Hello, I'm Dr. Richard Kovacs, Dick Kovacs, at the Cranor Institute of Cardiology and the Indiana University School of Medicine. And thank you for listening to this topic for the Cardiovascular Summit, which is entitled The Universal Principles of Leading Change Through ACC Quality Campaigns. What we're going to attempt to do in the next 25 to 30 minutes is to look at basic principles of leading change in any organization, but specifically to the cardiology practice, to the service line, to the hospital, to the cardiology group, how ACC quality campaigns have used these principles to drive cardiovascular quality throughout the years. At past CV summits, I have shared the podium with Dr. Dipti Achakwaria and with Kevin Casey Nolan, and so I do want to give them credit for both some of the content and much of the inspiration for what I'm about to say. Three basic objectives that I would have for the audience. First is that theoretical framework. What are the best business practices for leading change at the institutional level or at the organizational level? But also to merge that with some practical examples for important changes that have been brought about in cardiovascular medicine by the ACC quality campaigns. And then finally, to have you recognize some pitfalls that can occur on the road to change. The ultimate goal, of course, is your success, and this CV summit is all about successful operationalization and the practice of medicine. So perhaps we should begin with a quote, and I'll end with a quote as well, but this may actually frame your initial meetings. Mark Twain said, I'm all for progress, but I just hate change. So when leading change, realize that there will be some inherent inertia. There will be resistance to change, but if we frame it correctly, if we have the proper goals in mind, and if we have some structure to how we are leading change, I think that we will all be much more successful. And we use this framework. We have used this framework in the past. It's been very successful. This comes from the Harvard School of Business, and these are strategies for leading effective change, and I think it's worthwhile going around this clock beginning at high noon and working around in a clockwise fashion, and I want to spend a little bit of time in sort of the medical spin on this rather than necessarily the business spin, but that sense of urgency to create change, that sense of urgency is so, so important in that when we see a challenge that we identify that challenge and share that this is a challenge that needs to be met, that this is a change that we should be making, and that it is something that we want to make in a period of time, in a finite period of time, that this is not something that we're willing to take incrementally over and just wait for just the environment to simply change things for us, but that we are going to be active agents of change. And moving over to the importance of building then a coalition, a small group of those who are going to assist you in leading that change and leading that process and being your strongest advocates is so, so important, and to identify those folks early on. Those, that small core group, should have a strategic vision that is unified. They should understand what the future needs to look like. Remember that leaders know how things, see things as they should be. They know where we should be going, and they are going to take that group on its path to success. Then you'll find it much easier at that point to expand that and enlist your volunteers and enlist your army and have those that are not only going to lead the change process, but follow you along the change pathway. And as you are changing, as I said, as Mark Twain said, there will be resistance to that change, and the primary goal is to eliminate those barriers. And I would say, in my experience in the practice of medicine and in leading service lines and physician groups and quality improvement efforts, time. I do not have the time for this. As a member of this effort to make this change, my time is being pulled. And in the current environment, where we are pulled in so many different directions and our lives are so disrupted, I think the key, one of the key principles here is to remove the barrier of not having enough time in order to make the change that is necessary to improve our care. And with that, another key principle is that this group, your core group, your volunteer army, are going to want to see some successes. So pick out things that early on can be identified as a win, that this group is going forward, that the change is being made, that progress is being made, because that will allow you then to sustain the gain. Again, in medicine, my personal experience with quality improvement projects or with leading for change is that sustaining those gains, sustaining those small gains takes at least the same amount of energy as the initial small-term wins. And only then can you institute that systematic change. So working around this clock face from 12 to 11, you can see that there is structure, there are key strategies. And the Harvard Business School looks at this a little bit differently, and I think it's worthwhile to really go through what Cotter actually said. And, you know, in medicine we talk about patient care, but in business we talk about markets and competition, but we still want to identify the urgent need to change what we are doing to