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Seven Leadership Leverage Points

Innovation Series 2008

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For Organization-Level Improvement in Health Care

Second Edition

Copyright © 2008 Institute for Healthcare Improvement

All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, pro- vided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement.

How to cite this paper:

Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. (Available on www.ihi.org)

Acknowledgements:

IHI thanks staff members Jane Roessner, PhD, and Val Weber for their editorial review and assistance with this paper.

For print requests, please contact: Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138 Telephone (617) 301-4800, or visit our website at www.ihi.org

The Institute for Healthcare Improvement (IHI) is a not-for-profit organization leading the improvement of health care throughout the world. IHI helps accelerate change by cultivating promising concepts for improving patient care and turning those ideas into action. Thousands of health care providers participate in IHI’s groundbreaking work.

We have developed IHI's Innovation Series white papers as one means for advancing our mission. The ideas and findings in these white papers represent innovative work by IHI and organizations with whom we collaborate. Our white papers are designed to share the problems IHI is working to address, the ideas we are developing and testing to help organizations make breakthrough improve- ments, and early results where they exist.

Innovation Series 2008

Authors: James L. Reinertsen, MD: Senior Fellow, IHI; President, The Reinertsen Group Maureen Bisognano: Executive Vice President and Chief Operating Officer, IHI Michael D. Pugh: President and CEO, Verisma Systems, Inc.

Seven Leadership Leverage Points For Organization-Level Improvement in Health Care

Second Edition

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)1

Foreword to Second Edition

It is almost three years since we published the First Edition of our white paper, Seven Leadership Leverage Points for Organization-Level Improvement in Health Care, and in that time we have learned a great deal about what it takes to achieve results in quality and safety at the level of entire organizations and care systems. A primary source of our learning has been the application by committed leaders of one or more of these leverage points in the 100,000 Lives and 5 Million Lives Campaigns, in the course of which hundreds of organizations have achieved major improvements in system-level measures such as mortality rates and prevalence of harm. The Campaigns continue to be an extraordinarily rich source of learning to improve and extend our theory—and it is a theory—of “leverage” for leaders.

In addition to the Campaigns, the Institute for Healthcare Improvement (IHI) has also learned a great deal about what works (and, importantly, what doesn’t) from a diverse set of sources ranging from our involvement in national initiatives such as the The Health Foundation’s Safer Patients Initiative in the UK, large-scale collaborative programs such as the 200+ organizations in IHI’s IMPACT network that are participating in Learning and Innovation Communities, in-depth work with IHI’s Strategic Partners, and direct fieldwork and interviews with health care clients as well as industry leaders outside health care. We have noticed, for example, that many of the leverage points work well in the field without much modification, whereas others seem to need some reframing, or a special emphasis on particular elements within the leverage point, or even substantial revision.

Much of this ongoing learning about the role of leaders in quality has been distilled into three IHI white papers that deal either directly or indirectly with one or more of the original Seven Leadership Leverage Points. The 5 Million Lives Campaign’s “Get Boards on Board” intervention, for example, expands Leverage Point One, on the adoption and oversight of aims at the highest levels of governance, into the exceptionally detailed Governance Leadership “Boards on Board” How-to Guide.1 Leverage Point Six, on engaging physicians, has been the subject of intense interest, which in turn has led to the publication of IHI’s white paper, Engaging Physicians in a Shared Quality Agenda.2 And the work of Tom Nolan and the IHI Innovation Team has resulted in a very thoughtful new framework and white paper on the critically important issue of Execution of Strategic Improvement Initiatives to Produce System-Level Results,3 which has relevance to several of the original leverage points, particularly Leverage Points One (adopting aims), Two (developing and overseeing the execution of a strategy to achieve breakthrough aims), and Seven (building improvement capability).

Finally, as with any organically growing set of interconnected leadership theories, there is a constant need for “sensemaking.” In particular, many leaders have expressed the need for a “cross-walk” between frameworks, so that they can place their understanding of elements of various frameworks into some sort of meaningful context. For example, how does the IHI framework for strategic improvement (Will, Ideas, and Execution) relate to the Seven Leadership Leverage Points? What is the fit between the Framework for Execution and the leverage points?

