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Leading Change – Cincinnati Children’s Hospital

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1. The complexity of patient care and prevalence of system failures led to firefighting: • Delivering patient care in a hospital setting presented numerous complications and led to chronic system failures. Additionally, the intricacy of delivering sound patient care grew increasingly more difficult because several caregivers were involved in developing and executing a patient’s treatment plan. Often times most caregivers provided care for multiple patients at the same time, which required constant triage of the patient’s status.

Physicians were kept under constant pressure, which inhibited them from participating in process improvements when they recognized issues.

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This lead to physicians patching problems instead of finding long-term solutions. To this point, the head of their radiology department commented saying, “We have very talented physicians, but a system that is broken and full of workarounds. We think we need to fix the system. ” Inconsistent use of known best practices for patient care: • System and structures that were being routinely followed did not support evidence-based medicine.

Despite the hospital’s emphasis on medical research to discover new treatments, their philosophy was rooted in historical-based practices, rather than proven techniques. This system and mindset led to an inconsistent use of the known best practices for current patients. As an example, the intensive care units at CCHMC were often filled because primary care physicians referred patients that had bronchiolitis for extensive respiratory treatments, when the most effective treatments could be administered in the primary care physician’s office and patient homes.

Saw inefficiencies as a revenue source, which limited ability to see the need for change: • CCHMC used antiquated and inefficient historical-based philosophy as an avenue to increase revenue. Physicians were reluctant to alter protocols because they feared losing the profit margin that was being made using their current treatment strategy. Not everyone shared the vision for evidence-based medicine, case in point, the chief financial officer and Sr.

VP of Finance, Scott Hamlin, recalled an instance when he was confronted about the liver transplant protocol. When Dr. Uma Kotagal informed him that the current protocol was not scientifically proven to impact outcomes for patients, his response was “We make a margin on every one of those treatments you want to discontinue. Your plan would reduce the amount of money we make on liver transplants. ” In effect, CCHMC saw their inefficiencies as a path to grow their bottom line.

The absence of KPIs, the inability to monitor and trend outcomes, and the lack of transparency resulted in false assumptions about performance: • Like most institutions, CCHMC and its physicians believed themselves to be among the best hospitals in the country, despite the lack of statistical data or benchmark. CEO, Jim Anderson, recalled an instance in which he was speaking with an experienced physician and had to reiterate the researched data multiple times before the physician accepted the current method they use to treat patients was yielding poor outcomes.

The physician said “We have been wrong. ” The lack of transparency with regard to performance and patient outcomes hindered the foresight for improvements within CCHMC. 2. Workarounds deferred long lasting improvements and reflected a firefighting culture: • Dr Uma Kotagal knew that to pursue systematic and proactive solutions, the culture of implementing patches had to be eliminated or minimized. Workarounds were symptomatic of the firefighting mode of operation, wherein efforts diverted on short term urgent fixes took time away from the long term development of innovative new processes.

For instance, Dr. Kotagal realized that urgency trumped importance and that the CCHMC team focused on solving short term issues when a clinician asked her: “What do you want me to do, take care of patients or do improvements? ” Issue backlog degraded performance, increased costs and decreased revenue: • The chronic firefighting workarounds failed to eliminate recurring problems and yielded an ever increasing backlog of issues; this consumed CCHMC resources unnecessarily and increased costs as it yielded poor quality of patient care.

For example, the CCHMC Cystic Fibrosis (CF) patients’ lung functioning was only at 20th percentile, and, in 2005, serious safety events were measured at one event per 1000 adjusted patients. In a hospital setting this could be life threatening to patients, or yield malpractice lawsuits, driving up costs. Inefficiencies yielded “patient placement problems” and recommendations for “more ICU beds” or “operating rooms (OR)” at a cost of “$2. 5 to $3 million to build a standard OR” or “$200 M to build 50 or 80 new beds”.

Inefficient systems led to inconsistent quality of care: Process workarounds often were person and situation dependent, yielded incomplete solutions to fundamental problems, and produced inconsistent levels of patient care. They contributed to the hospital’s inability to accurately monitor quality of service as well as consistently repeat performance. As workarounds relied on the hospital staff’s individual knowledge and failed to transfer knowledge from person to person and from department to department increasing individual burnout leading to compromising the quality of service.

