Leading for Safety: Thoughts on Structure, Culture and Governance

March 4, 2011Debbie Barnard, MS, CPHQVictoria Inn Winnipeg, Manitoba

Presentation Outline

Introduction Reflections on

Governance/Leadership, Structure/ Infrastructure and Culture

Case Study Table Top Discussions Report Out/Reflections Closing Comments

Our Promise to Patients/Residents

Safety – “not harming people with our care”

Effectiveness – “matching science to care”

Patient centeredness – “nothing about me without me”

Timeliness – “avoiding needless delays” Efficiency – “Avoiding waste” Equity – “Closing the gap”

IOM Report 1999 & CAES 2004“The current care systems cannot do the job.

The chassis is broken.Trying harder will not work; we must

change the systems of care.”

Source: www.iom.edu

Are we up to it

Case Study: Dana-Farber Cancer

InstituteFROM

Errors are rare

Everything’s great

Great care

Made it up as you go along

TO Errors are everywhere

Excellent, not perfect

Great care in a high-risk environment

Principles of fair and just culture, guidelines, algorithms, flow sheets

Case Study: Dana-Farber Cancer

InstituteFROM

Risk of disclosure/ confidentiality

Great staff, poor systems

QI, RM, Safety staff drive the work

TO Moral duty, risk on

nondisclosure, transparency

Great systems, great staff

Board, C-Suite, Chiefs, Chairs drive the work

Case Study: Dana-Farber Cancer

InstituteFROM

Keep the board out

Keep doctors out of QI and RM

Deliver care to patients

TO Actively engage

Actively engage, nothing possible without them

Partner with patients and families

Case Study(Think Differently- video)

Governance & Leadership

HOT TOPIC!– Boards on Board – IHI 5 Million Lives

– Effective Governance for Quality

and Patient Safety - OHA Regional

Programs 2011

– CPSI Board Resources & Toolkit

What Does the Evidence Tell Us?

Outcomes are better in hospitals (organizations) where:

– The board spends >25% of its time on quality

and safety.

– The board receives a formal quality

measurement report.

– There is a high level of interaction between

the board and medical staff on quality

strategy.

Vaughn T, Koepke M, Kroch E, et al. J of Patient Safety. 2006;2:2-9.

What Does the Evidence Tell Us?

Outcomes are better in hospitals (organizations) where:

– Senior executive compensation is based in

part on quality and safety performance.

– The CEO is identified as the person with the

greatest impact on QI, especially when so

identified by the QI executive.

Vaughn T, Koepke M, Kroch E, et al. J of Patient Safety. 2006;2:2-9.

Six Things That Boards Can Do

1. Set a specific aim to reduce harm this year and make an explicit, public commitment to measurable quality improvement (e.g., reduction in unnecessary mortality or harm).

2. Select and review progress towards safer care as the first agenda item at every board meeting.• Get data on harms and hear stories; put a

“human face” on data.

Six Things That Boards Can Do

3. Establish and monitor a small number of organization-wide “roll-up” measures that are updated continually and are transparent to the entire organization and its customers.

4. Commit to establish and maintain an environment that is respectful, fair, and just for all who experience pain and loss from avoidable harm.• Patients, their families, and staff at the sharp

end of error

Six Things That Boards Can Do

5. Develop the capability of the board. • Learn how the “best in the world” boards

work with executive and MD leaders to reduce harm.

• Set an expectation for similar levels of education/training for all staff.

6. Oversee the effective execution of a plan to achieve the board’s aims to reduce harm, including executive team accountability for clear quality improvement targets.

Culture

“Every enterprise has four organizations:

the one that is written down,

the one that most people believe exists,

the one that people wished existed, and

the one that the organization really

needs.”

NHS Building & Nurturing an Improvement Culture

Scope for Leaders

What is the meaning of

organizational culture?

How to measure organizational

culture?

How to build/change

organizational culture?

When you discover you are riding a dead horse, the best strategy is to:

Beat the horse --> it may rise from the dead

Change riders --> it is clearly the rider’s fault the

horse is not moving

Appoint a committee --> if more people look at

the horse , it may not be really dead .

Arrange to visit other sites--> See how they ride

dead horses

Lower the standards: make dead horses

acceptable

Tribal Wisdom of Healthcare

Structure/ Infrastructure

Level of

Deta

il

Low

High

Viewing the Organization as a System:

Linkage of Processes at appropriate Level of Detail

Source

: L. Pro

vost, S

enio

r Fello

w

IHI

Common Themes

Inputs

Strategic

Objectives

Map Strategic Objectives to Organization system (processes) High Leverage

Processes or Services

New ProcessesNew Services

Charter Allocate Resourcesfor Improving the System

Resources forOperating the Business

Improvement

Where do we focus?

Planning for ImprovementSource: L. Provost, Senior Fellow IHI

Can you build a house without a frame?

Committees Technology Supports

– Databases and IT systems that communicate

Reporting System Human Resources

– Orientation & Competency Programs

Source: L. Provost, Senior Fellow IHI

Execution of Improvement Work in Organizations

Projects

Division or Department Level

Whole Organizational levelSource: L. Provost, Senior Fellow IHI

Execution Structure

Project

Sub-system Level

Organizational Level (whole system)

Sub-system Level

Sub-System Level

Project Project

ProjectProject Project

Project

Project

Source: L. Provost, Senior Fellow IHI

Table Work and Discussion

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27

Governance & Leadership

1. What do you think the leadership team did at DF to create their “to state”?

2. Leadership for improvement is difficult; what do you find most challenging in your organization?

3. What are some of the key strategies that the board and leadership team can do to “walk the talk”?

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Culture

1. What’s at least one successful strategy or tactic you can share from your organization’s improvement journey?

2. Pretend you are coaching a new leader, how can you help them to begin to use a system view of their organization as a way of creating a new culture?

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Structure & Infrastructure

1. How do you think the leadership team at DF began to redefine their processes so that they could view their organization from a whole system perspective

2. How can this approach support your team to connect structure, strategy and improvement?

3. Does your quality infrastructure require any changes to improve how quality improvement work gets done?

Report Outs

Observations & reflections from your group’s discussion

Your contribution to the “Ten Powerful Ideas for the Future Now”

Closing Video