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A Gameplan for Engaging Leaders, Staff in Quality and Safety

Posted By Administration, Monday, October 19, 2015
Updated: Monday, October 19, 2015

The Healthcare Adventures Graphic Gameplan for Patient Safety is a new tool created to engage leaders and frontline staff in discussing patient safety and quality challenges and setting a path for improvement. Developed by a group of researchers and practitioners in patient safety, organizational behavior, and human development, the Graphic Gameplan utilizes components developed by Grove Consultants International that have been used successfully to drive improvement in other industries.


The P.S. Blog sat down with researchers/practitioners Jay W. Vogt, MA; Michael Sales, EdD; and Sara J. Singer, MBA, PhD, to talk about this new tool and the free Facilitator’s Guide they developed (with Jeffrey B. Cooper, PhD) to help people use the tool. This interview has been edited and condensed.

The Graphic Gameplan
"functions as group memory...
you are building a story,
building an argument, and
mapping out a project."

P.S.Blog: You mention that the Graphic Gameplan has been used for improvement work in other industries. How did you come to adapt it for use in health care quality improvement and patient safety projects?


Jay Vogt: We were working with the patient safety leadership culture model that Dr. Singer put together. We wanted a means of allowing front-line workers, quality improvement practitioners, and leaders to interact with real patient safety challenges in a way that expressed the insight that came from that model. The Graphic Gameplan is the answer we came up with to do that. It’s highly visual, so it is, therefore, a very good tool for using with visual learners. If people are just talking, they are not tapping into their exceptional visual processing capabilities. Its visual nature is engaging. It functions as group memory; you’re writing things down, but in a certain way, in a certain place, so that you are building a story, building an argument, and mapping out a project. In this case, the elements were tailored for our model, so we came up with a template to hand over to people so they could let those questions guide their conversations.


It’s a template; people don’t have to wonder, “How do I approach this?” It’s already laid out for them. If you are asking these questions, you’ve got an evidence-based model behind you, and you’ll be doing fine.


My experience with the tool is that it is fun and fast. That was important to us. We wanted something effective but highly engaging and enjoyable.


P.S. Blog: Can you tell us a bit more about the Patient Safety Leadership Culture Model?


The seven behaviors of the Patient Safety Leadership Culture Model
include evidence-based leader traits and actions
that support a culture devoted to patient safety.

Michael Sales: The model is a description of leadership values, attitudes, and behaviors that combine into organizational performance where patient safety is a top priority. It informs habitual practice throughout the team or the organization that is using this model to focus attention and improve performance. Each of the components contributes to a leadership culture that is constantly and consistently supportive of patient safety.


P.S. Blog: Can you summarize the model—why are these behaviors so important to organizational learning and improving?


MS: The basic idea is that, if you have a cadre of leadership engaged in the model’s seven practices, you have people who are engaged in an automatic, habitual fashion in learning behaviors that contribute to a patient safety culture, and to high performance and probably other positive outcomes as well.


The seven elements of the patient safety leadership culture are, first, that the leadership group really cares about patient safety. Leaders place an emphasis on patient safety that leaves no doubt in anyone’s mind that it is a primary concern and a priority of organizational leadership. If there is a safety issue, the organizational team leadership gets personally involved in understanding the issue, in learning about the problem and the systemic issues responsible for the issue or problem that has shown up. The leadership group is expending its resources and political capital within the team and within the organization more generally, and its human energy, to make sure that patient safety becomes and remains everyone’s concern.


JV: My view of “really cares” is that it is the uber attribute; everything else falls underneath that.


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MS: It’s the overarching value out of which all the other actions fall.


The second element is having a welcoming, nondefensive attitude among leaders toward patient safety questions. Leaders need to take a stance actively toward learning and away from blaming. If something is happening that is a patient safety issue, especially if part of a pattern, it’s very likely not the fault of a particular individual, even if that individual is reproducing the problem. It’s probably systemic. Leaders who are curious and encouraging of reflection and discussion of patient safety—even when it’s challenging to remain in that stance—demonstrate that is psychologically safe to engage in collective learning.


That’s a big deal. When it’s a patient safety matter, people are understandably anxious about what’s going to happen in a discussion about it. How is my boss going to react, for example. It’s the responsibility of leadership to make it easy by not being defensive in that way.


JV: Through my affiliation with Partners HealthCare, I was able to visit the Middle East, and when we talked about this kind of thing over there, where many of the doctors are contractors from other countries, we learned that if people made a mistake, their contract would be terminated and they’d be sent home. It was a culture of mistake equals blame equals termination. The American health care system may not actually be that far from that, but it was shocking to see it laid out so plainly. So of course, in that culture, everyone hid errors. It was an egregious example of what we see in our own institutions.