make the progress. I think that developing that guiding coalition is the same in medicine and business. Developing a clear vision, a clear strategy. In medicine, that takes technical expertise. So I would say that vision should be, as many things we do in quality improvement, should be the combination, perhaps be that dyad relationship of the operational, the management, the hospital administration part of this, together with the clinical expertise that is necessary to make these kinds of changes. in what we do in medicine. So, again, that clear, that clarity of vision, that shared vision for what the future should be from the leaders of the change. And communicating. And I would say in business, as in medicine, communication is something we need to do. Communication is repetitive. Communication at times to leadership can seem like we are saying the same thing over and over and over again, but we need to realize that we need to over-communicate in order to make effective change. Removal of obstacles. Changing the things. I mentioned from a medical standpoint, time. Removing the need for extra time, making your process efficient, perhaps taking something else off your leadership or your team's plate in order to affect that change, I think is equally important. And on either side of the street, creating those wins, celebrating those wins, recognizing those short-term gains, and consolidating that and accelerating the change. And at the end of the day, so much of this is about changing culture. So where does the college sit in all this? The college has embedded these kinds of change efforts into our quality of care. And you can think of the quality initiatives of the college as being local efforts, but they're local efforts supported by evidence, the best evidence that comes from our national and international experience and what is best for our patients, and led to this several years ago, the formation of this concept of quality improvement for institutions, the QII effort that came out of Science and Quality, together with the National Cardiovascular Data Registries in order to truly drive the kinds of changes that are necessary to improve the quality of care of our patients. And the quality campaigns and the quality initiatives are just one part of a multi-pillared approach to this effort to make change. Certainly, the data from our National Cardiovascular Data Registries can drive change simply by presenting the clinical teams with their data, and importantly, for the registries, with benchmarks. Here I am, here is my like institution. What are they doing? Somebody is doing better than I am in this particular improvement project or this particular effort. How do they get there? Learning from that, and to do that you need to have credible clinical data best coming from the registries. One can pursue a formal accreditation process, building at the facility level that commitment and that infrastructure to establish and maintain change. And then the topic for today more are individual quality campaigns, those individual bites at the apple, those individual efforts to make change at a focused level. And that could include such things that can be used independently, like our clinical toolkits, expert consensus decision pathways, available mobily in order to address a particular problem. So this effort, the quality campaigns are one type of effort, but they are built on a foundation, and I would encourage you to understand all of these different components to advancing quality and making change. In addition, this QII and the quality campaigns fit within an even broader framework. How do we decide what we're going to do? The college cannot do everything. We can't boil the ocean, so to speak. So we have even convened roundtables to discuss what are the topics, where can we make, where can we truly influence change? And we discuss this, we discuss this with multi-stakeholders. I'll show you that in a second. We also commission long-term initiatives to advance science, to close gaps between what we know and what we are doing. A good example for that is anticoagulation, a revolution in anticoagulation and antiplatelet therapy over the last decade, which requires a continuous culture of change to improve practice. And then finally, our membership and even clinicians outside of the ACC need the tools and the applications in order to be able to perform these tasks. So I mentioned that these quality efforts do not come out of thin air. A call for change does not come without significant thought, and we have even systematized this, and this was a paper that I would urge you to take a look at, is our methodology for the Hart House roundtables. And much like you build your quality assurance team or your quality improvement team, we build our consensus with patients and their advocates, with payers, with the regulators and industry, clinicians, content experts, all come together to decide how we can make change. This, in essence, is your core group, your clinical leadership that is going to assist you with making those important changes, but this is at the macro level. So let's delve into a couple of concrete examples. What could create more sense of urgency than a heart attack? The ACC door-to-balloon effort took advantage of that to make fundamental changes in how we treat heart attacks by creating that sense of urgency. That sense of urgency is as clear as clear can be, and it took the New