The behavior of senior executives, and especially the CEO, is known to be directly related to an organization’s performance. In 2017, we reported on five behavioral dimensions required to build a culture of continuous improvement: willingness, humility, curiosity, perseverance, and self-discipline. Does changing leader behavior to embody these qualities lead to better patient outcomes? The leadership team at Zuckerberg San Francisco General Hospital (ZSFGH) has been studying this question over the last year and has determined the answer is yes. We will describe the outcomes ZSFGH has achieved since creating specific behavioral expectations for its leaders. But first, why is leadership behavior so important?
Health care has been slow to adopt modern management principles. Most health care organizations are still managed in a traditional autocratic style that does not allow for much worker input. The manager or leader makes most decisions and tells everyone what to do. Problems that arise are not managed expeditiously at the front line by people who understand the work. Instead, the problems pile up on the manager’s desk — and most aren’t solved. This lack of real-time problem-solving has led to terrible performance in the U.S., where it is estimated that at least 210,000 people will die prematurely from preventable harm in hospitals this year.
Many hospitals around the world are building a different management system to combat this unacceptable medical error rate. Leaders are taking lessons from world-class manufacturing and software companies to build systems that transfer decision-making to those who do the actual work. In software design, this is the software engineer who makes hundreds of decisions each day, none of which are reviewed by management. She simply runs small, rapid experiments of software changes to determine if she can build something the customer wants. At Disney, employees consider customer satisfaction part of their work and make changes in processes immediately, measuring with simple tick charts whether the customer has a better experience. In manufacturing, frontline workers have clear expectations that any problem identified in quality or workflow is their responsibility. The workers suggest ideas, test them, and make changes in real time.
In health care, on the other hand, a nurse with an idea to improve the patient experience typically keeps it to herself, knowing it would need to go through layers of management. It’s just not worth her time.
Many high-performing industries have management systems based on a set of fundamental principles, such as using scientific method to solve problems at the front line. But for traditional health care managers, relinquishing responsibility for problem-solving to the people closest to the work is hard to swallow. It requires a different way of behaving.
Health care organizations that have made these kinds of changes demonstrate undeniable results. At St. Mary’s General Hospital in Kitchener, Ontario, where an improvement management system has been in place for the last 7 years, the hospital has been named one of the top three safest hospitals in Canada for 3 years in a row. At UMassMemorial Health Care in Worcester, Massachusetts, patient mortality rates have dropped by 35% over 2 years by applying an improvement management approach that has unleashed thousands of staff ideas. The same transformation has been occurring at Zuckerberg San Francisco General Hospital.
Goals, Strategies, and Personal Growth
One step toward developing an improvement management system is defining what people should be working on. This is called True North, a handful of metrics that allow everyone to know what’s most important and whether the organization is making needed progress. ZSFGH adopted six True North goal areas — equity, safety, quality, care experience, workforce care and development, and financial stewardship — and decided how to measure each performance category. These measures are ZSFGH’s must do, can’t fail metrics for organizational performance.
As part of the improvement management system, hospital leaders also defined a few important strategies and deployed them across the hospital in 2017. This process, termed Strategy Deployment, is designed to make sure every worker understands the top strategic priorities, how those priorities impact the True North metrics, and how the work they do every day connects to what leaders have laid out as being most important.
If organizations are to change, then leaders have to change. That was the step ZSFGH took next in 2017. The workforce care and development goal focused on developing principle-based leaders who embrace the five key behavioral dimensions of willingness to change, leading with humility, curiosity of how things work, perseverance, and self-discipline. The observable behaviors necessary to know whether leaders are cultivating the five qualities include practicing self-reflection and going to where the work is done to observe, learn, and coach. We call the latter “going to the Gemba,” which simply means the place where value is created for the customer. Other observable behaviors include asking open-ended questions, listening carefully, and practicing the approach known as “A3 thinking.”
