The Leader's Role in

Quality Improvement Education:

A Framework for Change

>>Insert Facilitators: Name, Title<<

>>Insert Sponsoring Healthcare Institution<<
>>Insert Date, Location<<
 Welcome!

Pre-session Assessment

• Please take a moment to complete the

short pre-session assessment before we
begin.

• Thank you
 Changing Paradigms
• Increased diversity
• Less predictability
• Relationships and coalitions are critical
• Systems are unstable/ambiguous
• Small differences often produce large
consequences
 How does change feel?

Exercise – patterns of behavioral change

 Learning Objectives:
• Identify leadership behaviors to enhance team
performance
• Discuss how leadership behaviors affect change
and manage conflict
• Recognize the affect of human factors in
quality improvement
• Examine educational leadership strategies in a
QI case study when leading the change process
• Promote reflective practices for self-
improvement in leading the education team
 WORKSHEET #1
Individual Activity

• List characteristics of effective leaders

• Identify at least two barriers in leading

healthcare teams

• How might you overcome these barriers?

 Activity Debriefing
• List characteristics of effective leaders

• What are at least two barriers to leading

quality improvement for multi-
disciplinary health care teams?

• How might we overcome these barriers?

 Team Characteristics
• What is a team?

• What are key attributes of effective

teams?

• What are key aspects of ineffective

teams?
Key Aspects of Team Leadership
• There is no ‘one best’ style
• Understand yourself first
• Value others’ perspectives and
differences
• Strive for shared leadership
• Build and sustain trust
• Demonstrate courage
• Reflect and improve
 Leadership
• Provides direction and influences
individuals or teams to achieve goals; the
capacity to lead

• Process to create an organization that

aligns people with an inspiring vision that
overcomes barriers to change
 Managers vs. Leaders

• Keep system • Produce change

functional • Take risks
• Rely on status quo • Build trust
• Maintain stability • Inspire
• Control • Innovate
• Plan and Direct • Promote learning
• Administer • Listen then act
• Do things right • Do right thing
 Healthcare Assumptions
• Dwindling resources
• Traditional management practices
• View change as an orderly process
• Future events planned and predictable
• Organizational structures are fixed as are lines
of authority
• If given tactic worked once it will work again
• Roles and job descriptions are highly defined
• Hierarchies persist
• Reliance on technology
 Team-building and Leadership
Assumptions in Healthcare
• Change constantly influences day-to-day
activities
• Interdisciplinary teams are highly valued
for QI and Patient Safety
• Everyone is a leader and a teacher
• QI is attainable, as Healthcare Matrix
• Teaching hospitals are advancing quality
outcomes
 Model for Improvement - IHI
• Set Aims– What will learners achieve from
the learning opportunity?

• Establish Measures– How instructional

goal will be accomplished or measured?
How do we know when we get there?

• Select Changes – What changes in

learning strategies will result in
improvement?
 Human Factors Influence QI and
Change Management
Human strengths/limitations for team
effectiveness:
• Predisposing factors – biologic, psycho-
social
• Impact on decision-making – cognition;
culture; judgment, hierarchy
• Impact on execution and performance-
ability; skills; motivation; self-efficacy
People and organizations change
when they:
• Have a compelling reason
• Expect personal benefits (WIIFM)
• Have ownership in the change process
• Recognize their leaders as role-models
with serious conviction for initiating and
sustaining change
• Recognize consequences of errors in
patient care
Organizational change fostered by
leaders who:
• Articulate a clear and inspiring vision
• Challenge the process and embrace
change
• Enable and value each individual
• Align people and purpose
• Build enduring teams and coalitions
• Model effective communication
• Foster trust
 Kotter’s Change Model
Sense of urgency
Form a powerful coalition
Create a vision for change
Communicate the vision
Empower action – remove obstacles
Create short-term, quick wins
Build on change momentum
Anchor new approaches in the culture
 Worksheet #2 Case Study
You have twenty-five minutes to review this
Quality Improvement case and respond to the
prompts. Make notes and share with your small
group. Sample case study slides (blood
specimen mislabeling) attached.

