Leadership Versus Management

OBJECTIVE
To describe the quality gap in health care as it was referred to in the Institute of Medicine's reports, to try to harness pharmacy's potential to improve the quality of drug therapy, and to provide insight into the elusive leadership, management, and dynamics of change.


SUMMARY
Current health care is nowhere near ideal. Successful quality initiatives have included establishing a "culture of quality" (promoting a learning organization), having good leadership, and developing strong management. Ideally, all of these concepts must be applied concurrently for the best results because using only one will not spirit medicine across the gap. To close the gap, pharmacists need to understand various types of change and select a change mechanism that will continuously improve care.


CONCLUSION
Optimizing drug therapy is both a great challenge and a great opportunity for pharmacy. AMCP's Framework for Quality Drug Therapy is a continuous quality improvement model that gives us the tools to plan, implement, and evaluate strategies to improve the quality of patient care and cross the "quality chasm."

T his article bridges information about nonsteroidal antiinflammatory drug (NSAID)-induced adverse events presented in the first article with information presented in the next article. The former represents a quality gap for health care. The latter describes AMCP' s Framework for Quality Drug Therapy (Framework), developed by the Academy of Managed Care Pharmacy. 1 This article provides a primer on continuous quality improvement. The incidence of NSAID-related gastrointestinal adverse events is an ideal problem to be addressed. Using the Framework, leaders can step forward and promote good management and, most importantly, effect change. Three specific objectives are • to describe the quality gap, as it was referred to in the Institute of Medicine' s (IOM' s) reports, • to try to harness pharmacy' s potential to improve the quality of drug therapy management, and • to provide insight into the elusive leadership, management, and dynamics of change.
The initial IOM report, To Err Is Human: Building a Safer Health System, presented rather dramatic numbers. 2 The authors indicated that between 44,000 and 98,000 people die each year in hospitals due to medical errors. They also asserted that medications are responsible for about 7,000 deaths annually. Public and private policymakers saw these numbers and moved issues of patient safety and quality to the forefront of concerns. The statistics represent an opportunity for improvement.
Other figures are equally as appalling. Only 50% of Americans receive recommended preventive care. While 70% of patients with acute illnesses are treated with appropriate care, 30% receive treatments contraindicated for their conditions. For the 20% to 30% of patients with chronic conditions (a group that accounts for more than 70% of our health care expenditures), 60% appear to receive recommended treatments, but 40% receive treatments contraindicated for them, like NSAID therapy without gastroprotection. 3 Obviously, health care has room for improvement.
Errors are a fact of life. Thus, we need to identify an acceptable error rate. We can contemplate different error rates, using conservative goals that approach perfection. Yet translating an accuracy rate of 99.9% into every day life would mean approximately 84 unsafe airplane landings per day, 32,000 bank check errors per hour, or 16,000 pieces of lost mail per hour. It also means more than 9,000 prescription errors every day. Thus, even a 0.1% error rate has rather daunting consequences and is unacceptable in medicine. Contemplating an acceptable error rate is rhetorical in medicine-the only acceptable rate is zero errors.
The IOM' s second report, Crossing the Quality Chasm: A New Health System for the 21st Century, makes an urgent call for fundamental change to close the quality gap, recommends a redesign of the American health care system, and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. 4 "The current health care delivery system is not robust enough to apply medical knowledge and technology consistently in ways that are safe, effective, patient-centered, timely, efficient, and equitable…" 4 Current health care is nowhere near ideal. It is plagued by what the IOM refers to as a serious quality gap.

ss Management and Leadership
Other industries and companies have experienced quality chasms and successfully overcome their problems. Successful leaders and organization teams have described their efforts and interventions in the literature. Some of the most successful ideas have included establishing a "culture of quality," promoting a learning organization, having good leadership, and developing strong management. Ideally, all of these concepts must be applied concurrently for the best results because using only one will not spirit medicine across the gap.
Many organizations lack these 4 underpinnings of good quality and may be overwhelmed when they deliberate their implementation. Rather than thinking of these concepts as 4 more things to do, successful practitioners must incorporate them into their jobs so they become transparent and effortless. This makes quality a part of the organization' s culture.

ss Organizational Culture and Learning Organizations
An organizational culture is a set of beliefs, values, customs, and norms that form the foundation of the organization and against which organizations and their members judge themselves. Organizational structure can be sketched or drawn, but organizational culture is less tangible. American automobile manufacturers embraced the idea of introducing the quality concept to their cultures some years ago when Japan' s Toyota became a serious and devastating competitor. American automobile manufacturers restructured their businesses around quality, often incorporating quality into their mission statements. Although many manufacturers were concerned that better quality would be costly, they were mistaken. Quality-driven programs can deal with cost realistically. There is nothing wrong with doing the right thing for the right reason within limited budgets.
A learning organization is one in which individual members and groups at all levels continually increase their capacity to produce results they care about. The organization is aware of and monitors its own behavior. It makes achieving extraordinary performance and individual satisfaction and fulfillment surpass possibility and approach probability. Private business must promote a learning environment-a learning organization-to survive today. Health care is certainly no different.
The information needed for self-assessment and improvement is integral to any organization. One of the Framework's assump-tions is that pharmacies have this information and will use it to learn about themselves. This requires a systematic process of measuring and evaluating, then soliciting feedback and changing. This is not unlike many theories of biology; corporations and businesses are living organisms. The most successful among them adapt, learn, and move forward.

