Department of Human Services Patient Flow Collaborative Belinda Moyes Principal Nurse Advisor/Director Nurse Policy Branch Chair National Nursing and Education

Department of Human Services

Patient Flow Collaborative

Belinda MoyesPrincipal Nurse Advisor/DirectorNurse Policy BranchChair National Nursing and Education Taskforce1 April 2004

Welcome

Patient Flow Collaborative Patient Flow Collaborative AimsAims

• To tackle key constraints in the patient process identified by each health service

• To promote and facilitate the development of service improvement skills within

each health service


The challenge is to revolutionise our

expectations of health care: to design a

continuous flow of work for clinicians and a

seamless experience of care for patients.

Donald.M.BerwickPresident and CEO

Institute for Healthcare Improvement

Issues

• Excellent innovation in pockets

• Long waits in ED

• Elective surgery waiting times

• Inpatient delays

House keepingHouse keeping• Mobile phones and pagers

• Rest rooms

• Fire Alarm

• Informal – ask questions

Nurse Leaders Master Class Nurse Leaders Master Class AgendaAgenda9.15 – 10.00 Ancient myths and modern magic,

Kate Harmond10.00 –10.30 Morning tea10.30 – 12.30 Innovation case study – leadership,

Lee Martin12.30 – 1.30 Lunch1.30 – 3.00 Leadership for improvement, Kate

Harmond3.00 – 3.30 Afternoon tea3.30 – 4.30 Polarity management, Kate Harmond

Questions


Ancient myths and modern magic

Kate HarmondNurse leaders masterclass, Melbourne, April 2004

The case for changeThe case for change

“I believe that public servants are working flat out but in a system that shrieks out for fundamental change… If we don’t get the systems and structures right we will never get to the roots of the problem, only prune its visible branches… The key to reform is redesigning the system around the user.”

Tony Blair, 2001

Policy contextPolicy context

• Public opinion

• Service failures

• Workforce pressures

• Access improvement

• Clinical governance

• Investment

Changing cultureChanging culture

• Decisions based on training or experience

• “Do no harm” is up to each individual

• The system reacts to needs

• Professional roles shape the system

• Decisions are based on evidence

• Safety relates to the system

• Needs are anticipated and met

• Co-operation is an explicit priority

Lessons from top companiesLessons from top companies

• Constant improvement• Culture for innovation• Team development• Community involvement• Client centred• Open and blame-free environment

Know your strengthsKnow your strengths

If there had been three wise nurses instead of three wise men, they would have asked for directions, arrived on time, helped deliver the baby, cleaned up the stable, and brought something practical, like a nice casserole.

Barbara Bush (adapted)


Morning tea



Lee MartinCollaborative Director

Rochelle CondonImprovement lead


Leadership and behaviour styles case study on leadership

What is your styleWhat is your style

Expressive Amiable

Direct Driver Analytical

ExpressiveExpressive

• Verbal• Motivating• Enthusiastic• Gregarious• Convincing• Generous • Influential• Dramatic• Animated

AmiableAmiable

• Patient• Loyal• Sympathetic• Relaxed• Mature• Considerate• Stable• Trusting• Team person

Direct DriverDirect Driver

• Action oriented• Decisive• Problem solver• Direct• Assertive• Risk taker• Competitive• Independent• Determined

AnalystAnalyst

• Controlled• Orderly• Precise• Disciplined• Deliberate• Cautious• Diplomatic• Accurate• Fact finder• Systematic

ExerciseExercise

• Corners of the room are sign posted• Move to the corner of the room that

reflects your style

Positive and Negative Positive and Negative perceptions of Expressiveperceptions of Expressive

• Verbal inspiring• Ambitious• Energetic• Enthusiastic• Confident• Friendly

• Talkers • Overly dramatic• Impulsive• Undisciplined• Excitable• manipulative

How to work with expressive How to work with expressive people betterpeople better

• Tell who first• Be enthusiastic• Allow for fun• Support their creativity• Talk about people and goals• Handle the details for them• Value feelings• Keep fast paced