York Times to really point out how this made change, and it made change regardless of institution. It reduced disparities in care by making it the same. Heart attacks were treated the same in urban, suburban, and rural hospitals. They were treated the same as to whether you were black, brown, white, or yellow. It treated you the same as to whether you were a man or a woman. It made no difference. This was one right way to do things, but required fundamental changes at the institutional level. But while the door-to-balloon time was one of those examples on the road to an early success and a focus change, it was met with some later challenges as we moved on to surviving the myocardial infarction for a longer period of time. Door-to-balloon time focused the effort on ST elevation myocardial infarction only, based on a very sound principle that time to treatment was muscle, and really focused on the time horizon of in the hospital. When we expanded that to the effort to affect 30-day risk stratified mortality, we had a much bigger challenge, more barriers to remove. We had a heterogeneous population of STEMIs and non-STEMIs. We had less scientific certainty, and we had a longer time horizon, a bigger challenge on our road to progress and change. But we learned some important lessons that, as you attempt to change things in your own institution, I think will apply well across the acute MI scenario, but also to everything that we do to care for patients. And that was research into what distinguishes those top-performing hospitals from the hospitals that are not top-performing. And what are those strategies? What are those changes that are made in order to reduce mortality from acute myocardial infarction? We learned that there is a broad disparity. These are now publicly reported data. These are the 30-day risk stratified mortality rates for AMI, and we can see that, as with everything else we do in medicine, there's a bit of a bell-shaped curve, and a wide separation between top performers and the lower performers in terms of how well our patients do over a longer period of time. And our research allowed us to identify the kinds of strategies that we needed to put in place in order to make these changes, and some of these things were surprising. Moving across this slide from one to seven, first of all, having processes in place shouldn't be a surprise. Having a dyad champion, having the fusion of champions, and whether this is a nurse and physician, or whether this is an administrator and a physician, or whether this is an administrator and a nurse, or whether this is two administrators, but having that sort of dyad relationships and bringing those competencies to bear had so much to do with successfully executing the strategy to reduce mortality. Creating a problem-solving culture, critical, critical for anything that we are going to do in this area of improvement and change, is creating that culture where we can come together with all of our different competencies and skillsets and address the problem at hand. Reviewing the information with people outside of our sphere of interest. In this case, emergency medical services operating outside the walls of the hospital were very, very important to bring into that coalition, to that group that is going to lead the change for you. I'm not going to touch on cardiology presence around the clock or how you dedicate your nursing staff in the hospital, but I do want to, one other thing, is expanding our team. Sometimes to make the change, to make the positive change, we need to think outside of the box, and this has certainly been a major eye-opener for me, is identifying those people outside of your sphere of influence, the pharmacists, how important the pharmacists are in implementing this change, and having the data to back it up. So these are the seven strategies, and these are absolute reductions in risk-stratified mortality, in 30-day risk-stratified mortality for acute MI care, and this was a survey of these institutions, and you can see that not everybody implemented all of these strategies, but having the DIAD team working on this reduced risk-stratified mortality by almost a percent. These are lives saved. These are the improvements. These are not only the short-term gains, but these are beginning to be the long-term gains that we can see on your road to improving care. Well, let's shift out of AMI to examples of other quality initiatives, such as the anticoagulation initiative. Remember that I mentioned a few minutes ago that the anticoagulation initiative had a much longer time horizon. We're going much further around that cotter wheel in terms of developing the strategies for implementing the changes that will improve patient care. This involved convening multiple roundtables. It involved the publication of multiple clinical topic papers. It identified and executed on the needs of our clinicians to have mobile applications. The anticoagulation evaluator and the managed anticoagulation tool, it is actually for use by outside cardiology practices to manage transitions in care. And then finally, bringing the patients into this as well with the anticoagulation shared decision-making tool. These things take time. They take a dedicated team. They take both the short-term victories, but also the long-term strategy to see the future and to make the changes in anticoagulation care. Each of these efforts about change, about the college