Kathryn Walker Zavaleta, FACHE, quality manager, Central DuPage Health, Winfield, Illinois

ORGANIZATIONAL INFORMATION
Since its establishment in 1964 the health system has been a leader in providing a range of services across the continuum. Comprising a 400-bed acute care facility, a network of employed primary care physicians, urgent care centers, home health care, hospice, and rehabilitation services, the system also supports an assisted living facility and a retirement facility. It is operated as a not-for-profit corporation and has a board of directors with strong community representation and participation. Serving a primary market area of 250,000 residents, the system has established a strong reputation for providing high-quality care.

BRIEF STATEMENT OF THE PROBLEM
To meet the challenges of accreditation requirements and the need to demonstrate clinical excellence, the system needed to develop its capacity for improvement. Doing so required the design and implementation of training programs that would address the cultural and practical constraints within the system and medical staff.

DESCRIPTION OF THE PROBLEM
Although more than slightly embarrassed to admit the fact, the system realized that its focus on the topic of quality had taken a back seat. Quality improvement training, and the skills those training programs sought to develop, had lapsed entirely. The board dutifully, although infrequently, received performance improvement reports but rarely took action on the reasonably good news it received. In general, the CEO delegated matters of clinical "performance improvement" to the quality department and medical staff. Most quality improvement activities revolved around preparing for accreditation surveys. Patient satisfaction scores and any concerns those scores represented were left to the marketing department to address. The majority of board and executive attention was focused on financial reports and business expansion. Management meetings rarely included reports of improvement successes. Although the system was successful and had a good reputation in the community, it was content with "good."
In 2001, the Institute of Medicine reports, To Err is Human and Crossing the Quality Chasm, became to the board and leadership a resounding call for action. The latter report, in particular, echoed a growing sense within the system of a need for working differently. More and more frequently, discussions in the boardroom and among the leadership touched on this need for change. Executive management listened when an accreditation surveyor commented, "This organization just doesn't seem to get the concepts of performance improvement." Although the system was granted full accreditation and its scores were unremarkable, it heard the message clearly. It understood well that, in the not-so-distant future, regulatory and accrediting agencies would be carefully scrutinizing the effectiveness of its efforts to improve patient safety.
By early 2002, changing accountability to improve the quality of care and services seemed an imperative. Without improvement in the systems and processes that deliver care, alignment of organizational objectives clearly was impossible. Work at successive board retreats had focused on an objective evaluation of the system's clinical outcomes, market share, and patient satisfaction scores. Community board members with experience in quality management programs at large manufacturing and service corporations enriched management's conversations on quality and its relentless pursuit of excellence. To take the next steps forward, enhancing management capability and competency with quality management systems would be necessary. The system would be starting from scratch. No educational programs on process improvement or quality management were available to managers, nor was there a common approach to process improvement among the different enterprises within the system. One enterprise had some experience with the Rapid Cycle methodology through participation in the Institute for Healthcare Improvement's improvement collaborative. Another listed "FOCUS-PDCA" in its performance improvement plan. A third had previous experience with the FADE (focus, analyze, develop, execute) methodology, although concrete examples of its application were entirely absent from management discourse. However, to support effective improvement initiatives, the system needed a common language.
A palpable reluctance among key executives to participate in quality training seemed to make the design and implementation of the program all the more complicated. For some, the mere term "quality improvement" seemed to conjure up images of endless arguments (e.g., Deming versus Juran). Those who had been with the system for a number of years associated quality improvement with some very painful experiences from a reengineering initiative implemented eight years previously and explicitly linked with total quality management. Individuals recruited to the system since that time often expressed their frustration with quality improvement programs at other organizations that seemed to consume time and team meetings but produced little progress on key issues. The system's training program would need to demonstrate a return on investment for each of its participants as well as for the organization.
The medical staff had little experience with quality improvement approaches; their committee work was largely focused on case review. Few of the elected department chairs had ever had any exposure to key strategies for achieving clinical quality improvement. Their support and leadership were needed if our training programs resulted in successful improvement efforts. Under no circumstances could the medical staff be left out, nor could they be expected to drive a more disciplined approach alone.
The design of a successful training program would also have to create an explicit link to other organizational development initiatives. Specifically, the system had invested a great deal of time and attention in leadership development programs. Participation in these programs had indeed helped to make key principles of accountable leadership and clear communication part of the organizational fabric. Some members of the management team felt very strongly that "accountable leadership" represented an alternative, a more promising path than any quality improvement methodologies introduced to the system. The concepts of quality improvement seemed to be seen as noise, and distracting noise at that! Building on the concepts of accountable leadership was needed, not competing with them. Practical issues also needed attention. The need for cost effectiveness was a challenge. Competition for time and attention of managers demanded a very focused program, so we had to be parsimonious in our program design.
My role as quality manager for the health system was to design and execute an education strategy for enhancing the organization's capacity for quality improvement. I would work collaboratively with the director responsible for training and development and with the senior leadership team.