Positive and Negative Positive and Negative perceptions of Amiableperceptions of Amiable

• Patient• Respectful• Willing• Agreeable• Dependable• Concerned• relaxed

• Hesitant• Wishy washy• Pliant• Conforming• Dependant• Unsure• Laid back

How to work with amiable How to work with amiable people betterpeople better

• Tell why and who first• Ask instead of telling• Draw out their opinions• Explore personal life• Define expectations• Strive for harmony

Positive and Negative Positive and Negative perceptions of Direct Driverperceptions of Direct Driver

• Decisive• Independent• Practical• Determined• Efficient• Assertive• Risk takers• direct

• Pushy• One man/woman

show• Tough• Demanding• Dominating• Insensitive• Cuts corners

How to work with direct How to work with direct driver people betterdriver people better

• Tell what and when first• Keep fast paced• Don’t waste time• Be business like• Give some freedom• Talk results• Find shortcuts

Positive and Negative Positive and Negative perceptions of Analystperceptions of Analyst

• Accurate • Conscientious• Serious• Persistent• organised

• Critical• Picky• Moralistic• Stuffy• stubborn

How to work with analyst How to work with analyst people betterpeople better

• Tell how first• List pros and cons• Be accurate and logical• Provide evidence• Provide deadlines• Give them time, don’t rush or

surprise

Under stressUnder stress

analytical•will withdraw

driver•will become autocratic

amiable•will submit

expressive•will become offensiveor sarcastic

Fears about changeFears about change

analytical•not enough information•making a wrong decision•being forced to decide

driver•loss of control•failure•lack of purpose

amiable•damaged relationships•confrontations•not being recognised for efforts

expressive•being ignored•being asked for detail•being linked with failure

Change and learningChange and learning

Panic Zone•peopleclose up•they freeze•they don’t learn

Comfort Zone•people stay here•they don’t learn

•they don’t change

Discomfort Zone

Change and learningChange and learning

Comfort Zone

PanicZone

•uncertainty•learning

Change learning and comfort: Change learning and comfort: people respond differentlypeople respond differently

• some feel it’s an adventure and are excited and stimulated

• some feel it is a mission or a duty• some feel it is a forced march and are

fearful and cautious• some feel overwhelmed, depressed and

demotivated

Noer’s Response factor modelNoer’s Response factor model

Entrenched

Overwhelmed BSers

Learners

Comfort with change(learning readiness)

Cap

aci

ty f

or

chan

ge

(abili

ty t

o learn

)

highlow

low

high

Noer’s Response factor modelNoer’s Response factor model

Entrenched

Overwhelmed BSers

Learners

Comfort with change(learning readiness)

Cap

aci

ty f

or

chan

ge

(abili

ty t

o learn

)

highlow

low

high

Clings to narrow

learnings

Learns and grows

Withdraws and avoids

‘Makes it up’high drive but low substance

Can apply to individuals, groups, Can apply to individuals, groups, departments, directorates or departments, directorates or organisationsorganisations

Entrenched

Overwhelmed BSers

Learners

comfort with change(learning readiness)

Cap

aci

ty f

or

chan

ge

(abili

ty t

o learn

)

highlow

low

high

Clings to narrow

learnings

Learns and grows

Withdraws and avoids

‘Makes it up’high drive but low substance

Overwhelmed - Overwhelmed - low comfort with low comfort with change, low capacity for changechange, low capacity for change

Withdraws and avoids• avoids confronting real issues• retreats into old patterns that

are perceived as safe• hopes that things get better• engages in passive /

aggressive behaviour• avoids thinking about or

planning for the future

Overwhelmed:Overwhelmed: low comfort with change, low comfort with change, low capacity for changelow capacity for change

How overwhelmed feel• unhappy or depressed• frustrated, anxious, powerless• bruised self esteem• fearful of mistakes and failure• needs approval, reassurance and stability

What is needed• help in coping with stress, fear and frustration• phased transition and success loaded

challenges

Entrenched - Entrenched - low comfort with low comfort with change, high capacity for changechange, high capacity for change

