and additional improvement in project

measure(s) towards goal(s) is seen.

4.0 - Significant

improvement

Expected results achieved for major subsystems. Implementation (e.g., training,

communication, etc.) has begun for the project. Project goals are 50% or more

complete. See Note 2 below.

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50

Storyboard

� Most recent team accomplishments and decisions

� Typically organized around MFI

� Educational team advertisement

� Best to keep it simple

� Post in meeting and public areas

Benefits of Using

� Improves communication

� Tracks progress

� Keeps team focused

� Evidence of commitment

� Helps educate new team members

� Sells team to broader audience

Adapted from: John S. Dowd, Consultant in Continuous Improvement

99

Create and keep pace (continued)

• Build in points for reflection (successes AND failures) and celebration at the beginning

• Always question whether you are spending time in the right way– Use team time to make sure you aren’t just following a plan blindly

– Ask yourself, “what is the larger goal that these PDSA cycles are connected to?” “Is this change we are testing likely to move the aim?

– Reflect on the amount of effort going to measuring vs. improving –make sure the former is not more than 15% of the effort.

– Refer back to your theory. As you learn, your theory should change, as should your work and effort

• Quantify your theory numerically; test predictions and track contribution of various efforts to aim

100

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51

Doing the improvement work

Managing the improvement work

Make it easy101

Make it easy: Practical tips

• Leverage existing structures:– Use existing meetings, structures, one-to-one check-ins to do

improvement work

– Look for opportunities to swap existing meetings or work for improvement team time and work

• Keep meetings efficient and action-oriented:– Keep improvement team meetings short by using a standard

agenda that runs through key points

– Use meetings to do work, not just give updates

– Use hard copy PDSA forms or worksheets in team meetings

• Use project management techniques to reduce the “what are we supposed to be doing” time:– Leverage project management capability across the organization

– Identify and track practical next steps

102

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52

Time inventory

Current:• Redoing forms: 1 hour/week• Helping clients understand forms: 1.5 hours/week• General meetings: 3 hours/weekTotal: 5.5 hours/week

Swap:• 30 min redoing forms to run PDSAs• 30 min helping clients to create standard support materials• 1 hour in meetings to develop and manage improvement

projectTotal: 2 hours/week

103

Standard check-in agenda

4) Work through agenda items:

• Updates or changes on any of the charter (if needed):– Aim statement– Driver diagram– Measurement strategy– Portfolio of projects

• Working discussion:– Change ideas – share tests:

– What did you run since we last spoke? What did we learn?

– What will you run in the next two weeks?

– Share new data, review run charts, discuss learning– Translate to work process– Project assessment score

• Sustainability and scale-up (depending on status)

Type updates right into a central place

104

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53

4) Work through agenda items:

A. How easy was this task for you in the last week? (2

mins)

• Very easy, easy, difficult

B. Report out on any tests (5 mins)

• Anyone save a PDSA or data in Dropbox?

C. Review outcome data/measures (10 mins)

D. Project Assessment Tracker (5 mins)

E. Anything else? (5 mins)

27 minutes total

(includes building PDSAs and collecting measures)

This was their

balancing measure –

they collected the data

within two minutes at

the beginning of every

meeting

Example team meeting agenda105

PDSA tracking tool106

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54

Team storybooks

� A storybook is the ongoing historical record of the team's work.

� It belongs to the team.

� It includes meeting agendas, records, data gathered, and any other significant information

� The team leader and/or coach is usually responsible for the maintenance

� Best to update on a weekly basis between team meetings

Benefits

� Team can track progress of its learning, and see efforts of all hard work!

