IHI: How did you come to embark on this journey?

 

JA: In 2000, before The Robert Wood Johnson Foundation (RWJF) Pursuing Perfection grant, I asked our various communities what challenges we ought to take on in the next three to five years. One of the groups came back and said that in its view, we have a lot of great caregivers (physicians and nurses), but we do not provide an environment for the best delivery of that care. They saw a lot of barriers to the delivery of the best care we are capable of delivering. As we began to talk about whether it was a grand enough vision for the next three to five years, we also began to consider the external issues of national health care concerns, such as safety, and realized that quality was a compelling issue that we felt we should, and were capable of, addressing. Although we did not know what a transformed system would look like, we did not see why we could not make significant changes in the way care was delivered in order to meet these various needs. The outcome was a commitment-in-the-making to transformational change — not just to tweak on the edges of performance improvement, but also to really examine the way we were giving care and making dramatic change.

 

In the middle of that strategic planning process came the opportunity to apply for the Pursuing Perfection grant from RWJF. I thought we should do it, as it was congruent with our plan and would link us up with a wide range of helpful resources. We did get the grant, and it has worked pretty much as I had hoped. It has been an important part of our transformational effort, but we do not view it as a project, or a grant that has a beginning or an end date. We view it as shot of adrenaline into the strategic plan we are already committed to, helping to accelerate our progress significantly faster.

 

IHI: Where did you start?

 

JA: We started with two pilot project teams, addressing improvements in care for bronchiolitis and cystic fibrosis. We picked these because we wanted to develop and spread the learning about acute and chronic care. We also changed our clinical operations management structure to facilitate the spread and learning to all other components of the organization.

 

IHI: How has the work affected you and other senior leaders?

 

JA: I began to recognize and admit that we really do not deliver care nearly as well as we could, and that there is no excuse for that. As I became increasingly educated about how we are not doing this very well, my patience diminished. At the end of the day, there is no excuse for the systems issues we are facing to have the deleterious effect that they do on the delivery of care. Other high-performing industries have solved these kinds of problems some time ago, but teaching hospitals have not.

 

The other reality is that I did not come from health care. I was a business lawyer in a large law firm and spent several years at a senior level in an industrial company that was acquired by Emerson Electric Company, which is recognized for high-quality processes. My experience there taught me that one should not tolerate processes that do not work. If you fix them, the savings more than offset the costs, and the outcomes are such that the marketplace finds them very attractive. Thus, not only can you deliver a higher quality product at a lower cost, but also you can charge more for it. The business case is pretty compelling. There is no business reason not to tackle the issues. Coupled with the fact that this would produce better medical outcomes — and in our world, we care a lot about children and want the best medical outcomes for them — there is simply no reason other than cultural barriers or inept management for us to continue in an environment where we deliver care that is not as good as it could be.

 

The most recent, most riveting event was a short film that was shot on site. It depicted errors in the hospital and highlighted the care that families were receiving in our facility as well as the collaborative work we are doing to improve. We showed it at our Board’s Patient Care Committee meeting. We were all speechless at the end.

 

The non-health care professionals were more stunned by the tape than the doctors or nurses. The professionals said, “Of course, that’s how the system works.” Others could not believe it, but there it was, on film. We played the film at a senior leader retreat to the same reaction. When you talk to medical staff, and you know they are very good at what they do, and they are talking about these errors as normal experiences, it is searing. You want to think your standards are so much higher than that.

 

IHI: What you are not pointing out are the parts of the film that show how CCHMC is moving to correct these common problems, including adding family members to care design teams. You are stepping up to the plate with great courage.

 

JA: Well, this tape succinctly solidified our passion for fixing these issues and accelerated our transformation. People were concerned that they were going to be criticized because of this tape. I emailed them that it took great courage to show the tape to the Board committee, and thanked them for it. I told them that we could use it as leverage to make further change. Some say you cannot make change without a crisis — well, this tape articulates the crisis. We have used it fairly liberally since then with new residents and other groups within the hospital, saying this is what is going on, this is what we are doing about it, and asking them to share our commitment to transformational change.

 

IHI: What are some ways you are rolling out transformation to the organization?

 

JA: We are rolling out transformation in a number of ways. First, the Patient Care Committee is a Board committee, and its charter, created as part of the strategic plan, is to provide the Board oversight to our efforts to enhance the quality of the care delivery process, and to clear organizational barriers to delivering transformational change. Pursuing Perfection, safety issues, and customer satisfaction fit here. The Committee has a wide cross-section of people, including doctors, nurses, business people, board members, and members of the community. The Chairman of our Board of Trustees chairs it.

 

We also roll out changes through project groups, each of which has a senior leader that “champions” the project. The champion is there to make sure the group gets the institutional support they need, and frankly, to learn about the project. We report these results up to the Patient Care Committee, so the Board has a continuing role.

 

I find that sometimes project teams’ interests wane because they are uncertain of the institution’s commitment. That is where I can help. I will talk with them and reaffirm our commitment. I sit and listen. Sometimes they feel that they are in a box canyon, and I can usually get them out. I reinforce that the work absolutely is critical, that we can make these changes, and that they have my personal and institutional commitment. This effort includes dealing with people who seem permanently unenthusiastic about engaging in this effort. Performance evaluations increasingly focus on the extent to which people are constructive participants in the Pursuing Perfection process, and it is essential to their prosperity here at CCHMC that they become constructive participants. Over time, those who are not will be seeking employment elsewhere.

 

IHI: What are your next steps?

 

JA: A big next step is to redesign the fragmented clinical operations structure. We have recently and deliberately created a problem-solving structure that is designed to be not dependent on the top leaders in the institution. This approach gets down into the level of “do-ers” who can identify issues and take a cross-functional approach toward resolving them. Our plan is that these leaders will work on a horizontal plane across divisions, which will affect outcomes, quality, and cost in a way we have found difficult to get to before. It is a clinical operations structure change that will not change the line reporting relationships, but will create collaborative groups of middle management leaders who will identify issues and develop and implement action plans to resolve systems issues.

 

IHI: What is your advice for other CEOs?

 

JA: Clearly, do it. I think health care needs to grapple with these very fundamental issues and transform. The more I learn about it, the more deeply concerned I am about care delivery — not just here, but everywhere. Health care defects are well known to the broad public and unless we can credibly address them and make real change, we are going to continue to struggle in unnecessary ways, to the detriment of constituencies we care deeply about.

 

If there were some way I could wave a magic wand and give everyone the will and capacity to pursue these fundamental changes and make the cultural changes that are necessary, I would love to do it. When I meet with other CEOs from other institutions, I am concerned that (the quality movement) does not seem to have much traction. There are exceptions, but in my experience, not many are committing to the revolution. I think people feel beaten down by day-to-day challenges, and are not looking at the opportunity for transformation as one that can be productively pursued. I realize that it is a big job, but we just need to do it.

 

 

For more information about organizational transformation, read Jim Reinertsen’s paper entitled, A Theory of Leadership for the Transformation for Health Care Organizations.