MS: The third element is encouraging speaking up. Many people are intimidated by the hierarchical conditions that exist in hospitals and health care arenas. They don’t want to get other people in trouble and are reluctant to do things that look like they are criticizing their bosses. They don’t want to get themselves in trouble. That’s a problem when patient safety issues are avoided or not probed. A patient safety leadership culture encourages speaking up by using true inquiry, not “gotcha” questions that are intended get people punished, but questions that are really intended to get at what’s going on and what we can do about it. Leaders who demonstrate their appreciation for input by thanking people for bringing up matters that are uncomfortable tend to get a lot of a repeat business for that type of openness. Their active probing and support makes patient safety problem identification and analysis safe to do. The leader who is noticing somebody who is reluctant to go into detail about something that happened can encourage that person to speak up.


JV: We’ve worked with a prominent malpractice insurance company. They have a running record of every malpractice event or medical incident in their insured hospitals and, in a majority of those incidents, when they go back and do the deconstruction, they find that it wasn’t a technical error, per se, but a communication breakdown. Someone in the team knew a mistake was going to happen, or saw it happening, and didn’t speak up. So this communication phenomenon is widely documented and very difficult to break.


MS: The fourth element is facilitates communication. That means that by creating structures and processes that make patient safety analysis and action planning part of the everyday routine for the organization, it instills the habit of patient safety orientation. Some of the things we’ve seen that make this happen are daily huddles; timeouts before implementing key changes, and reflection on results in a timeframe that is close to the event itself.


Item five is takes action. This means doing something smart, proactive, and systemic around patient safety, even when you feel like you don’t have adequate resources to do all the things you want to do. Finding a way to move forward on patient safety regardless of the situation you are in, demonstrating it is always a priority, in flush and in spare times. A patient safety leadership culture shows we can make something happen. The reason I point out the resource thing is that, for a lot of people, the first thing they will start talking about is “We need more funds.” Everybody needs more funds for everything. But you’re always in a position to do something to improve the situation you are in. That’s kind of the orientation of being a leader in patient safety.


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P.S. Blog: That one did intrigue me. Because people are juggling so much already. It may not be money, but people and time in the day.


MS: Right, many things are suboptimal, but the overall effort and a continuous effort in the face of constraint still produces positive results. I recall Viktor Frankl, a psychiatrist who was a prisoner during the Holocaust. He developed “logotherapy,” an existential psychology that emphasized the importance of infusing your life with meaning regardless of the limitations present in a situation, even if it’s your last day. You’re still a human being, you can still do things. That’s a leadership attitude that’s proactive.


Mobilizes information is the sixth element. Leaders must institute and monitor the structures and processes needed to document, interpret, and disseminate knowledge. An example is making sure that a particular article, or set of performance data, is distributed and discussed by members of the health care team. Making sure patient safety information, both local information and more general information, is in wide circulation in the organization.


The seventh element is seeking input. Leadership of an organization or a team is frequently in a better position to reach across disciplines, work units, shifts and other organizational boundaries to obtain needed information and political support to effect necessary changes and ensure that information and skills flow as needed to where they are needed.


JV: The fifth, sixth, and seventh elements are the primary focus of the Graphic Gameplan. They are the hard skills. But while the Gameplan is being discussed, two, three, and four are all kind of in the process. The conversation content focuses on action, information, and input, but the process objectives for welcoming, encouraging speaking up, and facilitating communication can happen while that content is being generated. Second, we’ve learned, just from facilitating a lot of these, that leaders typically start with a bias for action, they want to do something, they want to show they care and get a result, and that’s great. What we often find are rich, surprising conversations around information and input. They aren’t really thinking, “How will we measure this? Where does the information exist? Who has access to this information?” They aren’t necessarily thinking about information as an asset. Leaders see things from above, and they want to dive right in. The idea here is “go slow to go fast.” Take the time to solicit the input form the orderlies who deliver the carts or the night shift or others who have things to add, and do it in a structured way. That is often an “A-ha” for them; they see there can be so many different parts of the puzzle that bring either a new perspective or new information, before we start thinking about actions.


P.S. Blog: How do you see the Graphic Gameplan being used in practice? Who is the primary audience for the facilitator’s guide?


JV: If you think about health care entities as systems, there are people at the top who have problems brought to them or go looking for them. They are the executives and they perform executive functions. At a minimum, we want them to be aware of the Gameplan because it’s such a fast and efficient tool for mapping out projects. We’d love to have leaders see it as a valuable resource to them that allows them to engage, but also to learn.


I think of the executive as a participant in the room with a point of view. The person who is facilitating would more likely be a quality improvement specialist or patient safety specialist, probably an internal resource, who thinks about project management a lot and is used to convening groups of people and would be willing to step up and perform that role.