ADMINISTRATIVE DECISIONS
Plan
The planning phase focused on the "who, what, when, where, and how" of the program design and implementation. With assistance from training and development, I took the first step of matching the desired competencies with specific roles within the system. I created a table of competencies based on input from an outside consultant and from the literature (see Appendix 1). The planning phase also addressed such questions as the content of the curriculum, format, potential need to purchase materials or services, selection of participants, and timetable for implementation. In terms of program content, I recommended focusing on specific concepts and tools directly related to the manager's or executive's role. Presenting the program as an extension of, not an alternative to, the leadership development programs already in place would be essential. The program would need to be practical and application oriented. We wanted each participant to feel that their involvement would make them more successful at their job.

On the advice of our human resources department, we began with small groups of 20 to 25 individuals in a classroom setting. Although we knew that alternatives to classroom work exist, we felt that in our environment a classroom setting would be the best way to emphasize applications of the concepts. The concepts and tools of quality improvement are very simple, but applying them is not. We wanted to ensure that participants left feeling that they could immediately use the material in their daily work. At this point we decided to contract with an outside consultant to conduct the training, as the current workload would not permit internal staff to develop and teach the curriculum. Another alternative was to use the train-the-trainer approach and contract with one of the well-established organizations in the quality field, such as the Juran Institute in Wilton, Connecticut, or Goal QPC in Salem, New Hampshire. Because of cost considerations we opted for an independent consultant. This choice also made it possible to add materials to the program content, which was designed to reinforce the connections between our leadership development training and the role of leaders in a quality-focused organization. The consultant recommended that senior management participate in the first offerings of the course. Although we would be cascading training through the system, beginning with the executive staff and senior management, we wanted to replicate the system's positive experience with providing opportunities for the executive staff to participate in training opportunities in a forum that represents a mix of roles and hierarchy. We also decided to begin with administrative staff and then address the needs of the medical staff. Happily, several of the employed medical staff leaders chose to participate in the program from the beginning. We could have selected one of the enterprises within the system as a pilot site for the program, but we opted to open the program across the system. The senior leadership team felt that providing a forum where individuals participate from different enterprises would help reinforce our identity as a health system.

Once the request for proposal, subsequent interviews, and selection of an outside consultant were completed, curriculum design began in earnest. The final curriculum design was a mix of opportunities for learning offered by both internal resources and the outside consultant (see Appendix 2). (In the future, we anticipate that the program will be entirely supported by internal experts.) One element of program design proved to be particularly useful. The consultant wisely included in her proposal and insisted that training programs use a minimum of two one-on-one coaching sessions with each program participant to reinforce application of the classroom material. The coaching sessions have reinforced the program content, provided key support in a just-in-time fashion, and undoubtedly enhanced the overall effectiveness of the program.

Do
The first class was conducted as a pilot, drawing on a mix of leaders in clinical and operational arenas. Participation in the class was by invitation only. The two vice presidents who had championed the program also participated in this maiden voyage.

Check
Conducting a pilot group afforded the opportunity to make changes in the program content and format. In addition to other evaluation tools, the one-on-one coaching sessions allowed the instructor to identify specific areas where participants were struggling with applying tools or concepts. After making improvements, we were ready to make the basic course, "Core Concepts in Quality Management," part of our standard offerings for the system's leadership.