ss Keeping It Continuous
Continuous Quality Improvement (CQI) is simply an organized way to do this. CQI mechanisms allow organizations to go through 3 types of change: incremental, transitional, and transformational. 5,6 • Incremental change approaches problems in a step-wise fashion. In slow-moving business environments, stability is a goal, and the ruling motto is, "If it ain't broke, don't fix it." • Transitional change acknowledges that the problem will be addressed gradually and continually, using a plan to move forward. The magnitude of the change is greater than just incremental over time because there are more external forces and greater risk in staying stable. There is also more opportunity. Consider, for example, the transitional change that took place as pharmacies incorporated computing technology. What began as primarily dispensing assistance has evolved into sophisticated electronic patient record and treatment management. • Transformational change is rapid and can be likened to the change that occurs after a hurricane devastates an area and forces rebuilding. Transformational change is most necessary when risk is great (i.e., risk of bankruptcy or loss of market share to a rival). Transformational changes in pharmacy often occur in the form of legislative action or mandates, sometimes with little notice, which require us to do things quite differently. Two examples are the implementation of the privacy provisions of the Health Insurance Portability and Accountability Act of 1996 and the forthcoming medication therapy management provision of Medicare Part D. Transformational change occurs only rarely in health care. Incremental change is more common because it is the nature of medicine to test, retest, study, then proceed cautiously to change. American health care, due to external forces, is in a mode of transitional change. CQI can be used to improve both clinical and organizational performance. The business literature describes organizations as evolving and improving. Clinical processes fit well into business models because both organizations and clinical processes involve many people working together in a structured way to accomplish a goal. CQI helps identify barriers within any organization or within structures with which we must work (but have no authority over) such as networks, contracts, or fee-for-service contracts. The latter types of organizations can be frustrating for management because of the lack of authority. If CQI becomes part of a culture, it makes transition a natural process. The terms "leading" and "managing" are often used interchangeably; however, leadership has to do with vision, while management has to do with the mechanics of achieving the vision. Managers are frequently asked to maintain the status quo, adding stability and order to the organization' s culture. They may be less skilled at instigating change and envisioning the future. On the other hand, leaders are able to raise people' s expectations, involve them emotionally, and change the organization' s direction. Management is a necessary but insufficient condition for moving organizations forward.
According to J.P. Kotter, leadership copes with internal and external change. Management copes with the complexity of using available resources to achieve the vision. 5 Successful organizational change is 70% to 90% leadership and less than 30% management. 6 Table 1 describes some specific ways that leaders and managers differ.
ss Any Path Suffices?
The Cheshire cat in Lewis Carroll' s Alice in Wonderland offers a lesson for all organizations. The Cheshire cat was somewhat Socratic, never answering questions directly, rather answering a question with another question. Alice meets the Cheshire cat when she comes to a fork in a road. She says, "Cheshire cat, Cheshire cat, which path do I take?" And he looks down, smiles, and asks, "Well, where are you going?" She replies, "You know, I don't know." He says, "Then it doesn't really matter which path you take." When organizations lack direction, it doesn't matter which path they take. The business environment is increasingly complex and competitive. Businesses, including health care, must have a sense of direction. Regardless, many companies, from small to large, do not. Most successful businesses use strategic planning to determine their sense of direction and communicate their direction using mission, vision, and values statements.
Steven Covey, a popular author on management and leadership, suggests that management is bottom-line focused, while leadership is top-line or vision-focused. His maxim, "begin with the end in mind," is simple, but remarkably insightful. 7 Leaders must inspire others to think about what they are producing or want to deliver, "beginning with the end in mind." In understanding our current situation or dilemma, we must realize that we are either products of our own proactive design, of other people' s agendas, of our own circumstances, or of poor habits. This begs the question, "Why are we doing things the way we are now?" Doing things one way because that' s the way they've always been done is almost always a mistake.

ss Making Change
To bring about change, we must understand clearly and communicate effectively what we wish to accomplish (beginning with the end in mind). Table 2 lists questions that are useful in implementing the change process. The change process begins with identifying the magnitude of the gap between the status quo and the vision we wish to achieve. How the change will occur must also be decided. Will the process be evolutionary or revolutionary? Most changes in pharmacy practice occur in an evolutionary or incremental manner; revolutionary or transformational change is much less common and much more disruptive. Identifying organizational leaders, their positions in the company, and their capabilities are key to successful implementation. Always keep in mind that leaders in an organization do not always hold managerial titles or top positions in the company. In the case of an unacceptable dispensing error rate, a pharmacy technician may be the person with the knowledge and skills to articulate the best way to resolve the problem and to lead the effort.
Change may be planned or unplanned. Planned change follows specific, proactive efforts to create a new direction. When managed well, planned change can have positive effects on an organization. Unplanned change occurs randomly and can have negative effects on the organization. Good planning, a clearly articulated vision, and a sound strategy, however, can reduce the frequency of unplanned events.
Everett M. Rogers, in his 1995 book, Diffusion of Innovations, identifies the typical stages of change associated with the adoption of an innovation. 8 These stages of change apply to many of the issues we face in pharmacy and medicine whether it is a new medication, a new technology, or a new theory of disease. Rogers