The LEADS framework as a roadmap for implementing quality management

Dawn S. Hartfield, MPH, MD

https//doi.org/10.37964/cr24716

 

Large-scale implementation is a significant leadership challenge. The task can seem overwhelming, but a structured approach can transform what seems to be an impossible problem into a solvable one. When implementing our quality management framework, our team used the LEADS framework as a roadmap. As a physician new to a senior leadership role, using LEADS, along with other tools, bolstered my skills, ability, and confidence and those of the team to carry out a significant, large systems change. This journey demonstrates a unique use of LEADS and other tools that medical leaders may find of value in their daily practice.

 

KEY WORDS: quality-management framework, LEADS framework, quality-improvement systems, implementation, system transformation, physician leadership

 

 

Establishing a framework for managing quality in health care systems is a challenge, and one that requires physician leadership and buy-in to be successful and sustainable. For medical leaders, knowledge of the concepts of quality and safety is important, and additional leadership skills are critical for success. This paper describes a case study in implementation using LEADS1 within Alberta Health Services (AHS), a provincial health authority in Alberta, Canada.

 

The LEADS framework (Figure 1) describes five core leadership domains (Lead self, Engage others, Achieve results, Develop coalitions, and Systems transformation), and each domain is supported by four capabilities. This practical framework is used nationally, is readily accessible, and provides an evidence-based model for health care leadership development.2 Using LEADS as a guide, as well as other tools borrowed from industry and the business world, we established a quality-management framework that is embedded in the work that we do in our complex system. This implementation journey demonstrates a unique use of LEADS and other tools that medical leaders may find of value in their daily practice. Top

 

The journey began in 2013 in the Edmonton Zone (EZ) of AHS when it was determined that a framework for quality improvement, distinct but supportive of our patient safety system, was required. This direction came from our parent organization, the senior leadership team in the EZ, but was also a requirement to meet the standards of the Health Services Organization (formerly Accreditation Canada). The goal was to establish a system that would provide vision, leadership, and direction for quality planning, monitoring, and improvement; to enhance an integrated approach to quality; and, ultimately, to develop a structure that connects the frontline provider to senior administration. The vision was to deliver better quality, in the form of better outcomes, experience, and value to our population. Top

 

I was hired as the “medical director for quality and safety,” and my primary task was leading the team that would establish this new system. I am an academic pediatrician and, at the time, had nine years of experience in quality and safety, had established a quality-management system at our children’s hospital, and was involved nationally with organizations where I taught quality and safety. I felt confident in my quality and safety knowledge and skills; however, I had little experience outside child health and was unfamiliar with the operational structures and leadership teams that worked across the EZ. I understood the importance of the task and the difference that could be made to the system, providers, and patients, but needed to expand my network. Top

 

I was excited about the new challenge, but many questions swirled in my mind. How does one engage others on a zonal or provincial scale, to participate in establishing a new quality system that comes with no resources? How could I provide a compelling story to encourage others to embark on this new quality journey? I clearly needed a strategy to approach this work. Top

 

I had recently been introduced to the LEADS framework through the AHS Executive Leadership Program.3 This program, developed by University of Alberta School of Business, Haskayne School of Business (University of Calgary), and AHS, is based around the LEADS framework and provides emerging health care leaders with fundamental leadership skills to enable success in their roles. On reflection, I determined that using the LEADS framework as a guide to establishing the quality-management framework would help break down what seemed like an impossible task into a series of logical progressive steps. If LEADS was designed to facilitate leadership development, why not use LEADS as a structure to develop a quality-management system? Top

 

I began the journey with Lead self, which involved significant self-reflection.1 As mentioned, I was comfortable with my knowledge, skills, and ability in quality and safety. I had established programs in the past and could lean on some of the same skills, but this work was at a completely different scale. I had recently completed the LEADS 360 assessment and again reviewed the feedback along with my executive coach results to look for pearls of wisdom from those who I had worked with.