Act
Based on our experience with the pilot group, we contracted for three sessions and an advanced class for project leaders and advisors in the coming fiscal year. Three sessions would provide for a minimum of 60 participants of a leadership staff composed of some 200 individuals, including senior leadership, directors, and managers. When demand was greater than our capacity, the senior executive staff was asked to submit names of those individuals leading key projects who should be given priority for enrollment. We also developed a quality orientation program for medical staff and, based on our experience with the pilot, computer training in using Microsoft Office software with seven quality-control tools.

RESULTS
Two years have passed since the initial pilot was completed. The content of our core curriculum has evolved and improved. We have now executed seven offerings of the core curriculum, and the waiting list has increased rather than decreased. Space in the class, despite the four-day time commitment, is coveted; at the time of this writing, some 30 individuals were on the wait list. The participant evaluation scores have been consistently the highest ratings that the system's education department has seen for any program it sponsors. In evaluating the first offering of the advanced class, 9 of 11 participants (80 percent) strongly agreed that their participation in the class had enhanced their success on the job. As a result, three more offerings of the advanced curriculum have been scheduled and the CEO has requested that all of his executive staff participate in the advanced forum.
Significant challenges remain. In a survey of participants in the first three classes of the core curriculum the most troubling statistic related to concerns about the expectations of participants once they left the classroom. Fully 27 percent of participants responded "no" when asked if their manager encouraged and inquired about their use of quality tools and concepts. Informal discussions raised difficult questions about why leaders within the system did not feel at liberty-in terms of either time or political barriers-to do this work. These concerns appear to relate to the organizational challenges of inertia and the status quo. We are asking leaders to work differently from how they may have been accustomed to performing their jobs and how the system has customarily conducted business. If we are to raise the standard of care and service in the system, the application of the basic principles of data-based decision making, customer focus, teamwork, and process orientation must become part of the way we do business. The tools of quality improvement are just that-tools. The training is of little use if it is not translated to organizational results.
To the system's credit these issues are being discussed openly and consciously. One of the outcomes of the advanced training class was a dialog between the senior executive staff and the participants in the advanced training forum. Some of the issues may be specific to our system, but I have no doubt that many of our challenges are the same as those faced by many other organizations seeking to establish an effective quality management training program. The key questions we identified included the following:

• How do we make practice permanent? What do we need to do to enhance competency? (Do executives need to do a demonstration project? If it makes a difference working with trained people, who should be trained first?)
• What gets in the way of using this? (fear, lack of discipline, arrogance, belief that we already know, resistance to incremental change, impatience, skepticism?)
• What do we need to be disciplined about? (launching a project, strategic priorities, actionable mission statements, right team members, focus on core processes, using data to go "an inch wide and a mile deep"?)
• How do we free up the people to do this work? Who should be involved (executives, managers, employees, staff, advisors?) and when (regular work time, project work time?)

Finally, we have also realized the importance of being systematic in measuring both participant satisfaction with our training programs and the extent to which the environment supports the participants when they return to the job (see Appendix 3). We are also considering the use of a tool, entitled "Are We Making Progress?", designed to measure the perceptions of the general workforce and developed and published by the National Institute of Standards and Technology (the administrators of the Malcolm Baldrige National Quality Award). Our training program has put us in good standing to meet the challenges of today's healthcare marketplace, and much work still has to be done!

SOURCE MATERIALS
Baldrige National Quality Program. [Online information; retrieved 11/02.] http://www.quality.nist.gov.

Barnard, C., and J. L. Eisenberg. 2000. Performance Improvement: Winning Strategies for Quality and JCAHO Compliance, 2nd Ed. Kansas City, MO: Opus Communications.

Carey, R., and R. C. Lloyd. 1995. Measuring Quality Improvement in Healthcare: A Guide to Statistical Process Control Applications. Milwaukee, WI: American Society for Quality.

Counsel from Ms. Gretchen Dahlen, FACHE, president, Dahlen Company.

Intermountain Health Care, Institute for Health Care Delivery Research. "Advanced Training Program in Healthcare Delivery Improvement-Course Description." [Online article; retrieved 11/02.] http://www.ihc.com/xp/ihc/physician/research/deliveryresearch/educationprograms/leaders/coursedesc.xml.

For a faxed copy of the appendices, please call (312) 424-9473, or send an e-mail to Jane Williams at jwilliams@ache.org. Please include your fax number, as the appendices will be faxed to you.