Q: What is the gap between leadership as it's currently practiced, and the "best practice" of leadership for system improvement?

A: In many health care organizations, leaders (the chief executive officer, chief medical officer, chief nursing officer and other leaders scattered throughout the organization) might have some idea about how to lead what we would call a "project" — that is, to apply quality methods to achieve improvement in a particular disease or condition in one department or unit. We have a lot of experience at project-level improvement.

But leaders are less sure about their ability to achieve whole systems improvement in measured performance. For example, to take a project and to scale and spread the improvement across an entire institution to every place that is applicable. Or to move performance of the "big measures" such as mortality rate, overall institution infection rate, and the like from one level to a significantly better level. So this is the challenge: to help leaders achieve system-level improvement, rather than just project-level results. (By "system," I mean an aggregation of many microsystems such as an entire hospital, an individual multispecialty group practice or clinic, or even a set of hospitals and physician practices within a community.)

Q: Why is achieving improvement at the whole system level so much harder than at the microsystem level?

A: Leading measurable improvement at the whole system level is simply a lot more complex than in any one unit or department. For one thing, there are just a lot more people involved. For another, there are many more types of people who must engage in the work — across multiple disciplines and professional backgrounds, for example. Also, to spread improvements across multiple units, leaders often discover that some of the underlying core systems — human resources policies, for instance — need to be changed as well.

For example, a project on one unit might improve the way the nurses document a process in such a way that it takes less of their time, is more reliable, and drives the use of evidence-based practice. But to extend that change to every nursing unit, first of all, the number of different people that have to change becomes a problem. You may have chosen to start your project on the nursing unit that has the very best local leadership. But leadership is not uniform across your entire nursing system, so you're going to have to get this change to happen in units with less than fully capable local leaders. That's a common problem; it raises the question of the quality of the entire nursing leadership system in the organization. Now you have to work on two problems: one, implementing the change itself in every local unit; and two, improving the quality of the nursing leadership system.

When you start to work across all parts of the system in order to achieve improvement, you get into the human resources policies of the organization, the information technology system, the budget process, the way managers are compensated, and the hiring processes for leadership. You're not just making a change in one set of processes and leaving the rest of the organization systems intact; you have to change lots of things throughout the system.

Q: What do leaders need to do to achieve system-level change?

A: IHI has formulated a theory, called the Seven Leadership Leverage Points for Organization-Level Improvement. We believe that starting to work on one or more of the seven leverage points frames an agenda that leaders can use to drive system-level improvement.

One way for senior leaders to begin whole system improvement is to start measuring whole system performance — not once a year, but once a month or once a week. For example, instead of measuring infection rates for a particular surgical procedure such as hip replacement, measure infection rates for all surgery in the hospital and track that at the whole system level. Starting to measure performance at the whole system level will actually start organizational leaders thinking about what it takes to move those measurements.

Another thing that leaders can do, which follows naturally after starting to measure something important at the whole system level, is to set an aim for improvement — an aim that actually states "how good by when" across the entire institution. This is not a vague aim such as "We would like to get a little bit better," but far more specific like "We would like to be at the benchmark level of performance within one year," or "We will cut the level of infections in this hospital in half within six months."

When you have an aim and a measure that you are tracking, then you have to develop a plan for how that measure might be improved. This forces leaders to think beyond the project and make spread a planned event, rather than something that you just hope happens.

Q: What are the barriers to leading in this way?

A: Quality improvement has always been the right thing to do. The driver for it has been moral and professional — if patients are suffering unnecessarily, or not getting all the the evidence-based care that could help them, then we have a professional obligation to improve our care. But other drivers are starting to appear that strengthen the imperative for improvement for organizational leaders. For example, the quality performance of all of the hospitals in the country is now being measured and publicly reported — for example, the Centers for Medicare & Medicaid Services (CMS) Core Measures — and achieving high levels of those measures has now been placed on the agenda of the CEO. Simply stated, for strategic and business reasons, hospitals want to look good when those reports come out.

Another reason is that hospitals and doctors' practices increasingly are being subject to pay-for-performance business models where they actually stand to either make some money or perhaps lose money depending on their measured quality performance. This is a very new thing and it's a bit too early to tell how much of an effect it will have, but it is another driver — in addition to the professional and strategic drivers — for leaders to pay attention to achieving measured improvement in quality.

