aJnllnl aql uI saqrro'rdde 'uau Surzea;;a5 a8ueqr aroru 8ur:npold pue surc8 SuutplTosuo3 sLIL{\\ urJet-l;oqs SuDerauag lrt ol saeLoldua Suue'nodug ,(8are-ns pue uoIsIA t Surle:tunurruo3 ,(8ale.ns pLIE uoISL\\ eql uo .,(8are.ns put uoISIA e Surdole,taq uollllsol Surpm8 1ry'ra'uod e Sunu;og erntlnl PIo eqr Sutzaar;ul :s^\\olloJ sE eJE sdals rq8ra aql ''hwnb ol e8ueqr st e Sur8eutu aJE oq,t\\ s.Isptel aprn8 or {Jo'^leuIEJ-J alqtt,t pue lI}sIIEeJ e psulpour 'sse:ord sa.\ as 'aluury3 iuryuaT )ro^\\ IELIIuras (qOOt ) s,lauoy tuo{ Surut]s aSurrlt eSets-tq8ra 3ur.,\\\\o11o3 aq1 '.(au;no[ ]ueura.^,o;dur ,brlEnb eql a8ueq: ssaro;d InlJsn puE rueat drqs.rapual eqr .ro3 aprnS E sE elJas utr lEHl pru:ud e patsaSSns (geil '966I) rello)I 'a8ueqr leuontzrueS;o e8ruetu o] slJtts drqsrepeal lolues se 1ryd1aq st a8ueql ;o; deu pEoJ e 8ur;eqg 'sllnsal JIqEuIElsns lnoqe 8ulrq l1ltr leqr alua]lalxe Jo uals,{s t eAIJp pue aleaJr oq'\\\\ sJeptel qlr,u slJe}s 'firpnb pJe't\\o} pue a8u*q: aqt 'slsa88ns llqrpa oql sV 'sfuollelxe alueu;o;;ad Suturtlsns Surlta;: uI oJnllnl Jo sloJ Sutssrdruorue-llt eql sepnllul ]Etll IJo'^aerIE{ '?luellerxe a8r,rppg eqtJo uoIs.I3A peuryotu dpq8rls t sluasa'rd I'9I ]lqlqxg a?r'rppg aqr '{q arueru;o;.rad ro-I Elrellrf, (gfOZ) tuuSo;4 'b1pn6 IEuoIIENI ut paqrJrs.lp tsaq eJe e-Inllnl elllellsfxe a:ueu;o3;ed ts qll{\\ uoDezlue8;o aq] put drqsrapcal Jo elor erll Jo srueruale erp Jo aluapuedaprslul 'r(Satens ]ueula^oJduIr 'brrcnb 3ql lno &;er ot popaeu aq ilp\\ letll s]1nIS pue solllllqeder aql sdol:'rep uoutztueS;o pJE'^'\\ol aqt tErlt oslE lnq sllrleur IEIIuEuU ut pepuno'r8 sI lueure^oJdur '{rrlEnb ''brrcnb srql Jo srnllnl Lau.lnof ar{} ]ELII ,(1uo lou ernsue or sdlaq q:eo'rddr a8ue't e Sutlea;t ot lElluasse sI snloJ d;euud eq] seJnsteu leuotltztutS;o 3o paluaualdut o] ',(rrrcnb e^oJdut ultlsns put peoJq srqr Suqeru ,(laltlaqrlaq sJaulolsnl IEUJe}xe puE IEUJ3}LII Jleql puE eq lsntll sass::o.rd ssaursnq lBq]\\\\ {sE asrc; '(eql 'uoilIPPE uI Jo uor]lEJslres Jql o1 pJIEIJJ suotlsanb prrS;ns 3o a8pa Surlln: eLIl uIeluIELU ol loqoJ IILIIA Ep JEIIop-uoqlIuDInuI pue 'sut3;Etu 'a;tqs e Sutstq:rrnd se qlns selloqf, 3o suontrrldur 'brpnb eql esslll ul sJa leIJEur lnoqE suoEsanb IErlrrEUr+ ISE Ol 3nulluol sttoneztutS;o a8ueqr -pEa'I '(ZI0Z ltllluorunlg) e-rtr jo ibrpnb uo sosllroJ rtqr '{Salerrs r'S,ru.rrurrldrut ot .{eu.lno[ Jlerp uo sseJppe rsnru '(aqr ]Eql sJo]lEJ luepuad asoql -apJalu 1o e8ut-t :pL{\\ 3q} 3o SurpuusJopun uE llagal suourzturS;o 'a:ur:uro;"rad IEIlueuIJ har,r pe:utleq eJoru pue JepEoJq srqr Surrdopt {g Sutu;ea1 's'(e'Lrqted put t;oddo qlto'r8 pue 'sae,(oldlue uo ,,',ro3 ,nt.1, 1 rlur pur lueued eql Jo *ol:1: IErru{l Jo asn st qrns srssrro /r\\ "{yrutl ''(8cle-rls rraq] adrqs -.red eqr sepnpul qreo.rddu p[*,,l[rs pa]uEIEq aq1 'uoIltAoLIuI {SalBrlS leuotleztueSlO alol aql se [1t1 rlueu-raldul 1 :9r raldeq3 