Sample Leadership Roles and Responsibilities for Quality Improvement: VTE Prevention

This is a multifunctional document that leaders can use to negotiate and coordinate their individual responsibilities and make sure that all of the essential activities are covered. It can be used by the BOD, CEO, CMO, chief quality officer (CQO), C-Suite champion (CSC), and physician champion (PC) as a starting point for discussion. It is provided in a native file format (MS Word) so that it can also serve as a template for the final, approved version of leadership accountabilities.

Board of Directors (BOD, or Board)—can include whole Board or just its Quality Committee • Approves a blood-clot prevention initiative as a high priority • Sets performance standards and benchmarks for blood-clot prevention • Approves the format, frequency, and level of detail expected for the quality reports the Board receives • Appropriates specific funds for clinic\al quality improvement activities • Formally reviews and discusses venous thromboembolism (VTE, or blood clots) performance data and seeks explanations for rates that fail to meet standards and benchmarks • Establishes and revises priorities for improving patient safety and clinical quality of care • Assures structure is clearly delineated for: a) obtaining stakeholder input; and b) approving materials for improving clinical quality and patient safety (e.g., policies, protocols, standing/pre-printed order sets, patient education/staff education) • Spends time on the nursing units talking to patients, families, and staff to understand problems related to preventing blood clots in hospitalized patients

________________________________________ _____________________________
Approved by Date of approval
Chief Executive Officer (CEO)
• Obtains commitment from BOD (or its Quality Committee) for a VTE prophylaxis initiative as a high priority
• Assures that the roles and responsibilities for the BOD and CEO are clearly delineated for quality improvement and patient safety
• Works with the Chief Quality officer (CQO) to delineate CQO roles, responsibilities, and authority for patient safety and clinical quality improvement activities
• Approves roles, responsibilities, and authorities of the CQO for patient safety and clinical quality improvement activities
• Works with the Chief Medical Officer (CMO) or chair of the medical staff quality committee to delineate Physician Champion (PC) roles, responsibilities, and authorities for quality improvement activities related to preventing blood clots
• Co-approves roles, responsibilities and authorities of the PC for blood-clot prevention
• Works with the CMO or chair of the medical staff quality committee to assess PC candidates for blood-clot prevention initiative
• Assesses candidates and designates C-Suite Champion (CSC) for blood-clot prevention initiative
• Works with the CSC to delineate CSC roles, responsibilities, and authorities for quality improvement activities related to preventing blood clots
• Approves roles, responsibilities, and authorities of the CSC for quality improvement activities related to preventing blood clots
• Co-approves list of key stakeholders for blood-clot prevention (i.e., individuals or groups that can facilitate or obstruct quality improvement activities or be affected by the resulting actions, objectives, and policies)
• Approves time and resources necessary to develop, test, and implement evidence-based practices for blood-clot prevention
• Co-approves multidisciplinary membership of medical VTE Prevention Team
• Announces and empowers the VTE Prevention Team
• Presents VTE performance data to the Board and provides explanations regarding barriers and proposed solutions
• Communicates to both employees and medical staff the clinical value and relevance of VTE prophylaxis. (Practicing physicians can be skeptical about newly discovered evidence for a practice change. They tend to embrace the principle more readily when they hear administrators emphasizing clinical outcomes over regulatory requirements or financial benefits.)
• Talks with physicians individually to learn firsthand of their issues and concerns related to establishing and implementing a VTE prophylaxis policy
• Rounds on the nursing units talking to patients, families, and staff to understand problems related to preventing blood clots in hospitalized patients
• Celebrates successes with staff and identifies opportunities for improvement

________________________________________ _____________________________
Approved by Date of approval
Chief Medical Officer (CMO)
• Assures that the roles, responsibilities and authorities for CMO are clearly delineated for quality improvement and patient safety
• Works with the CEO to delineate Physician Champion (PC) roles, responsibilities, and authorities for quality improvement activities related to preventing blood clots
• Co-approves roles, responsibilities, and authorities of the PC for blood-clot prevention
• Works with the CEO to assess PC candidates’ strengths and weaknesses for leading the VTE prophylaxis initiative
• Works with the CEO to recruit and empower PC for leading the VTE prophylaxis initiative
• Co-approves list of key stakeholders for blood-clot prevention (i.e., individuals or groups that can facilitate or obstruct quality improvement activities or be affected by the resulting actions, objectives, and policies)
• Appoints the medical staff membership of the VTE Prevention Team
• Talks with physicians to understand and recognize their reluctance to embrace a change related to VTE prophylaxis and addresses these concerns in a manner that is forthright and informed
• Provides CSC with information from physicians regarding their reluctance to embrace a change related to VTE prophylaxis
• Communicates to both employees and medical staff the clinical value and relevance of VTE prophylaxis
• Holds medical staff accountable for compliance
• Celebrates successes with staff and identifies opportunities for improvement

