Organizations often invest time, money, and leadership capital in performance improvement initiatives that show early promise only to later fail. The challenge of sustaining improvement continues to frustrate health systems across the globe. Through years of studying such change management and quality improvement activities, the Research and Development team at the Institute for Healthcare Improvement (IHI) has learned that the missing piece to sustained improvement at the delivery interface has less to do with care model redesign, incentive payments, IT hardwiring, or policy shifts and more to do with rethinking management structure and practice — or, more specifically, using the management system as a substrate to create a culture of transparency, continuous improvement, and frontline engagement.
In this article, we discuss the results of two pilot initiatives, led by IHI, that resulted in sustained, significant improvements in quality and value in two very different contexts — outpatient care in the U.S. and acute inpatient care in the U.K. — through management interventions that resulted in significant cultural change.
The High-Performance Management System: A Tactical Model to Drive Sustained Value Improvement via Culture Change
Management theorist Edgar Schein defined culture as a shared way of thinking and feeling about problems that an organization faces over time.1 Changing culture can feel amorphous and unfocused, whereas making investments in data systems and analytics that can affect behaviors sometimes seems more practical, tangible, and, in some senses, easier. In order to change culture and thereby realize the performance gains that they seek, leaders need a clear pathway that will allow them to impact values and beliefs. The literature suggests that this pathway can be provided by a set of disciplined management practices that engage the front line.
To that end, IHI partnered with multiple health care providers in the U.S. and Europe to synthesize and pilot test a set of management practices (which became known as the High-Performance Management System, or HPMS) to effect a set of behaviors that result in cultural shifts toward transparency, proactive problem-solving, and continuous team collaboration. These management practices, derived from systematic approaches to quality improvement and Lean principles, have resulted in sustained new levels of organizational performance and reduced costs with our testing partners.
Developing the High-Performance Management System
Starting in the summer of 2015, IHI studied a group of ten high-performing health systems in North America with notably strong organizational cultures (e.g., Intermountain Healthcare, ThedaCare, Denver Health, Geisinger, and others) to derive a set of management practices that might result in sustained high performance.2 The findings from that study suggested that the core elements of such a system included standardization, accountability, visual management, problem-solving, integration, and escalation.
Refining the System to Reduce Utilization and Cost
Starting in fall of 2015, IHI refined this set of ideas and tools to explicitly drive reductions in utilization and cost. The refinements included weekly collection and reporting of operational measures (e.g., time of discharge), capacity measures (e.g., time spent in direct face-to-face patient care), and financial measures (e.g., agency nursing cost), as well as the incorporation of refined visual management tools and a weekly value management huddle. (It should be noted that capacity measurement in practice does not necessarily take place weekly. Capacity measurement requires frontline staff to track their activities over the course of a shift, after which the manager aggregates data from multiple shifts. Given this sampling method, the data collection often best proceeds every 3 to 4 weeks.)
Testing the High-Performance Management System
To test the effectiveness of the HPMS, IHI ran pilots in two geographically and clinically disparate settings: (1) two ambulatory surgery centers in the United States and (2) fifteen units in hospitals in the Scottish National Health Service (NHS). These tests showed that the High-Performance Management System, combined with a focus on continuous review of financial data, offers a solid foundation for positive cultural change to effect continuous value improvement.
Ambulatory Surgery Setting: Testing the Fundamentals
In 2012, the Agency for Healthcare Research and Quality (AHRQ) began funding hundreds of ambulatory surgery centers to participate in multiple cohorts as part of a learning collaborative to improve patient safety.3 Participating centers introduced practices such as surgical time-outs, safety concern escalation behaviors, and improved processes such as the introduction of updated guidelines for equipment processing and sterilization. While progress was seen clearly during the cohort period, project leaders at the Health Research and Educational Trust (HRET) noted frequent regression to mean performance in the cohorts after attention was focused on the next cohort.
In early 2016, HRET invited IHI to introduce a set of practices to promote sustainability — in other words, to ensure that the safety practices that had been introduced were maintained after the sunsetting of the formal program. IHI worked to pilot test the key principles of the High-Performance Management System in two ambulatory surgery centers. In the spring of 2016, two expert IHI coaches skilled in applying the tools of improvement science worked with the sites to introduce management practices that they had identified as means to operationalize the HPMS. For example, the coaches worked with the sites to introduce a daily huddle that focused on a small set of specific actions (such as review of safety risks for the patients on the current day’s surgery list) and safety measures (such as the number of days since the last adverse event). The coaches also helped site leaders, including an administrator in one site and a quality manager in the other, to introduce simple visual management boards to display these measures, with examples of standard work and tracking of problems that had surfaced during the huddles.
One of the two sites reported its results. The other site experienced a change in ownership and leadership that led to discontinuation of the program. The site that reported its results experienced significant improvements, with a 10–percentage point increase in the AHRQ Patient Safety Culture Survey (from an average agreement of 82.5% before the beginning of the program to >93% 4 months into the program, with a higher percentage indicating stronger agreement with statements indicating a positive culture). Improvements occurred in every domain that was tracked in the survey, from prioritization of safety to teamwork and accountability. These improvements have continued, with the most recent survey results increasing to 95% in the winter of 2018.