An A3 is nothing more than an 11-by-17-inch piece of paper that tells a story about a problem or barrier. The story explains the background and current state of the situation. This leads to the most important step: defining the problem to be solved. As Einstein reportedly said, “If I had 60 minutes to save the world, I would spend 55 minutes defining the problem and 5 minutes finding the solution.” Thinking this way stops us from jumping to solutions that have no bearing on the actual problem. The A3 process can also be used for personal development, as we will describe below. Other observable behaviors include having an established coach for improvement and adopting a set of standards to guide the leader’s workday, called “leader standard work.”
In 2017, one of us (Dr. Ehrlich) focused the 55 top leaders at ZSFGH on the above behaviors. For each leader, the plan started with a 360-degree evaluation based on the five behaviors. With results in hand, each leader worked with his/her superior to develop a “Personal Development Plan–A3” (PDP-A3), focusing on those areas needing improvement. From there, each leader adopted “leader standard work,” which included daily, weekly, and monthly activities that codified what the leader was going to do to achieve the organization’s strategic goals. The process included reflection to help leaders assess whether they were carrying out their plans.
To promote this deep personal development work, the entire group of 55 leaders was brought together in small groups to share their Personal Development Plan–A3s. Dr. Ehrlich recruited a few leaders who were a bit ahead of the rest to describe their plans and their leader standard work. Because it was a peer-to-peer learning exercise, it was more readily accepted. It became a learning journey that everyone was experiencing together, rather than one more thing they were told to do.
Leveraging a Crisis
As the ZSFGH team was working to ensure the behavioral dimensions were being instilled in the culture, a crisis arose. The hospital experienced the heaviest winter volumes in its history in 2017. Emergency department volume had been increasing steadily by about 5 to 10% per year; in July 2014, ZSFGH saw about 175 patients/day, and in January 2017, during the initial crisis, volumes had risen to about 215/day. Volumes peaked at 240 per day in January 2018. Patient flow through the ED and hospital inpatient services became the number one priority and the biggest source of staff stress. Staff also had to adjust to a new acute and emergency facility that had just come on line and that required radical redesign of workflows — adding more stress.
ZSFGH’s leadership team leveraged this crisis as an opportunity to model its new leadership culture. Dr. Ehrlich worked with the executive leadership team to establish weekly standup rounds, during which the team reviewed metrics related to flow. Then leaders responsible for addressing issues such as workflow, staffing, supplies, and patient transportation recruited scores of colleagues throughout the organization to help. Leaders dove deeply into the situation, routinely demonstrating curiosity by going to frontline staff, asking questions, and removing barriers.
In addition, the leaders revisited the True North metrics, established earlier in the year, and selected a handful of new performance metrics: percentage of time on ambulance diversion, mean emergency department length of stay, and number of patient days attributable to non-acute patients. Using A3 story papers, they reported the progress of multiple rapid experiments focused on flow-sticking points, including staff ideas to accelerate progress. Dr. Ehrlich visited the ED, inpatient, and ambulatory areas to observe the work that was happening and to ask questions of staff and leaders. In this way, she had the opportunity to reinforce the new behaviors at all levels of leadership.
Quality Improvement Results
Over the past year, ZSFGH greatly increased the number of leaders adopting the key behaviors:
- 100% of our leaders were trained in A3 thinking, up from 81%: a 23% improvement
- 87% of leaders adopted leader standard work, up from 55%: a 58% improvement
The behavioral changes had a direct impact on ZSFGH quality results. Although ED volume increased by 13% over 2017:
- Mean ED length of stay declined by 9%
- Ambulance diversion declined by 25%
- Days attributed to non-acute patients declined by about 35%
These results reflect a work in progress, not a finished product. Most importantly, we continue to see improvement. The experience at ZSFGH shows that with consistent disciplined practice, leaders can continually focus on eliminating critical problems and get results.
The management system being developed at Zuckerberg San Francisco General Hospital is based on a common set of behaviors that have been proven to work in other industries. The behaviors are the bedrock of a culture of continuous improvement. There is much work to do as the hospital prepares for an enterprise-wide electronic health record go-live in mid-2019, as well as an aggressive capital improvement program focused on ambulatory and psychiatric services. But we believe ZSFGH will continue to ensure success by reinforcing leadership growth and development. The executive team will do that by cultivating the behaviors described above and by building a set of management standards across the entire organization designed to deliver better patient outcomes.