Healthcare Qu a lity Strong leadership is required to unfreeze the old culture and tN(sition the organization to one that focuses on high value (Gabow, Halvorson, anC IGplan 2Ol2). These culture changes may be facilitated through a shift in the development of healthcare professionals to better match what hospitals ancl society need (Aretz 201f ). Although a greater emphasis on interprofessionai teams may assist in this cultural transition, achieving the much-needed transformation to higher-quality and lower-cost healthcare delivery ultimateli' requires engaging physicians and leveraging professionalism (Conway anc Cassel 2012). r Forming o Powerful Guiding Coolition Tou cnn nccoruplish nnything iru life, provid.ed. yow do not ru.ind. who gets the crer{.it. -Harry S. Truman "Leaders get the right people on the bus (and the wrong people off ti:. bus) and set the direction," says Jim Collins (2001, 13), author of Good;: Great. Creating a strategy for qualiry improvement requires a team becaus. no single leader can drive a sustainable change lvithout the rest of the leade:ship on the bus and in the correct seat. The organization's change effort s:' determine r.vhat skills are needed in specific leadership positions. Senior leacers must coach, promote, or hire the right people u'ho clearly understand tr: urgency, see the need to change, and have the correct set ofskills essential :guide and slrpport the change. At this stage of the journey, a few ke,v lea;ers ma,v need to be asked to get off the bus or change seats because ther' .-: unwilling to embrace the shift to the nerv culture or do not have the require : skills. If, for example, a hospital CEO realizes that the market position olu:: hospital is challcnged by lor.ver reimbursements that negatively affect marg:::: and quality, all of the senior leaders must clearly accept the threat and -r: strategy to address this threat. Leadership that is responsible for communic.:ing this challenge in a troubled organization must recognize the feelings a:-: perspectives of ernployees. Atchison and Bujak (200I) provide the follos::: insight about this situation: lndividuals go through a predictable progression in working with an organization. First, an egocentric position, do I have a iob-am lgoingto get fired? Ontywhen that issue is worked out can the emptoyee progress to a role-centric situation, what is my job-where is my desk? lf the person has a good grasp on her rote then a mission-centric situation develops, what can I do to hetp-tet's do good for the organization? The first step is moving senior leadership to a mission-centric posiu: The leadership team must first clearly understand their job and expec:.: (]eIJEur cJerqlJEar{ e^Er}adurol ,.