I started this series describing an approach to execution of management goals described in the book  The 4 Disciplines of Execution (4DX) by Chris McChesney, Sean Covey and Jim Huling. The design of the WIG (wildly important goal) was described in detail. But what comes next?

execution disciplines

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:

sales execution

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

hierarchy execution


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.

execution summit

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



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!