Leadership though Compliance, Quality, & Process Improvement

Bobby D. Scott, MPAPI & Compliance Administrator

Definitions

• Compliance: activities the organization does to ensure it adheres with all applicable laws, regulations, standards, contractual obligations, ethical standards, etc.

• Examples: Policies & Procedures, Internal/External Auditing, Corrective Action Plans (CAPs)

Definitions (Continued)

• Quality: a measure of excellence or a state of being free from defects, deficiencies and significant variations.

Definitions (Continued)

• Performance Improvement: Systematic and continuous actions that lead to measurable enhancement in health care services and the health status of targeted patient groups.

Visuals…Measurement

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What Does Each Approach Look Like???

Quality/StandardCompliancePerformance Improvement

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Quality as a Standard for Leadership

• Edward Deming: 14 Points

• https://www.youtube.com/watch?v=tsF-8u-V4j4

Deming 14 Points Revisited

• Create Constancy of Purpose• Adopt the New Philosophy• Cease the dependency upon inspection

(Compliance) to achieve quality• Total Cost reduction• Improve constantly & forever…

Deming 14 Points Revisited

Deming 14 Points Revisited

• Institutionalize on the Job Training…Mentorship or Apprenticeship

• Leadership, Leadership, Leadership• DRIVE OUT FEAR• Break down barriers between departments

(silos)• Eliminate slogans/targets

Demings 14 Points Revisited

• Remove barriers/Empower hourly staff to take pride in their work

• Institutionalize education & self improvement

• Put everyone to work to make the transformation…

• Example…Janitor at NASA

A Picture is worth a thousand words...

So what’s the Point?

• Culture Trumps Strategy…• Deming’s 14 Points are all about creating

an organizational environment (Culture) where people want to work hard, smart, and where creativity is a highly sought after commodity

Reality Check…

• Unfortunately Compliance Activities will be with us for a while…but they don’t have to be our core activities…

• Breaking down Silos sounds good, but it is hard work...

• Giving up quality targets, or performance targets is even harder…Deming example/legend…

Let’s Circle Back to Measurement…

• Why do we measure?

• What are the basics?– Keep it positive– Keep it simple– Percentages/error

rates/counts/checklists

• Example…GPS1 4 7 10 13 16 19

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What Does Each Approach Look Like???

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Step One: Know where you are now…

• Establish a baseline (measurement)

• Communicate transparently, honestly, with INTEGRITY

• Build the case for the future state (VISION/MISSION)

Step Two: Bring a Map• Experience• Best Practices• Performance

Improvement• Lean/Six Sigma• Creative Staff• Teamwork

• Start with the END IN MIND

• Build the CULTURE• EVERYONE COUNTS…

TEAM• Celebrate wins & learn

from failures…(3 cycles)• Trust the process…

Sample Data…

Another way of looking at the data…

Still another …• Averages by year

– 2013 40.00– 2014 29.25– 2015 25.42 A net 15 ↓

• Soooooo….– Look at the date

critically from many different angles before you decide if the improvement is actually an improvement and if it is permanent.

Data Driven Decision Making

• Using Mission oriented data collection and analysis to drive the decision process and make it more objective.

• Business Intelligence/Analysis• Quantitative Analysis• Largely becoming dependent upon

databases and very large and multiple spreadsheets…

Six Sigma’s DMAIC Process

• DEFINE: What is the problem?• MEASURE: How is the problem

effecting the customer/staff?• ANALYZE: How big is the problem?• IMPROVE: Are the intended outcomes

occurring? Rule of three…• CONTROL: Can we sustain & spread

these results?

DEFINE: What is the Problem?

MEASURE: How is the problem effecting the customer/staff?

ANALYZE: How big is the problem? • Can this be addressed by my team?• Do we need to bring in other departments?• Is it going to cost money to fix?• Is it costing us money not to fix?• Is it a patient safety issue?• Is your current measurement adequate to

the task?

IMPROVE: Are the intended outcomes occurring? • Make the change(s)• Determine quickly if the changes are

having the intended effect• Rule of Three• Be prepared to make alterations as

needed to adjust to learning during the implementation or in some serious cases, stop the project entirely.

CONTROL: Can you sustain & spread these results

• Sustaining & Spreading results are the most difficult aspect of any PI Project.

• They require great documentation and the ability to transfer the knowledge to different environments.

• Remember Deming referring to the word “Institutionalize” several times during his presentation. The control phase is where you would codify and control the behaviors and system.

Why DMAIC? Is it really worth it?• Isn’t this a lot of extra work?• Measurement is a hassle…• What if you measure the wrong thing?• Leadership doesn’t think it is important…• My co-workers will think I’m weird• What if it doesn’t work?

Why DMAIC?

• YES this a lot of extra work, but it is proven to work!

• Measurement is a hassle, but once in place it provides routine feedback on performance.

• You will most likely measure the wrong thing…If at first you don’t succeed…

• Leadership doesn’t think it is important…prove them wrong…

Why DMAIC (Continued)?

• My co-workers will think I’m weird…– Be a Leader, not a follower…– Example…Disease Management

• What if it doesn’t work?– Rule of Three– If at first you don’t succeed– You learn more from failure anyway…

Lather, Rinse, Repeat…• Find your true

calling because once you hit that one milestone, it’s time to set new goals and start all over again…

The Choice…• A job that energizes

you• Or a job that

well…