� Enables understanding what has happened in the improvement effort

� Other teams get ideas on how to approach the improvement effort, although no storybook ever provides the "right answer"

� Essential material for developing team reviews and presentations

Source: John S. Dowd, Consultant in Continual Improvement

107

Make it easy: Practical tips

• Make any improvement team meeting the best part of team member’s day

– Start meetings with one good thing– Build in time to share stories about how the work is meaningfully impacting

customers or patients’ lives– Show people “what’s in it for them”– Use fun activities like music and energizers, celebrate success and learning

(especially from failure)

• Identify ways to build a habit:– Use internal deadlines to help individuals with accountability– Meet more frequently for less time– Discuss the “working styles” of your team

• Reflect on how to “make it easy and successful” for the team– Discuss successful and unsuccessful past projects– Allow teams to anticipate barriers; use a force field to surface– Use a “we would” exercise

108

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55

Make it easy: “We would” example

• We don’t have enough time.– Reframe: We would have enough time if…

– Examples:– …we engaged someone in the quality department to help

– …we limited team meetings to 15 minutes per week

– …we moved two other projects to “sustainability” mode

• The respiratory therapists will never go for this.– Reframe: The respiratory therapists would be willing to help if…

– Examples:– …they had a hand in mapping out the new process.

– …we engaged Christina, the thought leader for the group.

– …we really listened to their concerns and co-designed the solution.

– …the intervention takes no more than 5 minutes for them.

109

Your turn

• Think of one of your bigger challenges/barriers

• Use the “We would…” exercise, to see if you can gain some new insights on how to tackle it (3 minutes)– We don’t/can’t__________________

– Reframe: We would ___________________ if…

– …______________________________________

– …______________________________________

– …______________________________________

• We’ll debrief as a group with a couple of examples (2 minutes)

110

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56

111

Build a big tent

~5

100s Scalers: “I’m open to learning from your improvement.”

40s Adopters: “I’m willing to adopt improvements.

10s Stakeholders: “I’m engaged in the improvement effort.”

~5 Doers: “I’m actively driving the improvement efforts.”

Stakeholder analysis and engagement planRole/Dept/

Org/Group

Names of key

representatives

Stop? Let? Help? What matters to them? Engagement

Points or

Approaches

112

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57

Stakeholder analysis and engagement planRole/Dept/

Org/Group

Names of key

representatives

Stop? Let? Help? What matters to them? Engagement

Points or

Approaches

Academia

(early

adopters)

X Educating the next generation of

health care professionals to provide

outstanding patient care in a

changing environment

Engage in the

design of

sustainability

project.

Academia (late

adopters)

X O Educating the next generation of

health care professionals with a

deep understanding of science and

sharing what they have learned

during their tenure

Update after

testing has

begun.

Medical

Students

Associations

X Networking with like-minded

students and providing value to

members; being on the cutting edge

Engage in the

design of

sustainability

project.

Nursing

Students

Associations



members.

Engage in the

design of

sustainability

project.

Pharmacy

Student

Associations



members.

Engage in the

design of

sustainability

project.

Boards X Ensuring boarded members will be

good practitioners.

Keep updated,

as needed

X = Where I think they are now; O = Where I need them to be for this work to be successful

113

114Engagement and “share the work” strategies

~5

100s Scalers

40s Adopters

10s Stakeholders

~5 Doers:

• Ensure you have the right team

• Assign leads for drivers, activities, key docs (e.g., measurement, PDSA ramps)

• Decide upfront how you’re going to make decisions

• Build improvement capability

(a lot of what we covered in Workshop 1!)

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58

115

~10 Stakeholders:

• Put your sponsor to work

• Ensure all appropriate stakeholders are represented on team

• Engage “historians”

~5

100s Scalers

40s Adopters

10s Stakeholders

Engagement and “share the work” strategies

Put your sponsor to work

• Schedule regular check-ins with your sponsor – at least twice monthly – to review progress. – Consider keeping the meetings brief (i.e., 25 minutes) and focused.

– Send an agenda, your latest storyboard, and any questions or background information beforehand.

– Tip: To avoid scheduling another meeting, consider inviting your sponsor to a team meeting or a coaching session.