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Because we have gained a lot of new knowledge and field examples, and are also faced with questions about relationships among various IHI frameworks, we thought this would be a good time to write a Second Edition of the Seven Leadership Leverage Points white paper. In doing so, we aim to:

• Propose “Version 2” of the Seven Leadership Leverage Points, incorporating our learning since the original white paper was published in 2005, particularly the learning on the subject of execution.

• Provide a number of specific examples of the field application of each leverage point (rather than the extended “for example” of the 100,000 Lives Campaign that we employed in the First Edition).

• Describe the relationship between the Seven Leadership Leverage Points and other IHI leadership frameworks.

Finally, it is important to point out that this new and improved set of leverage points is still a theory, and a theory at the “descriptive” stage of development, at that.4 By “descriptive” we mean that we are able to describe associations between each leverage point and results, but we are NOT able to ascribe specific cause and effect. In other words, the leverage points theory is not yet a “normative” theory, in that we cannot make the following statement: “If you as a leader do these seven things, you will get dramatic system-level results.” But we can say, with perhaps greater confidence than three years ago, “Where organizations are getting significant results, several of these leverage points appear to be strongly in place.”

We hope you find the Second Edition of the Seven Leadership Leverage Points white paper useful in your own leadership work, and we invite all readers to give us feedback from their own field observations, so that this management theory can continue to grow and improve.

James L. Reinertsen, MD February 2008

© 2008 Institute for Healthcare Improvement

Innovation Series: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)3

Context and Background

Leaders of health care delivery systems are under pressure to achieve better performance. Through mechanisms such as mandatory public reporting, pay for performance, and “non-payment for defects,” regulators, payers, communities, and informed patients are pressuring leaders to produce measured performance results. These results are often framed for specific circumstances (e.g., “reduce rates of wound infections after cardiac surgery”) and sometimes specified at the system level (e.g., “reduce rates of all forms of harm during hospitalization”).

Many hospital and health system leaders have themselves become personally and painfully aware of defects in their own organizations and office practices—needless deaths, harm, suffering, delays, feelings of helplessness, waste, and inequities—and with a lot of hard work, some have become quite skilled at achieving project-level reductions in these defects (e.g., lower rates of central line infections in a particular ICU). But it is much harder to achieve organization-level results—for example, reduced rates of all hospital-acquired infections, across all units and services. Increasingly, it appears that while health care CEOs and other leaders want to make these changes happen, they don’t have a tried-and-true method by which to bring about system-level, raise-the-bar change. Specifically, health system leaders often say that they are pretty clear about what they should be working on, but far less clear about how they should go about that work.

Leadership models and frameworks can provide a roadmap for leaders to think about how to do their work, improve their organizations, learn from improvement projects, and design leadership development programs.5 The core of the comprehensive IHI strategic improvement framework is Will, Ideas, and Execution3: in order to get organization-level results, leaders must develop the organizational will to achieve them, generate or find strong enough ideas for improvement, and then execute those ideas—make real improvements, spread those improvements across all areas that would benefit, and sustain the improvement over time. And when this Will-Ideas-Execution framework is fully fleshed out with the addition of two other core components, “Set Direction” and “Establish the Foundation,” 24 specific elements emerge into an overall leadership system for improvement called the IHI Framework for Leadership for Improvement (see Figure 1).

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Figure 1. IHI Framework for Leadership for Improvement

Leaders can be daunted by the breadth and depth of this sort of comprehensive model. Even though the 24 individual elements are quite clear, many of them are still fairly broad in scope (e.g., “Plan for Improvement” or “Review and Guide Key Initiatives”). So leaders often look at comprehensive models such as this and ask questions such as “But how exactly do I ‘Plan for Improvement’ or ‘Review and Guide Key Initiatives’?”

The Framework for Execution3 is a superb example of an answer to the “But how…?” question. This framework expands and explains a system for execution of large-scale change, and provides concrete and specific examples of what leaders do and how they do it, in organizations that are highly capable of execution (see Figure 2).

