This is the third post in an occasional series by Kyle E. Johnson, PMP, Administrative Fellow, St. Charles Health System, about how the IHI Open School courses are helping to change culture in the hospital. Click here to see his first two posts.
Looking around the room, I observe a diverse group of St. Charles caregivers diligently working on a fishbone diagram. They are trying to determine root causes behind the death of a patient. The group includes clinical and non-clinical caregivers, as well as managers and non-managers. They are creating the diagram as a part of a case study that has been presented to them as part of a one-hour class on Causal Analysis. The Chief Clinical Officer for St. Charles Health System is teaching the class.
In January 2013, when St. Charles began using the IHI Open School as the foundation for quality improvement training and education across our health system, we began looking for ways to provide context and additional instruction, and to reinforce Open School concepts. We decided that a good way to do this would be to have our senior leaders teach quality improvement classes. In this way, the leaders who had already started working on their Basic Certificates would set a strong example and would gain an even deeper understanding of the content.
More importantly, leaders would provide a unique and valuable perspective on the importance of quality improvement.
We used the title “Causal Analysis” in lieu of “Root Cause Analysis” because there is often more than a single cause to a problem or error that occurs in a complex adaptive system such as a hospital. The Causal Analysis class is one of twelve in our year-long curriculum. The same design format is used for each class: 20-minute lecture, 30 minutes of practical application, and a 10-minute discussion. The classes are designed to be dynamic and interactive, and provide context as to why each improvement concept is important and how it can be put to use. We use storytelling, hands-on exercises, and group work to engage caregivers in ways that leave a lasting impression.
Following the lecture portion of the Causal Analysis class, the attendees created a fishbone diagram
and used the “5 Why’s”
technique to determine the root causes behind the patient’s death. The class did a great job at analyzing the case and using the tools discussed in the lecture to help identify root causes. Following that, we discussed causal analysis and how it applies to the Model for Improvement
and our everyday work. The class proved to be engaging and the exercise was effective at reinforcing key improvement concepts.
Despite a successful period of technical instruction, there is nothing that compares to the power of a story that connects with an audience or class through emotion. In their book, Made to Stick
, Chip and Dan Heath write, “Stories should put knowledge into a frame work that is more lifelike.” With this in mind, our Chief Clinical Officer ended class by telling the story of the patient in the case study who had died as a result of the medical error. He knew the story well because it was his patient. He went on to explain how he was part of a system of communication that had broken down and ultimately resulted in the patient’s death. It was a story that took courage to tell, and it had a palpable effect on everyone in the class. The story brought the lesson to life and it set an example of transparency that quickly spread beyond the walls of the classroom.
Anytime a story is used to emphasize a key point or lend context to data or systems, the effect can be significant. Each month at St. Charles, our leaders teach basic quality improvement skills and discuss why they are important. While the skills taught have a practical value, the leadership perspective and shared experiences are invaluable. It is proving to be an effective way to further engage caregivers and to help transform our culture.