iPods. Mountain climbing. Forgiveness. They’re not your standard tools of leadership. But they’ve recently become elements of an effective effort by leaders of one large health care system to create a deep-seated culture of safety throughout the organization, using the six interventions at the heart of IHI’s 100,000 Lives Campaign as the framework.
Creativity, say those with experience, is critical when pursuing fundamental change on several fronts — such as implementing all six Campaign interventions simultaneously. So is the willingness to question assumptions, upset the status quo, learn and use tools from other industries, set goals, delegate, motivate, inspire, and hold everyone from the Board of Directors to front-line workers accountable. All this while also empowering these same front-line workers to try new things and make mistakes. Talk about challenges!
But leaders from a range of health care organizations say great things can be achieved if the organization has fostered a culture that values continuous improvement and patient safety. And if everyone, at all levels, has a way to be involved.
Creating Culture Change
“Culture is a word that gets overused. People talk about a culture of safety, or a culture of accountability, but what does that really mean?” asks Barry Silbaugh, MD, MS, FACPE, until recently Vice President of Medical Operations at Catholic Health Initiatives (CHI), which operates 70 acute-care facilities in 19 states. Silbaugh, who is currently consulting and serving as president of the American College of Physician Executives, answers his own question this way: “Fundamentally, culture is behaviors. To change culture, you have to change behaviors. The six interventions in IHI’s 100,000 Lives Campaign are a great starting point for that.”
These interventions, proven to prevent complications and avoidable deaths, call for hospitals to:
More than 3,000 hospitals have joined the Campaign, pledging to implement some or all of the interventions. Implementing all six interventions, as more than 1,100 Campaign hospitals, including CHI, have pledged to do, requires particularly strong and focused leadership.
In his work at CHI, Silbaugh was fortunate to have a highly skilled ally in his work: Jeff Norton, Director of Clinical Services and a mechanical engineer by training, who co-leads CHI’s safety initiative. “Jeff is an incredible colleague in this work because his background is so different and the way he thinks is really useful,” says Silbaugh.
Norton, who spent much of his career in the manufacturing end of the automotive industry, says, “Manufacturing engineers bring some simple yet powerful tools for identifying and eliminating waste and risk.” He says health care is experiencing the same trends that he saw ten years ago in his previous work, particularly the emphasis on quality, involvement of front-line staff, and the use of tools such as lean principles. Used most famously in the Toyota Production System (TPS), lean thinking is now being adopted by health care organizations to improve everything from patient flow to patient safety.
“Rapid Response Teams are a perfect example of bringing lean thinking into health care,” says Norton. When a Rapid Response Team is called to a patient’s bedside to prevent a possible heart attack, Norton says this is akin to “stopping the line,” a fundamental TPS concept. “In manufacturing, it’s become unacceptable to let something defective go down the line. Rapid Response Teams are a way to stop the line.” And just as it does in manufacturing, empowering front-line health care workers to stop the line — to take direct responsibility for quality — and giving them the tools to address problems, has a powerful impact on how they view their roles.
Safe, Then Fast
When they were given responsibility for improving patient safety for the entire system, Norton and Silbaugh knew that making rapid and visible progress in improving safety would help motivate continuous improvement, and be important to the effort’s ultimate success. So they did not convene a large task force. “I learned from Jeff — and this is directly from industry — that our goal should be to improve safety, and do it fast. If it’s not fast, you get frustrated,” says Silbaugh.
So they organized an eight-person team to lead the safety initiative, composed of people spread widely throughout the system. Identifying people who will be effective change leaders is where Silbaugh’s climbing experience comes in. “When I’m on a climb, I know who I want as my rope mates,” says Silbaugh. “I want people who are both curious and critical, able to see possibilities and find ways to get there.” These characteristics also describe “early adopters” and “change agents,” people who can effectively lead cultural and behavioral change at macro and micro levels of an organization. Silbaugh and Norton sought out these “people with passion” to help foster change. Geographically dispersed, they meet weekly by teleconference.