Q: Can you give me an example of a best practice leader? What does he or she do?

A: One thing an effective leader does is to channel attention to the quality challenge. A great example would be Rob Colones, President and CEO of McLeod Regional Medical Center (Florence, South Carolina). McLeod has instituted daily Leadership Patient Rounds. Every morning, Rob's entire senior team meets in his office and goes out to a particular floor in the hospital that is designated in a rotating scheme, where each member of the senior team — the CFO, the human resources leader, the chief nursing officer, and so forth — visits two or three patient rooms, finds out about how things are going, and then returns to Rob's office. After a half-hour debrief, they go about the rest of their business. In other words, every day they are in touch with the customer directly and finding out about how the institution is working. I can't think of a better way for senior leaders to remain closely connected to what is happening at the front line and, in particular, getting direct patient input on the performance of the organization.

In addition, every week Rob leads a meeting of the entire senior team to review and focus on the major quality initiatives that the organization is working on. This is a weekly hands-on event with the senior executive team reviewing performances, reviewing data, breaking down barriers that cropped up in the course of trying to implement something. The results: McLeod is in the very top tier on all of the CMS Core Measures for hospitals, and has improved its mortality rate dramatically over the past year or two. This is not an accident.

Q: Why don't more leaders lead this way?

A: Leaders have a lot of things on their plates, so they can't just add quality improvement on top of that busy agenda. They must make quality a core strategy of the organization — and knit the quality agenda together with the market share, financial, and other aspects of their strategy. That's probably the most important barrier that must be addressed — a mindset change from "quality is the job of the quality department" to "quality is a core operational responsibility for every executive, every person."

A more subtle barrier, which I think is important to name, is that leaders sometimes don't feel comfortable taking on this task, particularly where it involves clinical matters. In many instances, the CEO is not a clinician by background, and so feels more comfortable delegating responsibility to a clinician and watching from the sidelines. The truth is — and this is the beauty about quality improvement methodology — if you know the Model for Improvement, if you know the Toyota Production System, if you know a good solid quality framework, you can walk into any circumstance, whether it is medical care, the airline industry, food management, or manufacturing of giant metal parts, and apply quality methods to the improvement of that set of processes. Without knowing anything technical about the actual work being done, you can be a good quality improver by being a skillful user of quality methods and tools, by working with people who do have the knowledge of the technology. What leaders like Rob Colones and others are discovering is that they don't have to have technical knowledge about clinical matters in order to be good improvers. The excuse that "I don't have the technical knowledge, therefore I shouldn't be involved in these activities" has turned out to be an unwarranted fear.

Q: How should leaders use the Leadership topic area on IHI.org?

A: We have pulled together resources that leaders can turn to as they try to improve their leadership work. A leader who hears about the Rob Colones example and says, "I'd like to have my senior team get out and visit with patients every day; how would I do that?," can turn to the Leadership WalkRounds Tool. These tools give leaders very practical guidance about how to change their leadership behaviors. Or a leader asking, "As I look at next year's quality agenda, and bring my Board and senior leadership team together to plan the work we are going to do, what do we need to be thinking about? What framework can we use to assess our current approach and make improvements to it?," can download the Seven Leadership Leverage Points white paper and do an audit of the organization's current leadership approaches and design improvements.

As the Leadership area of the website goes forward, we would also like to populate it with good leadership case studies and stories so that people can read and learn from the great leadership work of others who are struggling in the same business.

Q: If I am a leader reading this, what can I do by next Tuesday to start this work?

A: By next Tuesday, I'd read the Seven Leadership Leverage Points white paper and do the self-assessment at the end of the paper. (Note: The self-assessment is framed for organizations involved in the 100,000 Lives Campaign. If your organization isn't involved in the Campaign, you can easily transpose the self-assessment so that it refers to whatever system-level quality challenge you are facing.) I'd then ask my colleagues to do the same thing, and have a conversation with them about what this exercise revealed about our leadership for system-level improvement. The output of that conversation should be the beginnings of a plan to achieve measured improvement in something important at the level of your whole organization.