________________________________________ _____________________________
Approved by Date of approval

Chief Nursing Officer (CNO)
• Communicates to employees and medical staff the clinical value and relevance of VTE prophylaxis
• Assures nursing resources available as needed for compliance • Is prepared with data from professional journals, national groups, and leaders in the field that demonstrate the need for the change and support the evidence (along with PC and CSC)
• Holds nursing staff accountable for compliance with policy and procedures
• Rounds on the nursing units talking to patients, families, and staff to understand problems related to preventing blood clots in medical patients
• Reviews written reports regarding team plans, progress, and barriers to progress
• Works with organizational leadership in all areas to remove barriers related to preventing blood clots in hospitalized patients
• Celebrates successes with staff and identifies opportunities for improvement

________________________________________ _____________________________
Approved by Date of approval
Chief Quality Officer (CQO)
• Educates and guides efforts of CEO, CMO and medical VTE Prevention Team to establish the culture, frameworks, resources, and mechanisms for: – Empowering individuals and teams (with clear responsibility, authority, education, resources, feedback, and recognition) to develop, test, and implement desired changes – Channeling communications to the Board, medical staff, and hospital staff regarding the priorities, activities, and results of the desired changes – Demonstrating evidence-based, fair, data-driven, and practicable approaches to change – Facilitating and coordinating efforts to manage the patients’ clinical conditions effectively and efficiently – Monitoring and analyzing the ongoing performance rates of targeted QI measures and indicators – Aligning QI priorities and goals of the Board, C-suite, medical staff, hospital staff, and patients/families – Proposing solutions to address barriers in the hospital’s culture and infrastructure that are impeding quality improvement (QI) efforts and activities

• Identifies barriers in the hospital’s culture and infrastructure that are impeding quality improvement efforts and activities related to VTE prevention
• Provides the team with QI tools for process design/redesign and analysis of cases that do not meet the standard
• Approves VTE Prevention Team decision-making process
• Proposes approaches to VTE Prevention Team to address barriers in the hospital’s culture and infrastructure that are impeding quality-improvement efforts and activities
• Works with the CSC to research both the implications of the proposed changes for various parts of the system and the more remote consequences such a change might trigger
• Leads VTE Prevention Team in developing an Aim Statement that includes goals and objectives
• Provides guidance on developing key stakeholder list, communication plan, team decision-making process, and organization-level approval process
• Works with the CSC and PC on determining membership of multidisciplinary team for medical VTE prophylaxis quality improvement
• Works with the PC and DDL on determining time and resources necessary for the VTE Prevention Team to develop, test, and implement desired changes
• Determines the functional level of the VTE Prevention Team and provides for individual and team training and skills development—both clinical and quality management (e.g., root cause analysis, process mapping/flow diagrams, failure modes and effects analysis, recognizing human factors issues, optimizing teamwork
• Leads the ongoing monitoring and reporting of process/outcome rates related to VTE prevention interventions
• Works with the PC and DDL to implement proposed solutions to barriers
• Celebrates successes with staff and identifies opportunities for improvement

________________________________________ _____________________________
Approved by Date of approval
Designated C-Suite Champion (CSC)
• Works with CEO to delineate CSC roles, responsibilities, and authorities for quality improvement in VTE prophylaxis
• Works with the PC to delineate and co-approve roles and responsibilities of the Day-to-Day Team Leader (DDL) for preventing blood clots
• Approves VTE Prevention Team decision-making process
• Designates and empowers (eg., supports requests for resources) DDL for the VTE Prevention Team
• Researches both the implications of proposed changes for various parts of the system and the more remote consequences such a change might trigger
• Allocates the time and resources the VTE Prevention Team needs to achieve its aim
• Provides the CEO with information regarding barriers and proposed solutions related to preventing blood clots
• Rounds on the nursing units talking to patients, families, and staff to understand obstacles related to preventing blood clots
• Arranges for the necessary support to help schedule VTE Prevention Team meetings and get out the agenda, minutes, materials, and other communications
• Provides open access for Physician Champion and Day-to-Day Leader to approach the leadership/ administration with ideas and roadblocks to changes
• Attends VTE Prevention Team meetings
• Reviews written reports regarding team plans, progress, barriers to progress and successes
• Works with organizational leadership in all areas to remove barriers and celebrate successes related to preventing blood clots in medical patients
• Is prepared to answer the following questions: – What is the evidence to support the change? – Why is the change necessary? – Are there others who have already adopted the change? – Is there value to the change, or is this change only for the sake of change? – Why should I want to change (what’s in it for me)?
• Is prepared with data from professional journals, national groups, and leaders in the field that demonstrate the need for the change and support the evidence (along with PC and CNO)
• Uses multiple forums—such as hospital staff meetings, impromptu discussions in the hallway, the employee cafeteria, etc.—to disseminate information and share knowledge regarding VTE prevention in medical patient
• Communicates to both employees and medical staff the clinical value and relevance of VTE prophylaxis. (Practicing physicians can be skeptical about newly discovered evidence for a practice change. They tend to embrace the principle more readily when they hear administrators emphasizing clinical outcomes over regulatory requirements or financial benefits.)
• Celebrates successes with staff and identifies opportunities for improvement