© 2008 Institute for Healthcare Improvement

1. Set Direction: Mission, Vision, and Strategy

PUSH PULLMake the status quo uncomfortable Make the future attractive

3. Build Will • Plan for Improvement

• Set Aims/Allocate Resources

• Measure System Performance

• Provide Encouragement

• Make Financial Linkages

• Learn Subject Matter

• Work on the Larger System

4. Generate Ideas • Read and Scan Widely, Learn from Other Industries and Disciplines

• Benchmark to Find Ideas

• Listen to Customers

• Invest in Research and Development

• Manage Knowledge

• Understand Organization as a System

5. Execute Change • Use Model for Improvement for Design and Redesign

• Review and Guide Key Initiatives

• Spread Ideas

• Communicate Results

• Sustain Improved Levels of Performance

2. Establish the Foundation

• Reframe Operating Values

• Build Improvement Capability

• Prepare Personally

• Choose and Align the Senior Team

• Build Relationships

• Develop Future Leaders

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Figure 2. A Framework for Execution

The Seven Leadership Leverage Points framework, on the other hand, was developed in large part to answer a second type of question that leaders were asking:

• “This is a very broad framework; are there one or two places where I could get started, where my actions might have the greatest effect?”

• “We can’t work on 24 things at once. If we had to place our bets on a few specific leadership actions within this framework that would be highly likely to bring about system-level results, what would they be?”

Executives appeared to be asking about “leverage”: specific activities for leaders, and specific changes in leadership systems, in which a small change might bring about large, positive, system-level results. This white paper is an attempt to answer that question—that is, where leaders might place their bets to achieve system-level results.

© 2008 Institute for Healthcare Improvement

Build Capability

ENVIRONMENT INFRASTRUCTURE

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The foundation for our answer about leverage comes from at least four different sources:

1. Complex Systems Theory: Complex adaptive systems such as health care organizations and communities cannot be specified and managed in detail. It is highly likely that small changes in certain critical aspects of these systems might bring about surprising and unpredictable amounts of improvement or deterioration in overall system performance. If leaders could choose the right system attributes (“leverage points”) and make small, perhaps difficult, but important changes, very large performance change might result.

2. Observed Performance of Leaders and Health Systems: We have been able to watch the actions of leaders in organizations participating in IHI’s Pursuing Perfection and IMPACT initiatives, as well as in the 100,000 Lives and 5 Million Lives Campaigns, and simultaneously to observe the performance of those systems. Where system-level change has occurred, we have attempted to infer from these sources what some of the leadership leverage points for improvement might have been. For example, we have observed that system-level improvement does not occur without a declared aim to achieve it, and that how the aim is declared and adopted by leaders appears to be very important. These leverage points are based largely on qualitative data—more anecdotes and stories about the work of leaders than a solid research base. Nevertheless, these stories are powerful, and serve to support and refine the theory.

3. Hunches, Intuition, and Collective Experience: The authors come from a variety of backgrounds in health care and have tapped into our collective experience to postulate some of these leverage points—particularly those that surface as recurrent “difficult moments” for leaders. For example, it is our sense that the business case for quality is still fragile in many health care organizations, and therefore that if the chief financial officer (CFO) were somehow to become a champion for system-level improvement in quality, dramatic improvement would become much more likely.

4. Ongoing Research and Development of Management Theories and Methods: In the three years since the First Edition of the Seven Leadership Leverage Points white paper was published, we have learned a lot about topics such as execution, governing boards, transparency, and physician engagement, to mention just a few. We have attempted to weave this learning into the Second Edition of the Seven Leadership Leverage Points white paper, with a particular focus on the several areas of synergy between the IHI Framework for Execution and the Seven Leadership Leverage Points.

© 2008 Institute for Healthcare Improvement

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It might be helpful to note what these leverage points are not:

• The leverage points are not intended to be a comprehensive framework for the leadership of organizational transformation. That is a much broader subject, addressed by approaches such as The Baldrige National Quality Program.