• In those meetings, you may:– Jointly design PDSA cycles

– Discuss barriers and how you might overcome them

– Get answers to questions the team needs to take the next step

– Prioritize change ideas to test

• Share your progress with your sponsor via email each time you update it (approximately every other week) to keep them updated

116

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59

Put your sponsor to work

• Leverage your sponsor’s improvement science expertise to help with aim setting, driver diagram development, measurement, developing tests of change, etc.

• Think of the sponsor as a team member; engage them in problem solving, brainstorming, and testing.

• Ask your sponsor for ideas on benchmarking inside and outside your organization.

• Use your sponsor to identify strategic linkages across the organization (e.g., past and current efforts).

• Ask your sponsor to connect with other organizational leaders to understand their ideas or thoughts about how to improve.

• Begin early conversations about implementation and spread; engage them in thinking through what happens to this work at the end of project.

117

118

~ 40 Adopters:

• Create visual displays that pique curiosity

• Ask a diverse set of individuals to help with or

shadow PDSAs, provide comments

• Identify and tell compelling stories (hearts and minds)

• Ask potential adopters to predict “why this won’t work”

~5

100s Scalers

40s Adopters

10s Stakeholders


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60

119

~ 100s Scalers:

• Invite future scalers to shadow

• Communicate eight times, eight ways

• Tell stories of failures and successes

~5

100s Scalers

40s Adopters

10s Stakeholders


Getting the right team

• If you can’t engage a key stakeholder (especially “stop” partner), consider the impact on the success of the project

• Options:

– Change the team

– Identify “consultants”

– Re-scope the project

– Use your sponsor

120

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61

Focus on learning, not perfection

“The best time to answer the

three questions in the Model for

Improvement is at the end of the

project.”- Kevin Little, PhD

122

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62

Don’t let perfect be the enemy of good

• An incorrect theory gives you more learning than no theory at all

• People are more willing to give ideas when the product is less “final”

• Don’t laminate; aim, drivers, measures, etc. These will change throughout the course of the project!

• Step-down to learn quickly (e.g., can you go from weekly to daily?), manage trade-offs

123

Joy at work: One of three measures124

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63

Internal clarity measure

Leigh.m4a

Listen to one recording here

125

126

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64

Your turn

• What might you be able to “step down” (e.g., with measurement, testing, etc.)?

• Discuss with a partner

• We’ll debrief as a group with a couple of examples

127

Build a portfolio of projects

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65

Using a driver diagram to build a portfolio of projects

Primary Driver

Who is working in your

community now to make

this driver strong?

Mark with an asterisk (*) those

getting paid to do make the

driver strong

How strong is the driver right

now? How do you know?

129

130

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66

Doing a portfolio inventory

Projects Driver 1 Driver 2 Driver 3 Driver 4

Project 1 X

Project 2 X X

Project 3 X

Project 4 X

Project 5 X X

131

Energy grid132

Project Focus Areas(name focus areas)

Regions(name

regions)

BCG/Events/OS MarComm New Business

Finance Engineering (IS & IT)

Innovation R&E HR(incl D&I and

Wellness)

Faculty

Decreasing Refunds and Cancellations for Events and Memberships

o X (CSI)

X

Equity Measurement in Project Teams

o o o o X X

Project Design Process

X X X X X(resourcing

)

X

Energy Grid (draft)X = Primary resource for this projecto = Secondary resource for this project

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Scoping

• Relates to the portfolio of projects

• Part of predicting and planning pace

• Be realistic – test, learn, review with sponsor

133

Resources

• Five Practical Strategies for Managing Successful Improvement Projects– WIHI broadcast at:

http://www.ihi.org/resources/Pages/AudioandVideo/WIHI_Strategies_for_Managing_Quality_Improvement_Projects.aspx

– Blog post at: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=279

Include video and tips sheet

134

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Questions?Key take-aways?

135

Day 2 debrief and assignmentsImprovement Coach Professional Development Program

Workshop 2, Day 2

October 26, 2016

Karen Baldoza

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