In addition to these cultural improvements, the site reported multiple quality improvements and increases in the sustainability of previous changes following the introduction of the HPMS practices. For example, the site had previously focused on reducing immediate-use sterilization, which is an important process measure for ambulatory surgery centers as it can indicate inadequate planning for procedures. After the introduction of safety standard work in line with the AHRQ program’s teaching on standard work, surgical time-outs, and safety communication behaviors, the site initially saw a reduction in immediate-use sterilization but then saw some regression. With the introduction of the management practices, including huddles and visual management, the rate of immediate-use sterilization returned to approximately 0%, where it has remained for nearly 2 years.
In addition to these quantifiable improvements, HPMS practices resulted in numerous other instances of positive cultural change. For example, site leaders reported that frontline staff appeared to feel more empowered and engaged, with staff participation in the performance huddles identifying emerging leaders who subsequently received recognition via promotion. In addition, the site leaders adopted a set of key management behaviors to support these improvements. For example, the site’s quality manager routinely observed the team huddles, provided coaching, and worked closely with an administrative manager to monitor progress and provide the teams with feedback and encouragement.
The quality manager in the ambulatory surgery center also devised a particularly effective model of next-level leadership that has helped to sustain the High-Performance Management System over time and speaks to the “integration” dimension of HPMS. Specifically, she developed her own weekly report spanning all teams in the center, including preoperative and postoperative care, the sterilization unit, the business office, and the operating room. Each team has its own huddle system and huddle board. Every week, the teams report whether they conducted the huddle, whether they updated their measures, and which challenges arose during the huddle and required follow-up. In this way, the quality manager makes the observation of lower-level standard work (the huddles) her own standard work and supports sustainability.
Hospital-Based Setting: Testing the Approach with a Focus on Value
In tandem with the completion of the ambulatory surgery pilot, IHI introduced a modified version of the High-Performance Management System that focused on cost and value, with significant pilot testing occurring in the Scottish NHS4 that began in October 2016.
In this context, visual management included an explicit focus on cost through the use of a “box score” (a concise performance dashboard in the form of a spreadsheet that was updated weekly) and a visual management board (a physical bulletin board that outlined analyses and improvement projects linked to a small set of performance measures). In principle, the elements of the management system used in the inpatient setting were similar to those of the system used in the ambulatory setting, with a focus on cultural change through standard work and huddles, the introduction of visual management tools, a deep focus on problem-solving and continuous improvement, and the involvement of multiple levels of management.
Testing the Model in an Inpatient Respiratory Ward
The effort began in a single inpatient respiratory ward (hereafter referred to as the “value prototype team”), with promising results. Two IHI staff supported the team in the initial phase of the work, with help from Lean consultant Brian Maskell, who pioneered the box score in the manufacturing industry. The intensive work with the value prototype team included two site visits to introduce the tools and to teach the site-based staff the HPMS approach. The IHI team also remotely attended the weekly huddles, during which all team staff, a physician lead, and a supporting accountant reviewed the value-focused visual management board.
To assess staff engagement and organizational culture, the IHI team implemented a survey tool (adapted from the AHRQ Patient Safety Culture Survey) that focused on communication, management, and collegiality. Staff were asked to respond to the following four statements with use of a modified Likert scale (strongly agree / agree / neutral / disagree / strongly disagree):
- People support one another in my unit.
- We have enough staff to handle the workload.
- When a lot of work needs to be done quickly, we work together as a team to get it done.
- In this unit, people treat each other with respect.
Following the implementation of the High-Performance Management System, the value prototype team demonstrated positive results. In Year 1, 86% of staff either “strongly agreed” or “agreed” on a metric that combined the responses to the four statements above into a composite measure. A year later, that value was 92.5%. One team member recently commented, “[the] good atmosphere on the ward and good team makes work enjoyable even when there is high patient turnover and sometimes complex patients.” Another remarked on her appreciation of working together as a team: “[We have] good morale and [support] each other.”
These cultural changes coincided with improvements in cost management, productivity, and quality. Six months after the introduction of the box score, the team registered a statistical reduction in agency nursing spending (from an average of £2,278 per week to an average of £1,561 per week). Two months after that, the team registered an overall shift in cost per patient seen, based on a reduction in agency nursing spending, drug spending, and improved patient throughput (from an average of £535 per week to an average of £485 per week).
The impressive productivity improvements merit additional discussion. The value prototype team has seen three different shifts toward improved productivity — the first driven by improved use of nurse capacity to promote increased face-to-face patient time, the second due to the introduction of an improved discharge preparation checklist, and the third due to the introduction of a midday huddle in addition to morning and afternoon huddles, allowing for more proactive tracking of the timeliness of discharge orders. In all, productivity has increased by 32.8% since the start of the project, with the number of patients seen in the unit increasing from 58 to 77 per week.