Jeff Norton describes four parts to the CHI strategy to create system-wide change. “First, strong leadership and support from the very top is essential,” he says. Norton says the organization’s CEO, Kevin Lofton, FACHE; its COO, Michael Rowan; and its CMO, John Anderson, MD, are particularly vocal and visible leaders for patient safety. “They put the agenda on the front burner, they supported the goals of the 100,000 Lives Campaign to track our mortality rates, they created the structure for us to get going,” says Norton.
Second, Norton says, is the variety of people involved in leading safety initiatives, including those not traditionally associated with patient safety. “We have people from the finance department to help us make the business case for safety. We have knowledge management folks to help with communications and the spread of ideas, and folks from communications, mission, performance management, and pharmacy,” he says. The common denominator among them is passion for excellence and enthusiasm. “They bring lots of energy to our work.”
Third, Norton says front-line safety teams focused on improving specific processes — in this case, the six Campaign interventions — are responsible for some of the most critical and successful elements of patient safety work. “The best solutions come from those closest to the problem. The people in our hospitals are the ones taking care of patients and doing the work that saves lives. Without these people there is no change,” says Norton.
He gives an example of a medication ordering process at one CHI hospital that would sometimes get backed up. “When the team drilled down into the process, they found that orders would often get delayed when the receiving fax machine ran out of paper.” Norton says he and other higher-level leaders had “big ideas” about how to engineer a new process, but trusted the process of letting the people closest to the problem solve it. A team member suggested that a sheet of colored paper should be routinely placed at the end of the machine’s paper supply. “Now whoever gets a fax on colored paper knows it’s his or her job to reload the paper.” It’s a simple, inexpensive, and effective solution, he says, more powerful because it was created by the people who are invested in making it work.
The fourth element, says Norton, is effective use of proven tools for change, such as Plan-Do-Study-Act (PDSA) cycles of change. Silbaugh and Norton agree that these tools, which enable anyone to quickly test an idea on a small scale, have helped to reframe the way the organization views change. “Now there is an intolerance for waiting 24 hours to try something new,” says Jeff Norton. “We say, ‘Be evolutionary, not revolutionary,’ or to borrow from IHI, ‘What can you do by 5:00 PM Tuesday?’”
Financial incentives are also a useful tool, says Barry Silbaugh. “Every executive at CHI has multiple incentive goals related to improving safety and reducing mortality,” including the use of the six interventions in IHI’s 100,000 Lives Campaign.
An Epiphany
Information fuels change. CHI safety leaders gather information from staff through safety surveys (with broad participation, thanks in part to the opportunity to win an iPod), and widely disseminate it through safety scorecards at the local and system-wide level, regular local meetings, system-wide teleconferences, the Intranet, focused emails, and conference calls.
Silbaugh says that because CHI is a faith-based system, there is an extra layer of thought that pervades their work. “Patient safety work exemplifies Catholic health values: reverence for patients and for co-workers; integrity that requires us to tell the truth and admit mistakes; compassion built on forgiveness; and excellence in all we do.”
The connection between work and faith was further illuminated for Silbaugh at a national conference on patient safety, he says. “I had an epiphany in a session on medical error from the consumer’s perspective. I realized how hard we make it for patients to forgive us, because we don’t admit our mistakes. We can’t be forgiven or forgive ourselves until we fully recognize our own fallibility.”
So he asked Sister Diane Traffas, OP, CHI’s Vice President of Mission, to lead a system-wide educational effort on the power of forgiveness in health care. Admitting and even embracing human limitations fuels the organization’s efforts to put systems and strategies in place to compensate for, as Silbaugh puts it, “our wonderful humanness.”
Of course, the truest measure of CHI’s progress will be a reduction in the mortality rate. Norton says that signs thus far are very encouraging and, though data is still being analyzed, it looks like deaths are decreasing.
CHI hospitals are adopting the six Campaign interventions “with great enthusiasm,” says Norton, and the hospitals monitor process measures monthly. The figures below show how many CHI hospitals have implemented each intervention:
More than half of the hospitals have also completed a culture of safety survey to provide the organization with an extensive picture of attitudes, behaviors, and outcomes.
A Matter of Style
The four elements of CHI’s change strategy can work anywhere. Silbaugh says that starting and staying lean is key, and offers this advice to other health care leaders wishing to implement broad change: “If you are thinking about setting up a subcommittee of a user group of a council, you’re thinking the wrong way. Find a way to break through the usual corporate metabolism and do it now.”
