Let’s imagine that your team has selected a WIG. And the goal is written in the format of “from X to Y by when.” According to the authors of 4DX, the next step is to develop lead measures. Lead measures, if implemented, will result in improvements in the lag measure.

Consider an enterprise in which the WIG is “increase our sales of widgets from $50,000 per month to $75,000 per month.” The sales team knows that a certain percentage of calls on customers results in eventual sales. The lead and lag measurements might be written as follows.

• Lag measurement = monthly sales (goal is $75,000)
• Lead measurement = number of monthly sales calls

If chosen correctly, an improvement in the lead measure will result in an improvement in the lag measure. One of the common failings of goal implementation is to track the lag goal, but fail to create measurable lead metrics. It is the lead measures that can be tracked and shared with the team on a regular basis as a way to enhance execution.

However, in order to progress on a goal a team maintain focus on the goal, even as the daily whirlwind continues around us.

In their book, the authors spend a fair amount of time describing the process for maintaining that focus. It includes weekly meetings in which the lead and lag measures are reviewed using a scoreboard. The meetings involve everyone that has an impact on the goals. And it aims to maintain accountability of the team's success by making commitments and reporting on those commitments. This is what a scoreboard might look like:

How the Disciplines of Execution = Quality Improvement

The lead measures and lag measures described by the authors are very similar to what are called process measures and outcome measures in the field of Quality Improvement. The process measures are sometimes called core measures when referring to The Joint Commission-required quality metrics.

Core measures are specific process measures defined by TJC (and CMS) that hospitals must measure and report. They are used to measure compliance with quality monitoring programs, some of which determine adjustments to Medicare payments. Core measures are generally scientifically supported interventions that have been shown to improve outcomes.

When trying to measure and compare outcomes of hospitals, process measures became popular for several reasons:

• They are more timely. Measuring beta blocker or aspirin use for acute myocardial infarction can be measured and tracked in near real-time. Measuring, risk adjusting and reporting mortality or complications for patients with acute MI is slower.
• There is a greater range in performance of process measures. Improvements become obvious more quickly. Tracking compliance rate for a process measure from 60% to 99% seems more meaningful than demonstrating a small reduction in mortality from 3.0% to 2.5%.
• The process or core measures generally correlate well with the outcome measures. Demonstrating higher compliance with process measures usually predicts better results for outcomes.

Example: Ventilator Associated Pneumonia

My primary reason for discussing 4DX is to help physician executive understand how to translate goals into results. But I think it might be helpful to use a clinical example to demonstrate some of these principles. As physicians, we understand these principles pretty well, and they can easily be applied to business examples in the healthcare setting.

Ventilator associated pneumonia (VAP) is a subset of nosocomial or hospital acquired pneumonias. It falls under the general category of healthcare associated infections (HAIs), which is a subset of hospital acquired conditions:

Hierarchy of Hospital Acquired Conditions

If we want to improve this entire cascade of hospital complication, we need a team to address each one. If we focus on VAPs, we can see that the lag measure is the VAP rate, which must be measured reported, discussed and addressed. It is generally measured and calculated as follows:

[# of VAPs (meeting specific criteria)/Ventilator days] X 1,000

It is reported as VAPs per thousand patient days. The numerator can be measured manually via logs, or pulled from an EMR, as long as documentation and coding are consistent and accurate. Tracking ventilator days is generally done manually.

Lead or Process Measures for VAP

The process measures that have been shown to affect VAP outcomes are as follows:

• Elevation of the head of the bed (30 – 45 degrees)
• Daily sedative interruption and assessment for extubation
• Peptic ulcer disease prophylaxis
• Deep venous thrombosis prophylaxis
• Daily oral care with chlorhexidine

These metrics need to be manually observed and recorded in the units where ventilated patients are treated. There are checklists that can be used to help ensure compliance. An intensive educational program will need to be presented to staff to achieve understanding and “buy-in” to the project.

Achieving 100% compliance with the performance of these lead measures results in drastic reduction in the lag measure of VAPs per thousand ventilator days. Below are examples of real trends following the institution of VAP bundles and weekly quality improvement meetings in an anonymous organization.

Percent Patients in ICU with Ventilator Bundle

Average Stay of Patients

VAP in ICU

To achieve these results, however, the same principles that 4DX describes must be followed:

• Create a scorecard with weekly tracking of the process and outcome measures.
• Focus on the process by meeting weekly so that the whirlwind can be shut out – if non-WIG items come up, deal with them in another venue.
• During the weekly meetings
  • Follow-up on the previous meeting’s commitments
  • Review the dashboard
  • Make individual commitments to be reported on at the next meeting.

Final Thoughts

4DX provides much more detail about the process for implementing the 4 Disciplines of Execution. I find it very interesting that effective quality improvement methods closely mirror the detailed approach to executing strategic goals outlined in 4DX.

Physicians involved in QI and Patient Safety Initiatives should feel comfortable translating those skills to selecting and achieving management goals if they chose a career in hospital management.