By ignoring the need for communication and cooperation, workarounds failed to establish CCHMC best practices and improve process reliability, and resulted in negative patient outcome. 3. Stage 1: Establish a sense of urgency Examining market and competitive realities • CCHMC competed for and secured a $1. 9 million Robert Wood Johnson Foundation grant, which created a sense of urgency in regards to design, implementation, and measurement of the organization’s improvement projects. Identifying and discussing crises, potential crises, or major opportunities • CCHMC examined competitive realities and identified a ajor opportunity by compiling the CFF data and showing the physicians that they had been significantly underperforming compared to other CF centers. The data convinced CF doctors that the results from the status quo were worse than the unknown results of the new plan. Stage 2: Form a powerful guiding coalition Assembling a group with enough power to lead the change effort • CEO, the hiring of Lee Anderson and Chairman of the Board, Lee Carter championed change in positions of power and influence. • Dr. Kotagal led the hospital’s need for change and improvement efforts.

Her appointment satisfies the Kotter model’s requirement of a “senior line-manager” being represented in the change coalition. Encouraging the group to work together as a team • Kotagal facilitated the coalition and consolidated her team by taking 5 physicians and 1 nursing leader to Intermountain Hospital’s four-week-long improvement science training. • CCHMC encouraged work outside of the normal hierarchy by incorporating senior nurses into early vision-setting brainstorming sessions with senior physicians and trustees or by including parents into the CF improvement team.

Stage 3: Create a vision Creating a vision to help direct the change effort • In stating, “CCHMC would be the leader in improving children’s health” and “We will be the best at getting better,” Lee Carter articulated a simple concrete vision that guided others’ behavior and decision making throughout the change effort. [pic] This CCHMC vision and values are clearly defined. • Jim Anderson and his team led the formal development of both the vision and its strategic plans and developed scorecards to measure delivery system and patient care. Developing strategies for achieving that vision • Dr.

Kotagal’s team training to learn the science of improvement. • Learning and implementing best practices from other top performing hospitals (e. g. , Minnesota) • Creating processes supporting a culture of improvement to sustain the gains (e. g. , I2S2) • Standard of perfection (i. e. , zero safety events) to define constant need for improvement until perfection has been attained. Stage 4: Communicate the Vision Teaching new behaviors by the example of the guiding coalition • The guiding coalition “walked the talk” by teaching a clear goal of zero safety events while not mentioning money.

This served to teach through example and allowed caregivers to make the appropriate decisions on a daily basis. Using every vehicle possible to communicate the new vision and strategies • Performance Metrics were published both internally (e. g. , in the hospital hallways) and externally (e. g. , on the hospital’s website). These performance indicators illustrated the hospital’s progress in execution of strategies supporting the vision. • CCHMC connected employees’ incentive plans to the desired improvement goals as reinforcement.

CCHMC used continuing conversation and engagement through the year on employee’s progress against goals. • Jim Anderson met with ALL new employees during orientation to review a brochure which relayed CCHMC’s vision and connected the importance of their job to it. Stage 5: Empower others to act on the vision Encouraging risk taking and nontraditional ideas, activities, and actions • I2S2 was a non-traditional program which: o Empowered others to act through training to identify and test methods for change and improvement. Encouraged risk taking on things that might fail, but yield some learning in the process (e. g. , creation of their own improvement process during the course) o Developed those that could lead improvement in their respective departments after graduation. • The leadership encouraged the respiratory therapy clinical managers to take ownership of the improvement process through their expertise. A turning point occurred when the clinical managers asserted themselves and the doctors relinquished control of the process.

The management team embraced the non-traditional idea of incorporating patients’ parents into the CF improvement team. As result, parents were empowered to directly benefit the program, as seen in revision of the language which described patient conditions. Changing systems or structures that seriously undermine the vision • Dr. Kotagal was also allowed to ignore reluctant leaders and empowered to work with those “lower in the hierarchy who were passionate about transforming patient care. • In the follow-up article, Anderson indicates through his statements that he was keen on removing others who were not engaged in the change effort. Stage 6: Planning for and creating short-term wins Planning for visible performance improvements, creating those improvements • Through development of scorecards and obtaining of baseline metrics from the CFF, CCHMC gained ability to measure progress towards short- and long-term goals which enabled planning for visible performance improvements.

• In effort to advance larger goals (e. g. CF lung function and BMI targets), CCHMC identified small areas where they could achieve quick wins. Examples: o Advancing all CF patients with Level 1 nutritional status to the next level before targeting other risk categories o Focusing on the daily techniques performed by patients to improve lung functioning. Specifically, targeting effectiveness of equipment. o Providing carts to help patients in transport of belongings in and out of the hospital o Improving processes associated with CF patient visits through creation of preliminary chart reviews, checklists, and written treatment plans.