People on the team might be front line clinical people from a range of different levels and functions. This tool has the potential to engage people at the top, middle, and bottom of an organization. The senior leader would authorize it and be the executive sponsor. The QI or PS practitioner would be doing the actual facilitation. Clinical people would make up most of the team. The first part of the facilitator’s guide is the theory, which might be more useful for the executive, and the second part is the how to, so more for the hands-on facilitator.


MS: The leverage that the Gameplan gives executives to make a handoff and delegate patient safety challenges to teams—and be in a position to monitor what the team that received the road map is going to do with it—is a powerful intervention, because leaders have not had to invest a lot to keep track of a great deal. They will know that the things teams are working on are part of a map that the leadership understands, values, and approves.


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P.S. Blog: Are QI and patient safety projects doomed if the leaders of an organization don’t embrace these behaviors? Or can significant change and improvement still succeed at the unit or department level?


Sara Singer: Doomed is a strong word, so I wouldn’t say doomed. But one of the most consistent findings in the literature on implementation in general and quality improvement/patient safety implementation in particular is that leadership engagement and support are critical to the success of QI and patient safety projects. Leaders do critical things. They signal to the staff what’s important, so they can get everyone pulling in the same direction. They can smooth paths that need smoothing, open doors that need opening, and garner and allocate resources where required. It can be really hard to make significant change without these factors.


MS: You can make things happen as a mid-level manager even without support of leadership. Not as easily, but you can do it. First, they must exercise as much responsibility for quality as they possibly can. Patient safety issues are going to crop up in health care institutions with great regularity. If they aren’t addressed, they are going to get messy for patients, staff, the organization, and families who care about what’s happening. The more mid-managers are able to anticipate problems and take care of them before they happen, the more they are going to be able to influence leaders to move toward a positive safety stance as well. Even if patient safety is not as high a leadership priority as other responsibilities, they recognize that mistakes are made, and they’ll be grateful. Mid-level managers tend to have more authority and responsibility than they think they do. Getting fired for trying to do the right thing is more rare than people believe. Try to expand your authority!


If you’ve overstepped your bounds to save a patient or patients from error, ask for forgiveness in overstepping the bounds, rather than permission to do it. If you’ve avoided a preventable error, it will be difficult for a superior to retaliate because you’ve done the right thing.
Another thing you can do is take the blame for a patient safety problem that you didn’t really cause. That will feel lousy, but it could potentially empower you in future situations. A nonperforming leader who doesn’t give support, will know at some level that they are the ones that are responsible, and not the mid-level manager. They owe you. Even if they don’t, then the leaders who are aligned with patient safety will appreciate that you took one for the team and that you are part of the mix to make patient safety more of a priority than it is in a particular organization.


Finally, I’d say, learn how to be a coach and a facilitator. The organizational leader may not be making patient safety a priority, but they have to be responsive to input from others in the organizations or take the consequences for not being responsive. The middle level manager who can facilitate communication between folks, including his or her superiors, regarding patient safety, will likely be called upon to provide counsel in a range of issues.


P.S. Blog: How do you see the Graphic Gameplan as a complement to Lean, Six Sigma, or Plan-Do-Study-Act processes?


SS: The Graphic Gameplan can be a helpful complement to these other methods by helping leaders understand how they can engage and support quality improvement or patient safety initiatives. For example, say a unit wants to improve the way it hands off information with another unit. The Gameplan provides a structure to help unit leaders consider bigger picture questions about how to get this done. What exactly are the outcomes we’re trying to achieve? Who is on the team to make this happen? What factors might support or restrain this initiative? How do we access the supports and mitigate the restraints? Who needs to take what leadership actions to enable this work to move forward? What information is needed? And whose input is vital to seek?

A unit might employ PDSAs, for example, to test small changes, but the Gameplan lays out how do we know when the PDSAs have reached our goal, who decides which PDSAs to pursue, what or who is likely to promote or undermine the test, and what do the leaders need to do to facilitate the process? If used well, the Gameplan could be highly synergistic with these process improvement methods, and together they likely have a higher potential for achieving their goal.

P.S. Blog:
What else should we know about the Graphic Gameplan?


JV: One thing I’d add is, in the facilitator’s guide, we lay out how you can do this over 2 hours or over 3 hours. In theory you might be able to bang it out in just an hour. We want people to feel this is a highly leveraged commitment of time to learn this tool. And lastly, all this work is evidence based. The bibliography cites numerous peer-reviewed articles featuring this work.


MS: This is a way for leaders and facilitators to start to exercise the patient safety planning muscles, and once you start using muscles that are there but haven’t been activated, it gets easier and easier. Leaders are able to use this relatively brief process to get things started, and it becomes a positive feedback loop, because it becomes easier to do, as you’re using a tool you become familiar with and can adapt to fit the context of your own organization.


Download a free copy of the Healthcare Adventures Graphic Gameplan for Patient Safety Facilitator’s Guide.

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Contact the P.S. Blog by writing to the editor, Patricia McTiernan, at

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