Publication Date: 2012
Frank Federico, RPh
Executive Director, Strategic Partners
Institute for Healthcare Improvement
Q: Tell me the story of your career leading up to IHI: how did you get interested in safety and quality?
I’m a pharmacist by training. I started my career in a community pharmacy. Then I worked at Children’s Hospital in Boston, first as a staff pharmacist and then as director of the department.
Very early on, around the late 1970s, we were using some safety interventions. Back then, we didn’t call them safety interventions; they were simple changes that just made a lot of sense to us. Things like “read-back” to the doctors on the phone. We didn’t call it read-back — we just decided it would be a good thing to do because sometimes the calls would be garbled, or the doctor would speak too quickly, or there would be too much background noise to hear clearly.
So all the pharmacists agreed to repeat back to the prescriber the drug name, dose, and frequency. It seems so obvious now, and I suspect there were others using this technique, but it wasn’t the kind of change people talked about. It wasn’t a formal intervention that people identified or discussed.
While I was still at Children’s, I was exposed to my first dose of quality improvement work through Tom Nolan [IHI Senior Fellow, statistician, and member of Associates in Process Improvement]. Tom was our consultant for a period of time, and he taught us the Model for Improvement.
As we learned, we focused on different areas of the medication system. We made progress in reducing prescribing errors, reducing drug administration errors, reducing pharmacy preparation errors, and standardizing key processes.
Q: How did you come to work at IHI?
I had a lot of contact points. My colleagues at Children’s who were leading the quality improvement work were all involved with IHI in different ways: Pat Rutherford, a nurse manager on one of the wards [now IHI Vice President], and Don Goldmann, an infectious disease specialist and one of the attendings at Children’s [now IHI Senior Vice President]. They were IHI faculty members and close to Don Berwick [MD, MPP, Founder and Former President and CEO of IHI, also a former pediatrician at Children’s].
I was first exposed to IHI around 1995 when Don Berwick brought together leaders in patient safety for an expert meeting. The meeting served as a launch of IHI’s first Collaborative on reducing medication errors and adverse drug events, in 1996. The co-chairs of this Collaborative were Don Goldmann and Lucian Leape [MD, Adjunct Professor at the Harvard School of Public Health, IHI faculty member, and patient safety pioneer]. Don Berwick was an expert faculty on the Collaborative; Andrea Kabcenell [RN, MPH, IHI Vice President] was the director. Tom Nolan was the Improvement Advisor. And I was with the team from Children’s participating in this Collaborative.
During that Collaborative I also joined IHI as faculty, a role I have continued since then. Over the following years I co-chaired several IHI Collaboratives. In 1999 I also transitioned from Children’s Hospital to CRICO/Risk Management Foundation, a “captive” insurance company for the Harvard-affiliated teaching hospitals. I decided to make this move to broaden my horizons a bit. As director of the pharmacy at Children’s, I was completely focused on medication safety and managing the department; I wanted to explore the larger picture of patient safety. At CRICO, along with dealing with medication-related risk issues, I had the opportunity to learn about surgical issues, diagnostics, perinatal issues, and so on. Our whole approach to reducing risk at CRICO was to improve quality: we believed that if we delivered the best possible health care, we would reduce the likelihood of malpractice suits.
Then in 2004 I received a call from Carol Haraden [IHI Vice President and lead for patient safety], who said, “How would you like to work with IHI full time?” And I said, “Let me think about it. Okay, when do I start?” Becoming part of the IHI family was an opportunity I couldn’t pass up because I was learning so much from my IHI faculty work. After every one of the IHI Collaborative meetings my wife would say, “You always come home so energized from these meetings!” It was a great experience — the learning, the excitement, the people committed to this work. Yes, it was difficult work, but we all knew it was important; that we were doing something good for our patients.
I knew from my years of involvement with IHI that it’s a special organization: the culture, the dedication of the staff, the work we do. And being at the cutting edge is really valuable.
Q: What is your role at IHI?
My main responsibilities are in two areas: one, to work with Carol (Haraden) on IHI’s safety portfolio, which has two parts. One is coaching hospital teams to implement what we know should be in place — proven best practices. And second, to look towards the future: What’s next? What is the future of safety? What are the things we should be thinking about as we mature in our work and as hospitals need more help? And our scope is international: I’ve visited safety teams in countries around the world, wherever IHI has reach: Scotland, Denmark, Singapore, Portugal, to name a few.
My other hat at IHI is to manage IHI Strategic Partnerships, so I work closely with our team focused on those dozen or so relationships worldwide.
Q: What do you see as challenges ahead — for IHI and for the larger safety and quality improvement mission?
The main challenge I see for the hospitals we work with is that they have so many competing requests coming at them, so many demands on their time and resources: regulatory issues, accreditation issues, policy issues, community concerns. So the idea of having to work on another project, an improvement program with IHI, is overwhelming.
But then they begin to understand a key issue: safety is not a project; it’s something incorporated into the work they do every day. And if they work together to design more reliable and leaner processes — they’ll actually wind up with more time available. They won’t be spending time on rework, on treating patients who’ve been harmed in the hospital.
Another ongoing challenge is spreading the message about teamwork: that the work we all do is truly multidisciplinary. No one discipline alone can solve the safety problem; it’s too complex. But for people who have always worked independently this can be hard to grasp; we’re asking them to act differently.
Part of it is understanding that there’s a system behind everything. If you’re dealing with a medication problem, it’s not just a pharmacy problem; it belongs to the whole hospital to solve. No one department, no one area, can solve it alone.
For IHI, I think one of our main challenges is understanding the context of each organization we’re working with to help them implement changes. So, nationally, even from state to state in the US, from hospital to hospital within a city, different issues have to be addressed.
And likewise, when we work internationally, we have to understand not only the health system of the country where we’re working. We also have to understand the culture so we have a better idea of how to approach certain goals. There are cultures where transparency brings judgment or reproach rather than a learning opportunity, for example.
Q: What are you most excited about in your work?
When I see success and I see the teams really “getting it.” The teams are working hard on something and suddenly the light bulb goes on and they see improvement. Watching what occurs, for example, when you’re working with a nursing unit on a particular falls prevention program, and they say, “Wow, at first we thought this approach wasn’t going to work. But now we understand, and we see how important it is to run small tests and ask those who do the work to contribute ideas.”
The culture on that unit has changed; their willingness to work on improvement projects has changed. Inviting the staff on the unit to have an input into how to make things better means they have buy-in to do those things. They’re smiling about their work, which is one of IHI’s overall goals: to bring joy in work.
Those successes buoy you up and make you feel, “Wow, this is really an important effort.” It all comes back to the patients: We are in health care because we want to help patients. Whether you’re in a hospital setting or an office setting or long-term care facility or even in people’s homes, our job is always to do everything possible to help the patient get better and have a healthy life.
Working at IHI is also part of what makes it all worthwhile for me. The culture, the people … everybody is dedicated, everybody cares, everybody understands that no matter what their job is at IHI, they’re contributing to the greater mission of improving health and health care.