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See you in the next post!

The post Hospital Quality Improvement Mirrors Strategic Execution appeared first on NonClinical Physicians.

In a previous post, I described the importance of writing SMART goals. SMART is a good start. Goals must be clear. And they must allow us to envision what accomplishing the goals will look like.

But the so-called holy grail is not simply the statement of a clear goal, but having processes in place to achieve execution of those goals. The purpose of writing and executing them is to produce results that advance the mission and vision of your organization. 

In 2012, Chris McChesney, Sean Covey and Jim Huling released The 4 Disciplines of Execution (sometimes called 4DX). In it, the authors have written a detailed summary of their approach to articulating and achieving “Wildly Important Goals” (WIGs) that can drive the success of just about any organization. To do so requires adopting the four disciplines of execution.

I’d like to spend this and a future post discussing their recommendations, and using an example in healthcare that demonstrates the success of their process. Along the way, I will describe some of the mistakes I made in trying to implement some of the goals I pursued during my time as Chief Medical Officer.

I find the approach described in 4DX compelling. It is not very different from the way my team approached the topic. But if we had been more effective at following some of the recommendations made by the 4DX authors, I think we could have been even better at executing our plans.

Describing the Whirlwind

I loved the authors’ description of the distractions that get in the way of achieving important goals. The whirlwind is described as the daily work that we do just to achieve the core mission of our organizations. In a hospital setting it includes:

• nurses assessing their patients and safely administering medications,
• pharmacists processing medication orders and responding to questions from the nurses on the floors,
• respiratory technicians providing ventilator care and administering dozens of respiratory treatments each day,
• physicians rounding, assessing, and treating dozens of patients and documenting their treatment,
• housekeepers cleaning rooms and public areas,
• staff cleaning and sterilizing surgical instruments in the sterile processing department, and
• hundreds of others doing their daily work.

As 4DX recognizes, these activities – the whirlwind – must continue day in and day out. But growth and movement into new service lines and new locations depends on carving out time, away from the whirlwind, to identify new goals and to execute those goals.

“The whirlwind is urgent and it acts on you and everyone working for you every minute of every day.”

4DX starts by defining the first discipline: identifying the WIGs – the Wildly Important Goals – that must be accomplished in spite of the whirlwind.

What is a Wildly Important Goal?

To me, this is a goal that either must be achieved to ensure survival, or one that will take an already successful organization to a new level of success.

In 1987, when Paul O’Neill took over as CEO of Alcoa, the organization was struggling financially. It was also experiencing more than its share of worker injuries. As the new CEO, rather than focus on revenues or profits, he announced his wildly important goal: to reach zero injuries in his workforce.

At the time, injuries were running about 1.86 lost work days per 100 workers. He was able to reduce it to 0.2 by the time he left the company. So he made the company 8 times safer. As a result of focusing on a goal that inspired his workforce, not only did injuries goes down, but morale and productivity increased. And revenues and earnings rose dramatically as the share price skyrocketed. All as a result of successfully executing a single WIG.

The authors suggest selecting a WIG by answering this question: “If every other area of our operation remained at its current level of performance, what is the one area where change would have the greatest impact?”

What Makes a Good WIG?

As the organizational WIG is being developed, each subunit must develop its own WIG(s). The subunit's WIG will help to promote the organizational WIG. An example in the  hospital setting of a series of cascading WIGs might look like this:

These goals exemplify what the authors' of 4DX describe as the features of an effective WIG:

• No more than 2 per team,
• A WIG selected by a team MUST align with the WIG of the organization itself,
• The WIG of the teams must be selected by the teams, not dictated from above, and,
• WIGs must follow the format: “from X to Y by when.”

Looking back, our executive team made several errors over the years. Sometimes our executive team would present over 70 management goals to the board for review and approval. We achieved many of them, but certainly not all. Perhaps we could have made bigger strides if we had been able to really focus on 2 major goals.

We sometimes found it difficult to align our goals. Although we might have a goal focused on growth for the organization, we might have a goal focused on quality, safety or satisfaction at a department level that didn’t necessarily relate to the growth goal.

I was personally not always successful at defining goals with a clear deadline. Sometimes department goals would all be due by the end of the year. It would have been better to stagger them: one due by the first half of the year, with the second to be completed by year-end.

How Do We Take a WIG to Execution?

Defining a proper WIG is only the first discipline. 4DX describes three additional disciplines:

• Act on Lead Measures
• Keep a Compelling Scorecard
• Create a Cadence of Accountability

Next Steps

I recommend that you look at your goal setting process. How well does it lead into execution of those goals. Purchase the book  The 4 Disciplines of Execution and begin to think about how to apply its principles.

Then watch for upcoming posts in which I apply provide an example of how the four principles can be applied to a healthcare setting.

For more of my thoughts on healthcare and leadership Subscribe here.

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And feel free to email me directly at john.jurica.md@gmail.com with any questions about anything.

See you in the next post!

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