Clings to narrow learning• blames and complains• acknowledges need for

change but resists changing• works harder than ever at

previously successful behaviour

• tries to ride it out until things return to normal

Entrenched:Entrenched: low comfort with low comfort with change, high capacity for changechange, high capacity for change

How entrenched feel• frustrated, anxious, angry• unrealistically confident that past skills are

valid• reluctant to take risks

What is needed• understanding and help in coping with anger

and frustration• phased transition with a bridge from old to

new

BSer - BSer - high comfort with change, low high comfort with change, low capacity for changecapacity for change

‘Makes it up’ - high drive but no substance

• jockeys for positions of influence• presses for quick solutions and

actions• may initially come across as a

beacon in the darkness - ultimately becomes transparent

• often fools superiors

BSers: BSers: high comfort with change, low high comfort with change, low

capacity for changecapacity for change

How BSers feel• comfortable with need for change• compelled to do something - anything!• frustrated with the ‘confused’ and ‘whining’• confident in ability to function in any situation

What is needed • close supervision and close monitoring• assignments which are safe for the

organisation and push the employee

Learner -Learner - high comfort with change, high comfort with change, high capacity for changehigh capacity for change

Learns and grows• finds silver linings behind

dark clouds• finds humour in difficult

situations• is very aware of both

strengths and weaknesses• expands boundaries of their

comfort zone

Learners:Learners: high comfort with change, high high comfort with change, high

capacity for changecapacity for change

How learners feel• comfortable with need for change • challenged, stretched, optimistic• in control of own destiny / positive thinker• not afraid of short term mistakes and setbacks

What is needed • protection, latitude, air time• developmental roles and assignments with

impact• rewards and reinforcements

How leaders can helpHow leaders can help

Entrenched - find ways to let go of old and comfortable and learn skills

Overwhelmed -provide help and support during neutral zone of their transition

BSers - identification (uninformed optimist and the true hard core) and development

Learners - create an organisation to develop, select and preserve learners

Leading your team

Remember to consider your teams behavioural styles:

•Analytical/processing

•Amiable/supporting

•Expressive/enthusiastic

•Driver/controlling

Questions

Aims

• Remove unnecessary delays in patient process

• Build innovation tools and techniques at local level

Roll out plan

KeyOS Orientation SessionLS Learning SessionC/Call Team Conference Calls

SustainSustain

Patient Flow CollaborativeProject Plan

Feb Apr SeptJulJun

LS25 Oct

Dec

LS38-9Feb

Mar

LS419-21April

2004

Feb

2005

OS2th

April

OctMarJan Apr Jun Jul

LS519 July

Diagnostic phaseTest cycles and implementation Action phase:

Enable spread

HealthImprove-

mentSchool

Embed sustainability and mainstreamTrainingphase

Engage HealthServices

May

LS16 -7July

Celebration

Aug Nov MayJan

Site visitsC/Call

7-11 March

Site visitsC/Call

23-28 May

ActionLearningSession





9 Jun

Site visitsC/Calls

23-27Aug

ActionLearningSession6 Sep

ActionLearningSession9 Aug

Site VisitsC/Calls3-8 May

Site visitsC/Call 15-

20 Nov

ActionLearningSessionJan 04

ActionLearningSession3rd Dec

Site Visits

Nurse LeadTraining1 April

DataTraining17 Mar

PGMTraining

5 Mar

InnovationAssociates

Training30 Apr


Training29 Oct

ProjectTeam

TrainingDay 129 Mar

MainstreamAction Plan

Report


Training29 Apr

ProjectTeam

TrainingDay 227 Apr

ExecutiveTeam

Training31 Mar

Rigorous DiagnosticsRigorous Diagnostics

• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative involvement

tools

What do we mean ?

Simplify the complex systemSimplify the complex system

Simple tools in complex system

Elements of the diagnostic Elements of the diagnostic packpack

• Program measures• Sampling data tool• Brainstorm tool• Process mapping tool• Patient, carer and relative involvement

tools• Innovation intensive tool

Identify leadership elementsIdentify leadership elements

• Small groups review the story and identify the leadership elements and risks

• Identify how you would improve on the process from the story and also from your experience

• You may want to take notes when we tell the story…..