________________________________________ _____________________________
Approved by Date of approval
Designated Physician Champion (PC)
• Works with the CSC and CQO to delineate and co-approve roles and responsibilities of the DDL for preventing blood clots
• Co-approves medical VTE Prevention Team decision-making process
• Works with DDL to establish a meeting schedule for the medical VTE Prevention Team
• Convenes the first VTE Prevention Team meeting
• Attends and leads VTE Prevention Team meetings
• Engages physicians in multiple forums (e.g., medical staff meetings, hallway discussions, medical staff lounge) to disseminate information and share knowledge gained through implementation experience in VTE
• Talks with physicians to understand and recognize their reluctance to embrace a change related to VTE prophylaxis and addresses these concerns in a manner that is forthright and informed
• Researches and offers responses to the following questions: – What is the evidence to support the change? – Why is the change necessary? – Are there others who have already adopted the change? – Is there value to the change, or is this change only for the sake of change? – Why should I want to change (what’s in it for me)?
• Is responsible for securing data from professional journals, national societies, and leaders in the field that: – Demonstrate the need for the change – Support the evidence – Demonstrate potential gaps between the evidence and practice – Compare an individual to others
• Investigates and informs the medical VTE Prevention Team regarding what does and doesn’t work, the typical problems people run into, and how these problems can be avoided or overcome
• Shares successes of others
• Leads formal peer discussions to build consensus for the proposed changes
• Works with the DDL to determine resources necessary to develop, test, implement, monitor, and report efficiency and effectiveness of VTE prophylaxis program
• Works with the DDL to set agendas for VTE Prevention Team meetings
• Edits the minutes of the VTE Prevention Team meetings for presentation to the CSC
• Rounds on the nursing units talking to patients, families, and staff to understand problems related to preventing blood clots in hospitalized patients
• Provides the CSC with explanations of perceived barriers to achieving the aims of the VTE Prevention Team and shares successes
• Works with the DDL, CSC, and VTE Prevention Team members to design ways to overcome barriers for preventing blood
• Celebrates successes with staff and identifies opportunities for improvement

________________________________________ _____________________________
Approved by Date of approval
Designated Day-to-Day Leader (DDL)/QI Team Facilitator
• Rounds on the nursing units talking to patients, families, and staff to understand problems related to preventing blood clots in hospitalized patients
• Works with the PC to determine resources necessary to develop, test, implement, monitor, and report efficiency and effectiveness of the VTE prophylaxis program
• Works with the PC to set agendas for VTE Prevention Team meeting
• Serves as facilitator at VTE Prevention Team meetings to ensure that the team functions constructively and stays on track
• Provides the team with QI tools for process design/redesign and analysis of cases that do not meet the standard
• Between VTE Prevention Team meetings, monitors progress of the team members in accomplishing their follow-up activities and reports barriers to the CSC and PC
• Works with the PC and CSC to design ways to overcome barriers and share successes
• Reviews cases that fall out (of numerator) and reports to team
• Assists with workflow development for compliance with policy and procedure
• Celebrates successes with staff and identifies opportunities for improvement

________________________________________ _____________________________
Approved by Date of approval

Administrative Support Staff
• Documents (takes minutes) key discussion points, activities, decisions, and follow-up assignments from each VTE Prevention Team meeting
• Submits minutes to PC for editing and approval
• Disseminates minutes to team members from VTE Prevention Team meetings

________________________________________ _____________________________
Approved by Date of approval

Bibliography • Institute for Healthcare Improvement. Forming the Team. Available at http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/formingtheteam.htm. • Kotter J. 2006. Our Iceberg Is Melting. New York, NY: St. Martin’s Press. • Maynard G, Stein J. 2008. Preventing Hospital Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. Prepared by the Society of Hospital Medicine. AHRQ Publication No. 08-0075. Rockville MD: Agency for Healthcare Research and Quality. • Nash DB, Oetgen WJ, Pracilio VP. 2008. Governance for Healthcare Leaders: The Call to Leadership. New York, NY: Productivity Press. • Silvey AB, Chapin C, Warrick L. 2005. Identification and Synthesis of Components Essential to Achieving “High Performer” Status in Various Provider Types: Final Report. Prepared by Health Services Group, Inc., for the Centers for Medicare & Medicaid Services, under Contract N. 500-02-AZ02 AZ0023, Phoenix, AZ.