• The leverage points are not a substitute for a coherent quality method such as the Toyota Production System or the Model for Improvement. In fact, the organizations in which the leverage points would be applied are assumed to have adopted a coherent quality framework.

Finally, we would emphasize that we have framed these as leadership leverage points. In other words, we believe that these activities are the particular responsibility of the senior leaders of organizations.

This paper has three sections:

1. A detailed explanation of the Seven Leadership Leverage Points and specific examples of their application in health care, where available

2. A brief overview of the changes to the Seven Leadership Leverage Points from the First Edition (2005) to the Second Edition (2008)

3. A self-assessment tool (Appendix A) to help administrative, physician, and nursing leaders of health care organizations design and plan their work using the Seven Leadership Leverage Points

Leverage Point One: Establish and Oversee Specific System-Level Aims at the Highest Governance Level

A broad quality aim is part of the mission statement of most health care organizations. But if leaders are to achieve new levels of performance at the system level, we believe that governing boards must:

• Establish solid measures of system-level performance—for example, hospital mortality rate, cost per adjusted admission, adverse drug events per 1,000 doses—that can be tracked monthly, if not more frequently;

• Adopt specific aims for breakthrough improvement of those measures;

• Establish effective oversight of those aims at the highest levels of governance and leadership; and

• Commit personally to these aims and communicate them to all stakeholders in a way that engenders heartfelt commitment to achieving them.

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Establishing system-level performance measures helps to answer the questions, “What are we trying to achieve, and how are we doing at it?” Sometimes referred to as the “big dots” (a reference to the visual display of critical data points for important measures that reflect the quality of care delivered), well-chosen system-level measures collectively define what is ultimately important to the stakeholders of the organization. Collectively, they provide an answer to the question, “How good are we?”

To help measure the overall quality of a health system and to align improvement work across a hospital, group practice, or large health care system, IHI and colleagues developed the Whole System Measures.6

For each measure, IHI set an ambitious goal that would represent breakthrough performance—performance that exceeds previous believed “limits”—referred to as the “Toyota Specification.” The Whole System Measures provide an excellent example of a balanced set of world-class, system-level (“big dot”) quality performance measures from which an organization’s leaders might choose a few dimensions in which to seek breakthrough performance. The measures are intended to complement an organization’s existing balanced scorecard, measurement dashboard, or other performance measurement system.

The tables below list the Whole System Measures, the relevant Institute of Medicine (IOM) Dimension of Quality, and the Toyota Specifications. Table 1 shows the performance (“Toyota”) specifications for system- level measures, while Table 2 shows the performance specifications for specific components of the care system.

Table 1. Whole System Measures and Toyota Specifications: System Level

© 2008 Institute for Healthcare Improvement

† Due to the lack of nationally available data using the Functional Health Survey-6+, IHI used self-reported health status data from the Centers for Disease Control and Prevention Health-Related Quality of Life Surveillance report.

‡ Due to difficulty with calculating Health Care Cost per Capita, a surrogate measure of Medicare Reimbursement per Enrollee may be used for ease of collection.

IOM Dimension of Quality

Patient-Centered

Whole System Measure

Patient Experience Score [Response to the question in the How’s Your Health database, “They give me exactly the help I want (and need) exactly when I want (and need) it.”]

Toyota Specification

72% of Patients Report, “They give me exactly the help I want (and need) exactly when I want (and need) it.”

Effective and Equitable

Functional Health Outcomes Score 5% of Adults Self-Rate Their Health Status as Fair or Poor [Self-rating will not differ by income]†

Efficient Health Care Cost per Capita

[Surrogate measure: Medicare Reimbursement per Enrollee per Year]‡

$3,150 per Capita per Year

$5,026 per Enrollee per Year

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Table 2. Whole System Measures and Toyota Specifications: Component Level

Several aspects of Leverage Point One deserve emphasis, based on what has been learned over the last three years:

• The responsibility for adopting aims and overseeing measures cannot be delegated by the board. What the governance board pays attention to gets the attention of management, physician leaders, and, ultimately, the entire organization.