attempting to implement change, showed us lessons learned. And sometimes the lessons learned were not necessarily what was intended at the beginning of the operation, but they showed us important ways. I mentioned already that door-to-balloon showed us that good science can overcome disparities in care. And how important that is now in our environment where we are laser-focused on reducing disparities in society in general, but certainly removing disparities in care for heart patients. Door-to-balloon taught us that, that when we follow the science, we overcome those disparities because we're not making distinctions about who you are or your ability to pay. The hospital-to-home initiative was really a heart-failure initiative. I didn't touch on this before, but the hospital-home initiative, although the initial effort in quality improvement was sunsetted, it showed us the importance of learning communities and the development of that, as I mentioned, not just those core groups, but that larger team, those folks that are going to go out and be your change, your army for change, and the importance of bringing them together in meaningful ways to share knowledge. And the hospital-to-home learning community lived on well, well after, and continues to live on after the effort, the quality improvement effort was no longer. Surviving MI, and I mentioned this, and I want to reemphasize this again, this need for culture, for the culture to identify and then solve a problem together. And another more modern, more contemporary effort with reducing the risk of PCI bleeding is going back to that notion of data driving improvement. Clinicians will respond to credible clinical data. Clinicians will respond when they see a benchmark set by their peers. Clinicians will look at those data continuously if they feel they are of value in improving the care of those patients. But there are some negatives on this. So why will change fail? These are actually taken from the Cotter paper. First of all, lack of discipline, allowing complacency, that notion that I hear so often. My outcomes are such, and my mortality rate is high because my patients are sicker, and you do not understand my patients, and accepting that sort of notion. Yes, patients have high risk. Some patients are, there are patient populations that may be more challenging than others, but if we are going to make change in cardiology, we cannot be complacent. We cannot say that this is simply good enough. The failure to create that coalition, to create that at the front end, so often we will add people on, we will add those pieces on as we go on through time, but consider that you have to carefully think about what you are improving, who you need in the room, and create that coalition. We underestimate the power of vision. Leaders see what is possible. And we need to take that vision, we need to take that vision forward and convince our teams and our organizations and our institutions this is possible, this is where the future will be. Do not underestimate that. Communication, communication, communication. George Bernard Shaw said that the single biggest problem with communication is the illusion that it has occurred. You need to repeat yourself many, many times. We can fail if we fail to, if we allow obstacles to block our vision. If we do not remove those impediments, if we do not give the team the time that is necessary. We can fail if we don't give a little bit of positive feedback early on. Build your quality improvement so that you can create early wins, so that the team can see progress, but don't declare victory too soon. And finally, don't lose sight of the fact that so often what we are trying to do is change culture, because culture eats strategy for lunch. If you change the culture, that culture change and that thirst for quality improvement will lead itself, will pay for itself many fold. The next project will be much easier because they will say we have climbed a mountain before, we can climb this next mountain, we can do this. So, what I'd like you to take away then, and this is again with thanks to Casey for his slide, we recognize that nobody likes change. Medical folk are particularly set in our ways, but that change is inevitable, and it is that movement to progress, to improvement. But realize that everybody's favorite radio station is that one, and for those of you who don't know that, it's what's in it for me. So make sure that some of those early on victories are also victories for the individuals. That people feel like they are part of this team, part of this change that you're leading to make the improvement. I want to close with a couple of quotes. I began with that rather cynical quote from Mark Twain, but George Bernard Shaw, as I quoted before, also said that progress is impossible without change, and those who cannot change their minds cannot change anything. So as you lead, as you embark on these efforts to change, remember, you are going to have to change minds. And when people are feeling that their pace is not sufficient, perhaps Martin Luther King can provide a little inspiration that if you can't fly, then run. If you can't run, then walk, and if you can't walk, then crawl. But we need to keep moving forward for the patients that we serve. Thank you very much.

leading change

ACC quality campaigns

business practices

cardiovascular medicine

sense of urgency

building a coalition

barriers to change