(y8ursranur eqt uI 'qt8ua;ts pue ,b111qsorr -Ets Itlsg JoJ uJaf,uof tee.r8 lnoqll{\\ afuJtsrxJ paluerJo-uorSr^rur E ensrnd ol dlrunl.roddo eq] uo snJo-I o] popue] eAEq suoDezrueS;o ]qo;d-;ol-lou tsoru 'tseruof, r-rl 'pJefeJols paruEluq Jqt lo ]uJruele arro fluo sr q]rq,{\\ .s}r;o.rd 8ur,Lo;dtur uo sl1loJ reql .{8.lre.rts E pue rrorsrl E elreJl suorlrzrueS.lo luo'td -roJ lsow 'alels ernlnJ aqt eAerLIrE ot op ot eAEq IILI\\,(aqt req,n pue alrl {ool IIIA\\ aJntnl eql ltq,lt puelsJapun ol uortezrueS.ro eqr ur auo,{.ta,ra s,\\\\ollE teq} asrlJexe LrE sr uorlfa;rrp rr8alr.rls ,\\\\eu E Surtee.r: pur uorsrl e Surqsqqersg ,b1zra-rg au(q11'a4 ot fltto?st tltnd aa[ufi [a4tor1 luo,tfy puD /$a1ot1g uolslA o duldo1atag aell a"tltldt 0t saru\\s 'spo8 slrlo rroqs IJE-I 1mr .{8erer}s aqr pue pe^erqlr og ro,\\eu IIL{\\ IJo,\\\ uEel en.tt ,lsn.r} tnoqtr6 'JJqlo qf,Ea ur tsnrl sr alrq tsntu sJaqr.ueru rueel aqt lErlt tesst IElurJf tsoru eql sdeq;ad rng 'LrorlEurJoJSuEJ] JoJ qll{\\ uortrltor Surprn8 r Surtea.rr JoI )lJo,treure{ E sp ol_ras deu reqt uollelouul a,rqdn;srp -ro3 qoeo.rdde uE pauUer (OOOZ) 3ue,r11 pue d.ressarau s]IDIS aq] 'uetussorg 'uasuelsr.rq3 'l:e; u1 'GOOZ LresuelsrJLlJ pue ,ucs.ra8a.rg ,;a,{q) 8un1o,r,e aq ot suees uortclouur Jo etrLr)os aqt ,(leteuntJol pue ,1etqr.r: sr uortrltol Sulprn8 aqt unJlr,r\\ uouelolrlrr 8uuea.r3 'e8ueq: a.rrdsur or tq8noqr aAuElorrur Jo esop .{qrpaq E apnllur ppoqs uor}rleol Surprn8 y 'sEeJE aJEf ]ueutd ur salrlErlruruaure,ro-ldrur pEal ]snlu sJep?JI lelrurTl ,(a1 rnq 'puno;8 uourruol Surpug puu tIoIJElIUnururoJ eArlt3JJJ q8no.rqr uorsrl paJeqs e a;rdsur ot ldrueue ,teu s:,r.n -nfexg JJEIS lBllulp Jaqlo pUE 'sosJl-Iu 'suetrtsdqd aJE eJEf le]rurll 3ur,ro;drur Jo sJeArJp IEaJ eqt 'a8ueq: uoddns puu po-ld uEl sJlrlnlexe alrq/A .uorlrleo) 8urpm8 eqt ur JJEIs pue sJepeel IElrurlf, Ia1 apnl:ur ]snllr selrtnf,exg 'rbrpnb uo pastq aJnllnf Ieuortezru -t8ro,neu E preA{.o} alour ol po8 aqr puu uorsrl eq}Jo Surpuets;apun peJeqs e do1a,r.ap uorlezrueS;o eqt dlaq ot sr uorlrleo: Surprn8 aLI] Jo a1o.r eqa ',tr -pnb tnoqe alruorssed oq lsnu ,(aqt pue'3ruelsrsal qlr.{\\ IEap ot pue .e8ueq:feJrp ol 'uorsrl eqt t;oddns o] sllDls pue 'e8pal,trou>1 'e;rsap eqt JAErI ]sntu rutel eqt Jo sreqr.u3r.u JqJ ']JoJJO a8urq: :qr Surpeal ro3 ,tilqrsuodse; aqt seq lEr{t u0xtx/u03 OurymO aql pelaqel (EOO1)re}to)J leq.l.r e}ean ot sdleq r -lrqelurlorrt pue suorltlfedxa tnoqe Surpuels.rapun uourruol srrlT.dtclsaapual iquaefifla pellel e^eq (ttOZ) san8eallot pue raupreD terl,r\\ ol ltnursse sllDIS put 'snrog 'd1r:rual erp sa.rrnbar qrFI^\\ 'alueru;ol;ed .rraqt JoJ alqelunolle plaq aq lsntu 's.tolf,aJlp Jo ptEoq eqt 8urpn1:ur 's.repre1 Jorues 'Jor^Er{aq rleqt uo IleqpaeJ .