Apply Kotter’s leadership stages (e.g., urgency,

coalitions, vision/strategy, communicate
change, empower, short-term wins and create
change)
 Case Study Debriefing
How did the education leader create:
Sense of urgency
Guiding coalition
Create a vision for change and communicate
Empower others
Create short-term, quick wins
Build on change momentum
Institutionalize changes in the culture?
 Educational Professionalism
• Honesty and integrity
• Compassion and accountability
• Respect for others
• Patient confidentiality
• Know ‘the rules’ and align our moral compass
• AVOID: abuse of power (coercive,
authoritative), greed, deception, impairment
and conflict of interest/non-disclosure
 Summary Points
Reflect on your daily leadership successes and
short-comings for self-improvement. What are
important lessons learned and what to change
next time?
• Everyone can be a leader and sustain change
• Know your leadership strengths and limitations
• Plan for your success as an education leader to
improve quality of patient care!
• Post-session assessment – Please complete
• What was most beneficial about the session?
• What could be improved upon?
 Comments and Questions
References:
• Leading for Change1996; Kotter, J.
• H C Manage Rev 1997; 22 McDaniel, R.
• Acad Med 1999; 74 (Bland, et al)
• Jrnl Quality Pt Safety 2005; 31 (Bingham, et al)
• J Health Organ Manag 2005;19 Ovretveit, J.
• Adv Hlth Sci Ed 2006; 11 (Bakken, et al)
• Acad Med 2007; 82 (Loeser, O’Sullivan , Irby)
• Acad Med 2012; 87 (Neeman, et al)
• Am J Med 2012; 125 (Van Hoof, et al)
• Acad Med 2012; 87 (Lingard, et al)
• Agency for Healthcare Research and Quality. (2010).
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-11-002.html. (p.
5).
Optional: Sample Case Study
Description
Use these slides to review essential details in the
Blood Specimen Mislabeling, if you so desire.
The level of detail and processes may be useful
for selected target audiences. This is optional.
Case Discussion
1. A type and cross was sent form the ER trama
room
2. Resulted in type A positive(A+) with negative
antibodies
3. There also was no blood bank history for this
patient and a unit of compatible blood was
released and started at 17:30 completed @
18:45.
Case Discussion

• @1830, 1 milligram of Dilaudid is given for

rigors and abdominal pain.
• The transfusion was still infusing
• @1850, he becomes hypotensive and is treated
with a bolus of normal saline
• STAT CBC is sent to lab @1956
Case Discussion
• @2020 the MICU is notified the repeat CBC has
resulted with Red cell indices markedly different
from previously values
• In addition the chemistry specimen was
hemolyzed.
Case Discussion
• The patient-
1. Is bleeding from the IV site
2. Coagulation is now grossly abnormal with an INR-53.9
3. Fibrinogen -200mg/dL and his D-Dimer is 1262ng/mL
4. Platelets ↓from 73 to 43 K/uL.
5. He is transfused by a blood pressure cuff another unit of
blood and then four more between 2050 and 2140
• Disseminated intravascular coagulation (DIC)
is considered , blood transfusion reaction is considered
–Hematology consult called
• THE BLOOD BANK WAS NOT NOTIFIED
Investigation
• Improper patient identification by the health
care provider
• Improper label check on pretransfusion
specimen-lab staff
• Possible failure to identify a transfusion
reaction
• Failure to alert the blood bank when the reaction
was suspected
Investigation
• Starting at the beginning…
• The patient’s blood tube had two labels on the
type and cross. Two different names.
• One label was the patient who had the reaction.
(Patient-1) the other to patient 2 who had a
blood transfusion history.
• Patient 1 was O+ patient 2 was A+
Investigation
• In 2006, there were no labels printed until after
the patient had been registered.
• Labels could be prolonged-Patients were treated
pre registration.
Investigation
• Labels for type and screen were hand written
signed by the drawer and when the labels
became available they were placed on the tube,
over the hand written label.
• The tube had to be signed by the drawer
verifying that this was the correct tube for the
correct patient with the correct label.
Investigation
• The Lab Tech also had to go through the same
process and did not NO VERIFICATION
• Failure to follow procedure in performing a
second label check of pretransfusion specimen
when the reaction was called to the blood bank
Investigation
• Standard of Practice – when an untoward event
occurs in association with a transfusion, the
transfusion should be STOPPED and the
BLOOD BANK NOTIFIED IMMEDIATELY
• This was not followed
 Policy
The Safe Blood Labeling policy has been in effect
and all staff education needed to be completed by
Oct 15, 2007. The following unacceptable Blood
Bank specimen(s) was/were received in the
Laboratory. An investigation initiated into the
circumstance that may have led to the mislabeled
specimen(s) and include training documentation
that demonstrates the staff were trained. Your
finding may help to identify the root-cause and
process failures.
Case Study Report
• In 2006 we admitted a 42 year old male African
American patient.
• Diagnosis GI Bleed
• On arrival to the ER routine blood work, type
and cross and coagulation panel was drawn
• Decision made to transfuse