The storyThe story

• Introduction - one afternoon, actual brief about 45 minutes

• Identified who should be at brief and invited

• Short intro, discussion and then action plan

• Week later did exercise• Three weeks later feedback was given

Group workGroup work

In small groups discuss the process, what happened

who was involved etcWhat are the elements of leadership

you can seeWhat are the risksWhat would you do differently when you

do the sample tool

FeedbackFeedback

• What did you notice• What concerns did you have • What styles stood out• What do you think you would do

differently

Goldratt says….Goldratt says….• Any change is a perceived threat to security• There will always be someone who will

perceive the suggested change as a threat• Any threat to security gives rise to emotional

resistance• You can rarely overcome emotional resistance

with logic alone• Emotional resistance can only be over come

by a stronger emotion

Manager or Leader?Manager or Leader?• The manager administers; the leader innovates

• The manager is a copy; the leader is a original

• The manager maintains;the leader develops

• The manager focuses on the system;the leader focused on the people

• The manager relies on control; the leader inspires trust

Manager or leader?Manager or leader?• The manager has a short-range view; the leader has a

long range perspective• The manager ask how and when; the leader asks what

and why• The manager has an eye on the bottom line; the leader

has an eye on the horizon• The manager accepts the status quo; the leader

challenges it• The manager is the classic good soldier; the leader is

their own person• The manager does things right; the leader does the

right thing Warren Bennis, 1985

Simple check – What’s in it Simple check – What’s in it for me?for me?

Key participant or group

Whats in it for me?

What can participants do to prevent or contribute to process innovation

What can we do to manage the situation+ -

Simple tools in complex system

It’ going to be fun…..It’ going to be fun…..

let’s enjoy it!


Lunch


Nurse leadership for improvement

Kate HarmondMelbourne 1 April

Partnerships for Partnerships for improvementimprovement

• Clinicians and managers common agenda

• Investing in joint development• Openness and honesty• Reducing the hassle factors• Socialising!

““Better care without delay”Better care without delay”

• Focus on the patient experience• Analyse what currently happens• Identify areas for improvement• Small change cycles• Spread learning• Sustain improvements

BenefitsBenefits

• Access to accelerated training• Process mapping and redesign• Statistical control charts• National expertise• Leadership development• Reduced delays

Supporting activitiesSupporting activities

• Celebration days• Clinical leadership• Summer school• National and international conferences• Learn in lunch hours• Art in hospitals

Emerging needsEmerging needs

• Applying whole systems thinking• Strengthening the capacity of general

managers• Communication and co-ordination• Engaging the wider health and social

care community, including voluntary sector and housing

• Spread and sustainability

Attractors for cliniciansAttractors for clinicians

• Patient benefit• Peer pressure• Publications• Presentations• Praise• Political awareness

What do clinicians want from What do clinicians want from managers?managers?

• Accessibility?• Fewer e-mails?• Less hassle?• More evidence?• Thanks?10 MINUTES TABLE TOP DISCUSSION

Side effectsSide effects

• Clinical ownership• Morale• Conversion rates• Can do mentality• Eagles and donkeys• Empowerment

Clinical leadersClinical leaders

• Set patient goals eg mobility• Clinical governance• Research and development• Standards for practice• Education and training• Role model

Managerial leadersManagerial leaders

• Set organisational goals eg activity• Corporate governance• Systems development and investment• Quality standards• Organisational development• Role model

Nurse leadersNurse leaders

• Patient advocacy• Agitate• Emotional tone and intelligence• Team development• Manage complexity and ambiguity• Role model

Look after yourselfLook after yourself

• Be nice to yourself• Write it up, not down!• Treats and time out• Stay well• Celebrate• Shoes and towels

Thank you!Thank you!

Questions


Afternoon tea


Polarity management

Kate Harmond


Feedback and close

Documents

Department of Human Services Patient Flow Collaborative Belinda Moyes Principal Nurse Advisor/Director Nurse Policy Branch Chair National Nursing and Education