Evidence of performance progress was shared in public forums, such as posting of charts in hallways outside the units and publishing all 385 performance measures online. Recognizing and rewarding employees involved in the improvements • As result of Dr. Kotagal’s success with evidence-based medicine, she was tapped by Jim Anderson to lead CCHMC’s improvement efforts. Stage 7: Consolidate improvements and produce more change Using increased credibility to change systems, structures, and policies that don’t fit the vision • Dr. Kotagal used staff that bought into the overall vision regardless of their position in the hospital hierarchy.

Often, she would ignore noncommittal division directors in favor of clinician leaders who were more inclined to affect change. Hiring, promoting, and developing employees who can implement the vision • Hiring of CF parent team member Tracey Blackwelder, the QICs, and “several analysts” Reinvigorate the process with new projects, themes, and change agents • The hospital’s creation of the Quality and Transformation Department and its sustained efforts to Quality Improvement continued the push for improvement after the “Pursuing Perfection” grant had ended. The I2S2 Training was used for championing of the vision and training of more staff to buy-in and implement the vision. The I2S2 training also served to energize a new group of hospital staff and create new change agents to continue the hospitals continuous improvement projects. Stage 8: Institutionalize new approaches Articulating the connections between the new behaviors and corporate success • Goal of Zero changed the way the staff thought about acceptable performance and reinforced a culture of continuous improvement.

The pursuit of the Goal of Zero would also improve the hospital performance and daily results. • CFO Scott Hamlin’s comments regarding the “Do the right thing for kids” model connected CCHMC’s profitability to improved quality of service and process. Developing the means to ensure leadership development and succession • CCHMC’s instilled continuous improvement into the culture through programs like I2S2 and provided for development of potential leaders who were consistent with its values. 4. The Self-Efficacy Theory – Dr.

Kotagal wanted to use small initial successes such as the Cystic Fibrosis Center (CFC) performance improvement to build self-efficacy among the clinical staff. For instance, posting performance metrics online and in the hospital hallways helped for the CFC personnel build their progressive mastery and believe that they had the required skills to succeed at improving the CCHMC system and quality of care. The small wins also acted as modeling experience for other departments’ personnel who witnessed success by identifiable peers.

The A-B-C Performance Management Theory – Small wins created Positive, Immediate and Certain (PIC) consequences for each staff member, such as lowering firefighting and stress level, or improving morale (see empathy box below). They acted as positive reinforcement for the desired behaviors that supported the CCHMC vision of improvement and transparency, and showed personnel that suggesting and supporting rapid and incremental small process changes made their work more effective, efficient, and rewarding. |Positive |Negative | |Desired Behaviors: |PIC: lower stress level, high morale, true |NIC: If fixed mindset, getting out of comfort | |Support small win improvement |performance awareness, intrinsic satisfaction |zone may become an obstacle. | |projects |PFU: enhanced patient care, increased revenue | | |Undesired Behaviors: |PFU: Lack of data and awareness may delude staff |NIC: constant firefighting, high stress, low | |Oppose continuous improvement |into thinking that they are performing well. |morale, burn-out, workarounds, errors, capacity | |effort | |limitations | | | |NFU: mediocre performance, inefficiencies limit | | | |revenue |

Small wins reinforce the desired staff behaviors. Goal Setting Theory – Small wins represented short-term goals, which broke the more complex task of changing the hospital system into small, relatively easier steps that became progressively more difficult. Proximal goals like the CFF improvement were coupled to more distal strategic goals like refocusing the CCHMC activities on patient care excellence. The Mindset Theory or Progress Principle could also apply as shown in the summary cycle below: [pic]Small wins kick-start CCHMC’s continuous improvement process 5.

The following three recommendations supported by the Harvard Business Case (Leading by Leveraging Culture, CMR260) target using culture as a leadership tool to address CCHMC’s current challenges and sustain the hospital’s improvement efforts going forward. Challenge #1: Key Leaders of the Improvement effort are all retiring soon. Recommendation #1: Continue recruiting and selecting people based on cultural fit.

• The most pressing issue is to ensure proper succession plans are in place to replace the key leaders of the improvement effort, who are all retiring within a few years. CCH should hire replacements for Anderson and eventually Kotagal who fit the established culture based on Anderson’s original vision of patient care excellence, transparency, and committing resources to be a leader in improving child health. • It is paramount that CCH’s leadership and staff to continue to leverage social control or The Power of Shared Norms such as the “Do the right thing for kids” model because these norms influence how physicians, clinicians, and administrative leaders interact with one another, approach decisions, and solve problems.