 

I realized that relationship building was going to be critical for me, and personally challenging. I am an introvert who tends to be quite private and prefers not to “overshare”; therefore, I avoid asking colleagues a lot of personal questions as I fear being too intrusive. I was surprised to learn from the LEADS 360 assessment that people needed this from me as a leader, to take relationships with team members to a different level. People I worked with wanted to know how I thought and felt about things. This was clearly important information I would need to use as I was building relationships. In addition, it was apparent that given the scope of the work, project management would be important, as would a very structured process to change management. Top

 

A second domain of LEADS is Engage others.1 In this project, engaging others included a multi-faceted approach. Most immediately, I sought to establish relationships with the new project team I was leading. This involved many coffee conversations, learning about their incredible skills and abilities, as well as about their lives outside of work. (I found a comfortable balance!) Top

 

We took a change-management course together (ProSci, Halifax, Nova Scotia), which was extremely helpful and resulted in great team bonding. We reached out to local leadership teams to learn about their current resources in terms of quality and what was important to them, as well as our provincial quality team. It was extremely important to ensure that our approach aligned with the province’s direction and to avoid any duplication of efforts. We also reached out to external organizations to learn from others (the Develop coalitions domain of LEADS1) and completed a literature search. Top

 

The information gathered from the engagement exercises allowed us to establish our structure, which is very simple (Figure 2). The frontline unit quality councils are the heart of the system — at the interface of care. These are multidisciplinary teams whose membership mirrors that of the care team, supported by improvement experts, whose role is to identify and solve problems in their environment. The unit quality councils are supported and guided by the site/program quality councils in their area. The zone quality council provides support and guidance for the quality management framework in the EZ by helping to guide priorities, remove barriers, and provide education and other support. They link directly with the provincial teams to ensure alignment of priorities. The system is the ultimate responsibility of the Senior Leadership Team in the zone which includes the operational leaders (the executive directors) and their physician dyad partners (LEADS Systems transformation: demonstrates systems and critical thinking1). Top

 

Once the structure was defined, we moved on to establishing an implementation plan. Thus, achieving results1 involved establishing a clear project management plan, including a change-management strategy. Our team used our newly acquired skills from the ProSci course (Systems transformation: champion and orchestrate change). We set goals and established measurements that we could use to define success. As part of this, we set up a reporting system for the quality councils, so that we could understand the work they were doing, and the enablers and facilitators needed to complete quality work. We also used the Institute for Healthcare Improvement’s (IHI) capability self-assessment tool, to track the progress of our system over time.4 Top

 

We developed coalitions with the program and site leadership teams and used a structured process to support the establishment of their quality councils. This was an iterative process that we adjusted as we learned by bringing on board teams across the EZ. Included in this structured process were tools for our teams to use, as well as guiding documents for the quality councils. One of these was a standard terms of reference based on Juran’s trilogy of quality planning, monitoring, and improvement5 so that the teams understood the work to be done.

 

One year after we began our work, we began to see system transformation1 (Figure 3). Eighteen of 23 targeted quality councils were established. By the fall of 2016, after nearly two years, the number of councils in the EZ had stabilized and, to date, remains just over 100. Top

 

Our reporting system has provided some interesting results. Quality councils have regular multi-disciplinary participants and reflect care team membership. Over half of the quality councils have regular physician attendance. Of note, councils with physicians involved were more successful in achieving their goals. Over time our system became more transparent; from inception, the number of teams with quality boards in public facing areas had doubled to 70%. The councils had work plans in place, these teams were completing quality-improvement projects successfully, and these were having a positive impact on outcomes. Only 9% had a patient advisor, identifying an area for focused system improvement. Top

 

Most important, we could see that organizational culture with respect to quality improvement was changing. Early on, a common “barrier” to success identified by quality councils was not having adequate access to a quality consultant to do project work for the team. As time passed, the most common barrier shifted to the team having insufficient time to complete the work themselves. The teams were engaged and were hands-on, rather than having someone else do improvement to them. In addition, teams were learning basic concepts and realizing the importance of change management and the need to invest training and thought in this part of the process. Indeed, the structure was in place, and we were seeing a shift in culture: system transformation. Top

 

In early 2017, we completed a comprehensive review of the quality management framework including a SWOT (strengths, weaknesses, opportunities, and threats)6 analysis, repeat application of the IHI capacity self-assessment tool,4 extensive internal consultation (within the zone and province), and a follow-up literature review culminating in a five-year strategic plan7 (AHS, internal communication) to continue to foster the development of the system. Our findings aligned with Frankel’s white paper, “A framework for safe, reliable, and effective care,”8 which validated our approach. Top

 

This work is part of our ongoing quality journey and includes the following elements:

Improving safety culture

1. Building quality and safety literature
2. Establishing a leadership management system
3. Enhancing use of quality indicators to drive improvement

 

