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4/25/2015
Profound Learning
If Not Me, Who?
If Not Now, When?
OAHQ Conference
For your service to your patients,
families, staff, and communities.
Jim Conway
Adjunct Faculty, HSPH
Trustee, Winchester Hospital
[email protected]
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Profound Learning
My Personal Journey…
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CH,B
MIT
DFCI
IHI
HSPH
Winchester Hospital
Pascal Metrics
Out and About
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OUT AND ABOUT
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Outline
• Profound Learning
– CH, Boston: PFCC, Service to Others
– MIT: Culture & Leading Change
– Dana-Farber Cancer Institute: Quality, Safety, PFCC
– IHI: Systematic Improvement, Leadership, Respect
– Harvard School of Public Health: Leading Change
– IOM: A Learning Healthcare System
– Winchester Hospital: Teamwork
• Excellence to Perfection: Closing the Gap
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“There is no force in the world stronger than a mother
advocating for her child” J. Conway
“I don’t care who you
are. I am going to stay
with my child.”
That’s nice Jim, but….
Pediatric Mother, 1976
“Just cause you’re
poor doesn’t mean
you’re stupid
How will it help the kids?
Pediatric Mother, ~1984
Popper B, Black A, Ericson E, Peck D. A Case Study of the Impact of a Parent Advisory Committee on Hospital Design and Policy,
Boston Children's Hospital. Children’s Environment Quarterly. Vol 4, No. 3, Fall 1987.
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An Important Friend
Nice for Grandchildren, Essential for Me
Change is Wicked Hard…
Even with a great vision, wonderful
people, exceptional resources… It’s
hard, hard, hard.
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Managing Change: An Essential Element
Creative Tension: Peter Senge
• Leadership in a learning organization starts with the principle of
creative tension.
• Creative tension comes from clearly seeing where we want to
be, our 'vision', and telling the truth about where we are, our
'current reality'.
– The gap between the two generates a natural tension.
• Creative tension can be resolved in two basic ways:
– by raising current reality toward the vision, or
– by lowering the vision toward current reality.
• Individuals, groups, and organizations who learn how to work
with creative tension learn how to use the energy it generates to
move reality more reliably toward their visions."
“Mental models are deeply held internal
images of how the world works, images that
limit us to familiar ways of thinking and
acting. Very often, we are not consciously
aware of our mental models or the effects
they have on our behavior ”
Peter Senge, MIT
The Fifth Discipline: The Art and Practice of the Learning Organization Peter
Senge, 1990 - 1st edition, 1994 - paperback edition, xxiii, 413 p., ISBN 0-385-26095-4
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“Defensive routines are the policies
or actions we put in place to prevent
ourselves and our organizations
from experiencing embarrassment
or threat.”
DANA-FARBER ADMITS DRUG OVERDOSE CAUSED
DEATH OF GLOBE COLUMNIST, DAMAGE TO SECOND
WOMAN
When 39-year-old Betsy A. Lehman died suddenly last Dec. 3 at Boston's Dana-Farber
Cancer Institute, near the end of a grueling three-month treatment for breast cancer, it
seemed a tragic reminder of the risks and limits of high-stakes cancer care. In fact, it
was something very different. The death of Lehman, a Boston Globe health columnist,
was due to a horrendous mistake: a massive overdose of a powerful anticancer drug
that ravaged her heart, causing it to fail suddenly….
Chris Argyris, Harvard Business School
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Key Learning
in Journey
• The responsibility and power of all
leadership [trustee, clinical and
administrative] over safety
• The need for relentless vigilance to
safety, risk, error, near-miss, harm
• Addressing the multiple victims of error
• The crucial role the design of systems
and application of technology play in
support of safe practice by excellent
staff
• The synergy of interdisciplinary practice
and team work
• Patient and Family Centered Care
In the gap
between
excellence and
perfection is
suffering, harm,
tragedy, death and
waste
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http://www.asco.org/ASCOv2/Education+%26+Training/Educational+Book?&vmview=edbk_detail_view&confID=40&abstractID=615
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Key Learning
in Journey
• The responsibility and power of all
leadership [trustee, clinical and
administrative] over safety
• The need for relentless vigilance to
safety, risk, error, near-miss, harm
• Addressing the multiple victims of error
• The crucial role the design of systems
and application of technology play in
support of safe practice by excellent
staff
• The synergy of interdisciplinary practice
and team work
• Patient and Family Centered Care
Our systems are too complex to
expect merely extraordinary
people to perform perfectly 100%
of the time. We as leaders must
put in systems that support safe
practice.