Some examples include: o Communicating success stories (CFF parents enacting change through feedback and transparency and eliminating SSI to refill beds with new patients) that complement the hospital’s culture and espoused values o The goal of zero (another espoused value from Leadership) for serious safety events Challenge #2: Developing a strategy for project selection and management of improvement resources Recommendation #2: Manage CCH’s culture through Socialization & Training. • CCHMC should continue to administer and refine the I2S2 program.

I2S2 helps clarify their cultural values and communicate their standardized approach for implementing change. It also teaches project selection techniques (the Pareto Principle), drives project results, and develops resources to lead future improvement efforts. • The socialization of best practices prescribed by QIC’s is key for the hospital’s continued success. QIC’s provide an external overlay that help CCHMC staff integrate QI projects into their daily schedules. Further, these resources are well versed in CCH’s standard approach to improvement and share the very latest industry specific knowledge. A steering committee leveraging I2S2 practices and QIC input should prioritize project selection, assign improvement resources, and guide management of improvement resources would address this challenge directly. Recommendation #3: Manage a culture of improvement through the reward system

• CCH should continue to use their solidly ingrained culture of quality and improvement as an informal reward system as illustrated by some of the employee comments below: o “Here at CCHMC physicians ask, “How do I maximize the hospital’s value”” (CCH#21, p. 1) o Dr. Frederick Rickman, “We have embraced the philosophy that profitability comes from doing the right things in the right way” (CCH#21, p. 10) • As the improvement process at CCHMC matures, they should use this same culture of quality and improvement to strategically embed improvement into the daily work of entire clinical divisions, and ensure that they continue rewarding employees based on overall hospital performance rather than performance of individual departments. 6.

Lessons Learned: Success requires a clear vision, a plan, and a systematic process analysis approach: • Successful organizational changes require senior leaders to work hard and early at defining, understanding, and communicating the new vision, needs and values for the enterprise. Anderson knew it is very import to develop a vision to be successful (CCHMC Update, page 1). • A systematic improvement approach should be established to guarantee the successful implementation of the initial vision.

During the strategic plan development, Anderson systematically involved leaders from different functional groups to produce a plan that would work (CCHMC Update, page 2). Small wins build success: • Small fast-paced incremental process improvements are more effective at motivating employees and improving long-term process efficiencies than larger-scale, more extensive changes. Dr. Kotagal identified and executed small and measurable improvement project to build momentum toward enhanced quality of care. Organizations should focus initially on low-risk improvement projects, such as Bronchiolitis or CF treatment, to motivate and educate their teams, and convince the entire organization of the improvement methodology value. • Small wins should be prioritized according to their potential impact to optimize the use of limited resources and increase the likelihood of long-term success. The CF improvement project was one example of a limited effort and high impact project.

Involve all stakeholders in the continuous improvement process: • The front-line employees, closest to the work, bring value to the customer, are best suited to improve the process, and should be empowered to do so. All stakeholders should be involved in process improvement as they bring different perspectives and can contribute to the organization success. Anderson involved nurses and front-line thought leaders in the strategy development meeting to empower them. Out-of-the-box improvement approaches drive revenue: A standard methodology for continuous improvement should be applied across markets and activities, from manufacturing shop floors to operating rooms or administrative offices. CCMHC leveraged Litvak’s operation management to improve the patients flow. • Organizations should realize that data-driven efficiency improvements yield better resource utilization, happier stakeholders, and enhanced financial results. The CFF data helped the staff understand the seriousness of the problem and work towards a solution, and the improved numbers gave them intrinsic satisfaction and motivated them to seek more quality improvements.

Internal and external transparency drives buy-in: • Enterprises should analyze and communicate true performance data honestly to assist its employees in understanding the severity of the issues and motivate them to change. Carter and Anderson committed for transparency and had performance improvement charts on hallways that patients and employees could see. • Organizations should make process results visible to all stakeholders to identify problems and celebrate successes. By informing the CF patient’s parents of the poor hospital performance, CCHMC took the first step toward improving their CF quality of care.

Cite this Leading Change – Cincinnati Children’s Hospital

Leading Change – Cincinnati Children’s Hospital. (2016, Nov 16). Retrieved from https://graduateway.com/leading-change-cincinnati-childrens-hospital/

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