The value prototype team has also maintained high-quality care. For example, the team reduced an already lower readmissions rate of 12% to 10%, representing a statistically significant change. Moreover, the team has maintained a low level of patient falls (roughly 2 to 3 per month, mainly controlled falls) and has introduced a set of improvement projects to bring this number down to 0. These improvement projects have focused on greater fidelity to existing fall prevention bundles and have involved a deeper analysis of the time of day during which most falls were occurring, resulting in heightened attention to staffing levels during those periods. The latest data indicate a 27% drop in falls in the past year — from 51 to 37.
Expanding the Model Within NHS Scotland
The health board that commissioned the work (NHS Highland, a regional health system in the north of Scotland) subsequently spread the application of the management system in two consecutive waves, first to 4 additional hospital-based cardiology teams and then to another 9 teams, separated by intervals of approximately 6 months. Several of these teams have shown significant sustained improvements in terms of quality and cost. For example:
- An endoscopy team reduced late starts from a median of 100 minutes per week to consistently 0 minutes per week.
- A medical unit in an outlying community hospital reduced the number of patient falls (including mostly controlled falls) from 12 to 7 per month.
- A pediatric inpatient unit successfully introduced a new standard operating procedure for children’s meals, with the fidelity to the standard increasing from approximately 18% initially to >80% (maintained consecutively for 8 weeks) and then to 100% (maintained consecutively for 7 weeks).
- A cardiac intensive care unit reduced its cost per admitted patient by 7% by reducing spending on drugs and supplies.
In all, among the 14 teams that have implemented the value-focused version of the High-Performance Management System for at least 6 months, 9 have shown at least 1 statistically significant improvement in terms of quality and/or cost, and some have shown >1 such improvement.
As part of these efforts, the additional teams also periodically received the AHRQ culture survey questions. The cardiac intensive care unit mentioned above had an average score of 94% (“strongly agree” or “agree”) across its two latest surveys (n = 20 respondents). All surveyed teams have had either stable or improving culture scores. One team has not administered the survey.
As with the ambulatory surgery centers, unit leads and quality leads in the test sites in Scotland emphasized the key role of management behaviors in sustaining the system, again reinforcing the importance of the “integration” component of the High-Performance Management System. Middle-level managers routinely attended huddles, asked questions, and provided encouragement. An assigned physician lead helped to address challenges in engaging physicians — particularly specialists and those without significant quality improvement experience. The hospital executive teams were involved in all key decisions in the development of the work, including the selection of teams, the pacing of spread, and relative investment in improvement priorities (e.g., a focus on overall flow and productivity).
In addition to their focus on the weekly management of value, the Scottish teams have now begun work to introduce daily management boards and to evolve existing daily management huddles to include more of a holistic view of performance (rather focusing simply on patient status updates during transitions between staff shifts). In this way, their work has started to resemble that of the ambulatory sites. Taken together, the combination of daily management and weekly management of value offers a powerful set of tools to rigorously manage all aspects of performance.
Across both the ambulatory surgery and inpatient sites, the teams that showed the most impressive results shared some factors in common:
- Improvement capability: Successful teams used basic quality improvement methods with ease: they could generate effective run charts with annotations, conduct detailed cause-and-effect and Pareto analyses, and then plan and execute a sequential series of Plan-Do-Study-Act (PDSA) cycles. These different methods reflect part of what is meant by “problem-solving” in the overall management model.
- Standard work: Successful teams invested significant time focusing on standard work — not only by having checklists and other tools, but also by carving out aspects of standard work for different roles in order to ensure seamless execution. For example, standard work for effective patient discharge likely requires assigned tasks across many different roles: a nurse assistant might assist with arranging the patient’s belongings and family transportation; nurses might lead teach-back activities, communicate with the physician regarding discharge orders, and review safety bundles as a quality check; and a charge nurse might adjust staffing to ensure that others can complete their discharge tasks in an orderly way and also ensure that those in other roles complete their standard work through observation.
- Leadership: Successful teams had support from several levels of leadership. The most important of these included:
- Senior executives: Buy-in from the C-suite team (as indicated by such activities as attending huddles, removing barriers, coaching unit leaders, and celebrating success) helps to maintain momentum. Ideally, senior executives have their own measures and visual boards as well as a role in solving problems and executing improvement.
- Physicians: Having physicians attend huddles and lead their own PDSA cycles helps to drive improvement and engagement.
- Next-level managers: In the Scottish NHS setting, each team had administrative support from a service manager, who was accountable for issues such as physician scheduling. The active involvement of such an administrator helped to ensure accountability for the frontline team leader. In the ambulatory setting, a senior quality improvement coordinator helped to provide similar support.
An Evolving Approach
The HPMS practices described here offer health systems a way to improve quality and reduce cost, to sustain the results of their systems improvement and change management work, and to improve value through cultural change.
The High-Performance Management System takes significant time to introduce and evolve. Teams must start with a small number of pilot huddles, and the system should ultimately evolve to include huddles, visual management, standard work, and other elements at each level of management. This process represents a long-term organizational journey rather than the strategic flavor of the year.
Overall, the experience to date indicates that, when adopted at a health system level, these management interventions can create a strong set of linkages between otherwise abstract and discontinuous initiatives focused on value, staff satisfaction, and culture change.