"Moving off of the status quo takes leaders who can inspire others to take action," says Julie Kliger, MPA, BSN, RN, founder and principal of The Altos Group. This statement is not a simple adage; it is a lesson learned from direct experience. From 2008 to 2010, Ms. Kliger led a nine-hospital collaborative that reduced sepsis mortality by more than 50 percent, a study featured on the Agency for Healthcare Research and Quality's Innovations Exchange.
"Even when the level of 'pain' (e.g., high levels of sepsis mortality, long wait times to see specialists) is high in an organization, people do not intuitively know how to organize to create change and implement improvements," she says. Here, she shares nine critical leadership behaviors exhibited by individuals and organizations committed to healthcare quality improvement, developed by The Altos Group.
1. Setting a vision and goals. "Leaders need to understand the importance of setting a common vision and cluster of goals that all key stakeholders can embrace — and be held accountable for," she says.
2. Communicating strategically for commitment. Once quality improvement leaders establish a vision, they need to communicate the vision to physicians and staff to gain buy-in. "Leaders need to frame the need for change in language that appeals to the values of the organization," Ms. Kliger says. For example, leaders at hospitals should discuss the initiative's potential benefit to patient care to appeal to physicians and other clinicians. While there may be an economic benefit, focusing on how it supports the organization's mission may be a more effective persuader, according to Ms. Kliger.
3. Creating an environment that encourages constructive accountability and constructive conflict. Constructive accountability is shared aims that define success, uniting disparate groups under a common goal. "In order to achieve excellence, which is a combination of reliability and performing against established evidence, you need to have individual providers understand how they are linked and aligned to the larger organization's mission, goals and outcomes," Ms. Kliger says. A physician alignment model is important but in itself is not sufficient for creating constructive accountability. Clearly articulated job descriptions or obligations (for non-employed physicians) and incentives and disincentives are tools leaders can use to tie individuals to the organization's broader goals.
In contrast with constructive accountability, constructive conflict is a process in which two or more people or groups discuss their needs and differences of opinion and eventually develop a solution. "In general, we don't have a culture of feeling comfortable discussing opportunities for improvement, especially when it comes to the way relationships can be managed," Ms. Kliger says. "The more we normalize the idea that we can have respectful conversations about different opinions, we can come to a shared understanding of how to tackle common problems."
4. Removing barriers to success. Leaders must seek opportunities to remove barriers to success and provide physicians with tools necessary to achieve goals. For example, leaders of a hand hygiene initiative should ensure there are sufficient and staff-approved alcohol sanitizers, soap and other necessary products.
5. Coaching (versus telling). Leaders' purpose is not to do the change all themselves, but to inspire and empower others to enact a change. To effectively motivate others to improve quality, give front-line workers the authority to implement new processes. "When front-line physicians and nurses are nurtured to think for themselves and build their skills at bringing about change (e.g., [Plan, Do, Study, Act] cycles of learning), leaders multiply their ability to create change," Ms. Kliger says.
6. Celebrating success and failures. Realize that celebrating failure is just as important, and often more so, than celebrating success, Ms. Kliger suggests. "Celebrating and embracing failures lets others within the organization know they can seek the best ways to improve care, even if every effort does not work out," she says. "Being able to creatively try new approaches to care delivery must live within a culture that normalizes 'failures.'"
Normalizing failure is at the core of small tests of change, such as PDSA cycles. Quality improvement leaders need to acknowledge and communicate to their teams that failure is not just acceptable, but that it is inevitable and even valuable for teaching lessons about people and processes. "It's [useful] to understand what works and what didn't, because the organization documents what doesn't work so it doesn't waste time in the future," Ms. Kliger says.
7. Earn the trust. Quality improvement leaders need to earn the trust of physicians and staff members to create a strong relationship that will withstand the trials and triumphs of improvement efforts.
8. Working from self-awareness. "Successful leaders develop emotional intelligence and are aware of how their words and actions empower or disable others," Ms. Kliger says.
9. Working with and through others. Successful quality improvement requires routine collaboration among leaders and front-line workers. Taking a team approach to improvement brings multiple perspectives that can help spark creative solutions.
Julie Kliger can be contacted at julie@thealtosgroup.com.
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