Of course, leadership styles vary, and every leader brings his or her own creativity to the job. Here are some additional strategies being successfully used to foster system-wide change at other health care organizations that are part of IHI’s 100,000 Lives Campaign:
At Abington Memorial Hospital, a 508-bed community teaching hospital outside Philadelphia, Pennsylvania, an emphasis on improving the working relationship between physicians and nurses is changing the culture in positive ways, says Associate Patient Safety Officer Doron Schneider, MD. “We try to have a physician and a nurse co-lead every improvement team,” he says. Each of the six Campaign interventions also has a clinical systems safety specialist supporting it, along with Schneider himself.
Nurses have redesigned the nursing flow sheets, with input from physicians, so that physicians can more easily find the information they need. Physicians and nurses collaborate to document use of evidence-based care, such as the steps in the Ventilator Bundle. Nurses double-check the History and Physical forms that physicians complete for each patient, using them for medication reconciliation and providing feedback to physicians on any potential “red flag” issues they note. “It is a change in their relationship,” says Schneider, noting the importance of starting this sort of change on a small scale and learning from each cycle.
Performance-related financial incentives — particularly keyed to the six Campaign interventions — are also in place at Abington at many levels, including for the chair of each department, nurse directors and managers, and key clinical leaders.
The University of Kansas Medical Center, which includes the 475-bed University of Kansas Hospital, in Kansas City, Kansas, was one of the first organizations to join the 100,000 Lives Campaign. “Our CEO, Irene Cumming, came back from the IHI National Forum where the Campaign was announced and said, ‘This makes sense,’” recalls Terry Rusconi, Senior Director of Organizational Improvement. Though he says the hospital already had most of the interventions in place, the Campaign helped them tighten up their processes, and spurred them to implement Rapid Response Teams, something they did within 45 days of Cummings’ announcement about the Campaign. Cummings set the 45-day goal, says Rusconi, and said, “Tell us what you need and then make it happen.”
This example underscores the importance of establishing very specific goals, something that Rusconi says has not always been done at KU Med. In the “old days,” he says, “We had goals, but whether or not you reached them didn’t really matter.” In 1998, when KU Med broke from the state health care system to become private, that changed. “We established the patient as our primary focus, and declared that the old, slow timeframes wouldn’t work anymore. Now our leaders commit to providing resources and removing roadblocks, and implementation of new ideas is aggressive,” says Rusconi.
Rusconi says other ingredients that have transformed KU Med include a singular organizational focus on the patient and a culture that values questions and even uncertainty. “It used to be if you didn’t know the answer you hid your ignorance. Now you say, ‘Gee, I don’t know, but let’s find out,’” says Rusconi. The use of small, rapid cycles of change has also been liberating. “We used to have a nine-step performance improvement model that no one even understood.” Small tests of change have energized the organization, while improving patient outcomes and reducing staff turnover.
BayCare Health System, in the Tampa Bay area of Florida, has used many of the same leadership techniques to continuously improve in each of its nine hospitals. Cindy Righter, Director for Clinical Outcomes, says that once the Board approved BayCare’s participation in the 100,000 Lives Campaign, a “process owner” who could ensure that process changes were effectively implemented at the patient care level was chosen to lead each of the six interventions. “Having all these initiatives fall on the Quality Director’s plate is not an effective way to make long-lasting changes,” says Righter.
In addition, she says, “each initiative has a senior leader assigned to it to ensure that barriers are removed, and at least one physician champion to help build physician buy-in.” Righter says that teams work in collaboration across the system sharing ideas and experiences, and identifying best practices.
The Board reviews quarterly-updated data gathered from the organization’s outcomes data warehouse, showing how each of the nine hospitals is doing in the Campaign. That accountability is important, says Righter. “We’re a better organization than ever before, because accountability for our success goes all the way to the Board.”
As a result of its efforts, BayCare measured a 5.45 percent decrease in mortality across all nine of its hospitals during the first nine months of 2005. BayCare calculated that this mortality rate reduction represented 123 lives saved. Compliance with the six interventions is climbing, particularly with the Ventilator Bundle and AMI protocols, where compliance approaches 100 percent.
01/26/2006