One highlight of this part of the journey is establishment of a full-day improvement course that tackles all four pillars of work. It is targeted at quality council members and has them complete the day with a “straw-dog” of a project that they can take back to their quality council to refine and implement. We have assessed this process using the Kirkpatrick Model,9 as we wanted to be sure that the day was a worthwhile investment for participants and the organization alike. We have demonstrated significant improvements in knowledge of participants through the use of a pre/post-test (Figure 4). We are aware of teams that have completed the projects they developed at this session and received grant funding to support the work. A formal assessment of the longer-term impact is currently underway. Top

 

Now, over five years into our quality journey, our framework is seemingly entrenched in the system, but, as with all organic systems, will require ongoing nurturing. It is, of course, not perfect. On reflection, the decision to use the LEADS framework to guide our early actions was a sound one. LEADS is a flexible model that can be used at a personal level for leadership development and, as we did, to structure an approach to a large leadership challenge. This ensured that we used a comprehensive approach and were intentional in our actions each step of the way. Top

 

When one considers complexity and the Stacey matrix (Figure 5), this approach enabled us to transform a complex implementation challenge into one that was complicated and manageable.10 The domains Lead self, Engage others, and Develop coalitions fostered a shift toward “agreement”; the domains Achieve results and Systems transformation supported a shift towards “certainty” as theories were discovered and tested in the innovative and iterative processes that we used. To take the small steps required to move from complex to complicated required patience and time, trust, creativity, and the ability of our team and senior leadership alike to tolerate risk of failure. Top

 

As an industry health care has much to learn from other disciplines, such as business, the social sciences, and manufacturing, to improve our ability to both lead and manage. In addition to the LEADS framework, our team used many valuable tools to facilitate our work toward systems transformation, which I have shared as part of our journey. Education in leadership and management, change management, project management, team building, executive coaching, just culture, quality and safety are invaluable for physicians leading both small and large teams. Having tools in an easily accessible toolbox is invaluable in navigating through the complex leadership challenges one can face in health care. Top

 

References

1.Dickson G, Tholl B. Bringing leadership to life in health: LEADS in a caring environment. London: Springer-Verlag; 2014.

2.Health leadership capabilities framework. Ottawa: CHLNet; n.d. Available: https://tinyurl.com/uaoxf2d

3.Ilches S, Fenwick S, Harris B, Lammi B, Racette R. Changing health organizations with the LEADS leadership framework: report of the 2014–2016 LEADS impact study. Ottawa, Canada: Fenwick Leadership Explorations, Canadian College of Health Leaders, Centre for Health Leadership and Research, Royal Roads University; 2016:15-7.

4.IHI improvement capability self-assessment tool. Cambridge, Mass.: Institute for Healthcare Improvement; n.d. Available: https://tinyurl.com/rg76ktl

5.Juran JM. The quality trilogy: a universal approach to managing for quality. Presented at the 40th Annual Quality Council, 20 May 1986, Anaheim, California. Milwaukee, Wisc.: American Society for Quality; 1986. Available: https://tinyurl.com/sasmgou

6.SWOT analysis: how to develop a strategy for success. London: MindTools, Emerald Works Ltd; n.d. Available: https://tinyurl.com/orj7fnm

7.Hartfield DS. Quality management framework (QMF) strategic plan 2017–2022. Edmonton: Edmonton Zone, Alberta Health Services; 2017.

8.Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A framework for safe, reliable, and effective care (white paper). Cambridge, Mass.: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.

9.Kurt S. Kirkpatrick model: four levels of learning evaluation. Champaign, Il, USA: Educational Technology; October 24, 2016. Available:  https://tinyurl.com/y2lqcb2n

10.Stacey RD. Strategic management and organizational dynamics (2nd edition). London: Pitman; 1996. Top

 

Acknowledgements

I thank Dr. David Mador, who was senior medical leader in the EZ while we were implementing the quality management framework (QMF), for his support and encouragement and, most important, for challenging me. His initial vision of moving from just “talking about quality to doing quality” paved the way. I also thank our QMF team, and specifically Dr. Michael Auld for his support of the work as well as critical review of this paper.

 

Author

Dawn S. Hartfield, MPH, MD, is an academic pediatric hospitalist who has been working in the field of quality improvement and patient safety for nearly two decades. She is on the Faculty of Medicine and Dentistry, University of Alberta, and, until January 2020, was the associate zone medical director, Integrated Quality Management, Edmonton Zone, Alberta Health Services. She has since become assistant registrar at the College of Physicians and Surgeons of Alberta.

 

Conflicts of interest: None.

 

Correspondence to:

Dawn.hartfield@ahs.ca

 

This article has been peer reviewed.

 

Top