(1aur1 puE a^nlolJa apr,ro;d lsnu ueq] pue a:urru.ro;-red Jreql Jo-I suorletradxe eql purtsJeplrrl sJJpEel aqt ]Erl] JJnsua tsnlu OgJ er{l 'snqJ '(ZI0Z ee-i sur8cq tuaurano.rdrul ,tqenb ot Ieu;nof Jqt sE sa,rr]tafqo g {EarBrls leuorlezrueEro aroJ aq} sp {1r1enI Eurluatualdtul :9r raldeql The Healthcare Quatity Book it becomes won't be kept." This backr.vard the norm that perfbrmance corl) slide is described by Mankins and St. (2005) as an "insidious shift in culture," and they note that "once it t:, root it is very hard to reverse." become experience, l Refreezing New Approoches in the Culture The birurest iruped.iruent to creatitrg change in ogroup is cubwre. P. I(otter -John One vital purpose of the process is to unfreeze the old culture and refret:: a new culture that has nerv behaviors and approaches at its core that supp,-: qualiry Culture matters bccause it drives employees who are responsible:." executing strategy. The key, to solidi{,ing the ner.v culture is to measure -*,: success of the strategic goals and share thc data throughout the organizati, -_ Sharing data in a transparent way lyill help to drive the change to qualin' -: reinforce the neu, behaviors that bror"rght about the positive results. The cl-rallengc for the leadership team and the guiding coaliriorl i::. decide just hou, detailed and precise the information has ro be to supi -: the change arnd anchor the new culture. Information paralyrsis is a comr ,: problen-r in healthcare organizations. Despite the promise of data from p,' erful manageffrent svstems, the ef-fective leader mlrst act on trends rather t:'wait for statistical significance. Achieving statistical significance for cri:;r marlagemcnt decisions may take years. An executive r,r,ho ,uvaits for per:.-inforn-ration mav impede the change process and damage the organizatic -. competitive positior-r. One must knou, what to measlrre . \\4&ile the por,verful data systen:. most hospitals can churn out reams of data, only a fer,vpieces of infornta:-,: are uscful to irnplementing improvement. Michael Lervis (2003), in his h-.x Morue\\,bo,ll, prcsents the story of hor,v thc Oakland A's achieved char-r-rp: - ship baseball seasons despitc having one of the lolvest-salaried tearns in ---,: major leagucs. The manager of the team found that the traditional rrreirs*r3 of batting average and home rllns were not necessarily the most ilnpor:--: measures correlatcd to lvinning baseball games; he understood that on-; r perccntagc u,as fhr more important. lvith this neu, rvalr sf thinking, the -r, u,ere able to recruit less-expensive players r.r,ho could consistently get on b .\\: rnhich helped r.vin games. This simple story demonstrates the importanc; .r. knor,ving the critical fbr.v measures that r.vill drive change . Healtl-rcare lea;=: can learn frorn this base ball story to look at their data in a differenr u ar l ' identifi,ing the right measures to achieve the organizational vision, execu:' :. can bcttcr lead the organization to success. In rnaking informed decisions, the executive must consider the e:--of those decisions from all pcrspcctives. A decision to improve flna