IHI: How did you come to embark on this journey?
DK: I was the COO when we received The Robert Wood Johnson Foundation Pursuing Perfection grant. Our CEO John O’Brien, who was instrumental in initiating our improvement efforts, left, and I became acting CEO. Our situation is not atypical in that four out of the seven original CEOs in Pursuing Perfection in the US have left their positions. The good news about this transition was that I was already the point person for John for the Pursuing Perfection program, and worked with our Project Director Carol Jones to implement the various projects that were part of the grant. (If I were to point to someone in the organization who really got us engaged in this project, it would be Carol.) Therefore, it was not too difficult to transition when I was named CEO on a permanent basis. One of my core strategies was to keep us focused on Pursuing Perfection so that we would not lose momentum during the transition, and so people would not think that because there was a new CEO, we would waver in our commitment.
I think my journey started with reading the Institute of Medicine’s (IOM) report, Crossing the Quality Chasm. One has to read and reread it. It is all there. The way I characterize it with my senior leadership team is that you have to passionately believe the system is broken. Then, in terms of the work, you have to passionately believe that you can fix it. That is where the rubber hits the road.
Some people may not believe the system is even broken. After all, we are all health care providers. We have all helped build this system, and I acknowledge that fact whenever I talk about the current health care system. I am one of the people who helped build it; I have been in the industry for over 20 years. I cannot distance myself from the provider-centric health care system that works for providers but not very well for patients.
However, I can understand it, own it, reflect upon it, and try to do whatever I can to fix it going forward. It is hard for some members of the clinical staff, who are dedicated to their careers and their patients, to believe the system is broken. Many clinicians cannot conceive of having done anything but the best thing possible for their patients. However, they are not looking through their patients’ eyes.
IHI: What is the difference between people who see the problems and take ownership for change and those that do not?
DK: It is a great question and I believe I have the answer. I think you have to experience the system on a personal level. For example, in one of our Pursuing Perfection projects, we are trying to create perfect care for children with asthma. My daughter has asthma. I have gone into an emergency room and know it is a gamble whether the physician: 1) has good experience with children, 2) has good experience with people with asthma, and 3) is up to speed on the best clinical care for treating asthma. Typically, there is no online medical record, so there is no way for the doctors to access any prior clinical information about my daughter, and this is all happening at 2 AM or 3 AM. My experience is that when you are on the consumer side, physicians do not necessarily listen to what parents and patients have to say, even though they are very well educated in the disease. On one occasion, my daughter was given the wrong medication despite our protests as very educated health consumers — and my wife is a nurse. My daughter was almost admitted to the hospital. I have to say that it is more the rule than the exception. Unless you experience it, you do not honestly believe it could be that bad.
The other advantage I have is that I am not a physician. So truly, when I experience these incidents with my daughter or other members of my family, the system treats me like anyone else. I do not go into it saying I am a CEO of a health organization. I go in as the father of Kristin Keefe, or the son of Thomas Keefe, and they know I am not a physician because I do not have the “MD” at the end of my name. I am not saying, however, that it necessarily would be better every time if I were a physician.
Overall, the passion for change comes from reading the IOM report, dealing with the system personally, seeing it through the patients’ eyes, and seeing how flawed the current system is, despite the very dedicated, well-intentioned people. It is the American health care system. There is really a chasm out there.
IHI: How did you change the people around you who have not had personal experience with the system?
DK: I think it is powerful when the CEO and other leaders talk about their personal experiences and relate them to some of the projects. I try to support very strongly and visibly the Pursuing Perfection initiatives. In addition to speaking passionately about the issues, I back it up with a commitment of resources to ensure that we do fix them. When we talk about asthma, I understand what we are trying to do. I understand that there is a major investment in the information technology infrastructure. I understand that there is a major investment in making sure we have best practice standards at our fingertips. I understand the value of making sure that these resources are all available to everyone in our network. I find that this support spreads confidence and purpose across other Pursuing Perfection projects.
IHI: How do you roll the transformation out to the entire organization?
DK: We have the Pursuing Perfection Steering Committee, which is becoming more like a senior leadership committee. We also are redefining leadership in the organization. We are reorganizing leadership around transformation, using Pursuing Perfection as the vehicle. I am trying to get away from this concept of Pursuing Perfection, the “project,” to getting people to understand we are transforming the organization. We are going to develop and track system-wide indicators to demonstrate that we are, in fact, transforming the organization. We also talk to all staff about the various projects and how they link to that transformation.
The Steering Committee meets twice a month. It is a multidisciplinary group of all of the senior administrative and medical leaders in the organization. At one of the monthly meetings, we talk about the projects specifically: where are we, what are the barriers, what needs to be done, how do we continue to accelerate the work, how do we become more patient-centered, etc. At the other meeting, we talk about organizational transformation: how do we move beyond Pursuing Perfection as a project, how do we know we are there, what system-wide indicators can we use, what is the overall framework that will get us there (e.g., Baldrige criteria balanced scorecard, etc.), and so on.
We are fortunate that we have the most patient-centered organization in the country right here in Boston - Dana Farber. I have been working closely with Jim Conway, COO, Dana-Farber Cancer Institute and others there for a number of years, and we are working hard to incorporate their best practices.
IHI: What are some of the barriers you have run into and how have you overcome them?
DK: I certainly have run into barriers but I cannot say I have overcome them all! Transforming the organization depends on strong leadership at a number of levels. Following on the great work that Jim Collins has done in his book Good to Great , I think getting the right people, in the right positions, doing the right things, and all pulling in the right direction is paramount. I think there needs to be a relentless focus on this goal. If the right people are in place, and they are competent, effective, and passionate about the work we are trying to do, I believe you meet your goals much more quickly. If you do not have the right people in place, it is a barrier and a delicate issue.
Besides leadership, the financial situation is always a major impediment and could be an excuse, quite frankly, for not doing organizational transformation. People say, “It’s too expensive! We do not have the time or resources! Why don’t we hunker down, get into a cost-cutting mode, and forget about Pursuing Perfection and organizational transformation?” In the short term, it is true that you probably end up investing resources before you start reaping the benefits. I have to be really clear with leadership that we are not stepping back from this work. The great organizations out there invest in quality when times are tough. That message has to come loud and clear from the CEO. Even though we have financial challenges — and we have many here, believe me — we are not going to step away from this work. As Collins says in his book, you need “fierce resolve” that you will prevail.
I try to make it clear to people that this is a journey. As Collins’ points out in his book, the journey takes 10-15 years. It does not take two to three years. I think people initially thought that much more progress could be made than was made within the two-to-three-year time frame of the RWJF grant. I think people now have a better understanding that this is a journey.
I am focused on the people first and getting the right message out regarding our financial situation, stressing that this will continue to be a realization of our vision to be the premier academic public health care system in the nation. I am linking the organization’s transformation to our vision statement, and I think people see how it all relates now.
IHI: Do you have advice for other CEOs?
DK: Get out and talk to other CEOs to learn and accelerate the learning. I have found talking to Jim Reinertsen and Jim Conway extremely helpful. I am also making a personal commitment to go to the other Pursuing Perfection organizations for a site visit. That was the original vision of Pursuing Perfection. It is important because we are breaking ground in a number of areas and should all be learning from each other. That would be my suggestion, because when I do that, I learn something every time.