• Aims must be focused. It is unrealistic to set breakthrough aims across the entire spectrum of performance. In fact, it is highly unusual for any organization, in or out of health care, to achieve breakthrough levels of performance in more than one or two dimensions during any one year.

• It is impossible to overemphasize the importance of the data feedback loop that boards use to oversee the achievement of system-level aims. For strategic breakthrough aims, the primary question that the data must answer for boards is “Are we improving? Are we on track to achieve our aim(s)?” To allow boards to answer this question, measurement of performance must:

o Use consistent operational definitions so that the board can track the trajectory of performance over time;

© 2008 Institute for Healthcare Improvement

IOM Dimension Whole System Measure Toyota Specification of Quality

Safe Rate of Adverse Events 5 Adverse Events per 1,000

Patient Days

Safe Incidence of Nonfatal Occupational 0.2 Cases with Lost Work Days per

Injuries and Illnesses 100 FTEs per Year

Effective Hospital Standardized Mortality HSMR = 25 Points Below the

Ratio (HSMR) National Average

Effective Hospital Readmission Percentage 30-Day Hospital Readmission =

4.49%

Effective Reliability of Core Measures 10-2 Reliability Levels

Patient-Centered Patient Satisfaction with Care Score 60% of Patients Selected the Best

Possible Score

Timely Days to Third Next Available Primary Care: Same-Day Access

Appointment Specialty Care: Access Within 7 Days

Efficient Hospital Days per Decedent During 7.24 Hospital Days per Decedent

the Last Six Months of Life During the Last Six Months of Life

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o Be timely (no more than a month’s lag between data and review); and

o Not necessarily be risk-adjusted or use “rates of events per number of interactions.” (These sorts of measurements tend to be more complex, can delay feedback loops, and are primarily used to answer a different question, “How do we compare to other organizations?”)

• It is not enough for boards to review performance measures. When they hear stories of the patients and families whose lives have been affected by quality and safety events, boards will drive for improvement with a much greater sense of urgency and commitment.

• Boards must develop the capability to oversee quality and safety. The best boards are bringing in members who are experts in quality methods in manufacturing and other industries, and are investing in education of all the trustees.

• It is often helpful to develop specific scorecards of measures to track progress on efforts such as a hospital’s work on the 5 Million Lives Campaign, or its major strategic goal to reduce hospital-acquired infections, rather than have key data elements related to these initiatives simply reported out and mixed together with all other quality and reporting metrics. Initiative- specific scorecards create context, which facilitates both understanding and monitoring of progress.

• When boards start holding management accountable for achievement of breakthrough aims, the trustees start asking tough questions. This sends signals throughout the organization that can be a powerful force for culture change.

Ascension Health’s board provides us with an excellent example of the practices described above. In 2003, the board of this 70-hospital system adopted a specific, focused breakthrough aim: zero preventable deaths and injuries by the end of 2008. The boards in each region have incorporated review of patient stories about preventable deaths into their meeting agendas, and the boards must approve the action plan to prevent similar events in the future. Furthermore, the regional boards do not simply accept every action plan passively, but often send the management team back to develop more robust solutions to serious safety risks. The Ascension system tracks the risk-adjusted mortality rate on a monthly basis, and has built the achievement of their aim—zero preventable deaths and injuries—into the management performance expectations. The results at the system level are shown in Figure 3.

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© 2008 Institute for Healthcare Improvement

Figure 3. Example of Board Oversight of Performance Measurement for System-Level Aims at Ascension Health

Leverage Point Two: Develop an Executable Strategy to Achieve the System-Level Aims and Oversee Their Execution at the Highest Governance Level

Execution tends to be the weakest link in the Will-Ideas-Execution triad. As depicted in the Framework for Execution in Figure 2 above, and as described in detail in IHI’s Execution of Strategic Improvement Initiatives white paper,3 there are four critical steps for leaders who wish to achieve breakthrough results:

1. The senior team and board must adopt a few focused breakthrough quality and safety aims (as described in Leverage Point One, above).

2. The senior executive team must develop a plan—a “rational portfolio of p