http://www.asco.org/ASCOv2/Education+%26+Training/Educational+Book?&vmview=edbk_detail_view&confID=40&abstractID=615
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Four Key Concepts of PFCC
• Dignity and respect: Providers listen and honor
patient and family perspectives and choices
• Information sharing: Providers share complete and
unbiased information in ways that are affirming and
useful
• Participation: In care and decision-making
• Collaboration: In policy and program development,
implementation and evaluation, as well as the
delivery of care
Set the Expectation
Position People for Success
Hold Them Accountable
Without clarity of expectations,
deviance can’t stand out.
Roger Berkowitz,
Trustee, DFCI
CEO, Legal Sea Foods
American Hospital Association and the Institute for Family-Centered Care. (2004). Strategies
for leadership—Patient and family-centered care toolkit. Washington, DC.
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IHI Framework for Leadership for Improvement
• Burden
• Responsibility
• Power
Setting Direction: Mission, Vision and Strategy
Making the future attractive
PUSH
PULL
Changing the old
Will
Ideas
Execution
Establish the Foundation
http://www.asco.org/ASCOv2/Home/Education%20&%20Training/Educational%20Book/PDF%20Files/2006/Practice01.PDF
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It seems many, if not most, are
drowning in the waterfall!
“Every day I come to
work I feel like I’m
sitting at the bottom
of a waterfall. The
stuff keeps coming
and coming”
Zeev slide
Staff RN
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In the Aftermath of Harm…
Seeking To Achieve for All
Patient, Family, Staff, Organization
The IHI “Triple Aim”
• Improve Individual Experience
• Empathy
• Disclosure
• Support
• Improve Population Health
It’s Back To School for Most of Us
• Control Inflation of Per Capita Costs
The root of the problem in health care is that the business models of
almost all US health care organizations depend on keeping these three
aims separate. Society on the other hand needs these three aims
optimized (given appropriate weightings on the components)
simultaneously.
Tom Nolan, PhD
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• Apology
• Resolution
– Including
compensation
– including
reimbursement
• Learning
• Improvement
• Assessment
http://tinyurl.com/IHIEffectiveCrisisMgmt
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Change Failure Rates
% Failing To Achieve Target
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Most Change Fails
Everyone
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66% A. D. Little
70% McKinsey
70% Senge
80% Bennis,
On, and on,
and on
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The Challenge is Huge
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Conference . McKinsey & Company. 2007
Aiken
C, Keller S, Rennie M. The Performance Culture
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Spray and Pray
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Transition Must Be Managed
The single most important factor that
distinguishes major culture changes
that succeed from those that fail is
competent leadership at the top. No
single effort at culture change has been
successful starting at the bottom
John P. Kotter & James L. Heskett,
Corporate Culture & Performance (Free Press 1992)
http://www.wmbridges.com/
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Collaboration is highest…
When we’re out to get the same person!
Crappy Cultures Produce
Crappy Results
High Performance Cultures
Can Accomplish ANYTHING
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Secondary
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What leaders do, pay attention to
measure and reward on a regular
basis
How leaders react to critical
incidents and organizational crises
incidents and organizational crises
Deliberate role modeling, teaching
and coaching
Observed criteria by which leaders
allocate rewards and status
Observed criteria by which leaders
recruit, select, promote, retire and
terminate organizational members
E. Schein. Organizational Culture and
Leadership. 1994
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Organizational design and
structure
Organizational systems and
procedures
Organizational rites and rituals
Design of physical space and
buildings
Stories, legends and myths about
people and events
Formal statements of
organizational philosophy, values
and creed
Publicly Verifiable
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Team training improved
communication, task coordination
and perceptions of efficiency,
quality, safety, and interactions
among team members as well as
patient perception of care
coordination.
How Culture is Imbedded
Primary
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Bunnell, Craig A., et al. "High performance teamwork training and systems
redesign in outpatient oncology." BMJ quality & safety 22.5 (2013): 405-413.
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We’re from Harvard…
We Can’t Fail
The Focus on Outcomes Grows!
Organizations with the Best
Demonstrated Integrated
Outcomes Will Win
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Clinical
Financial
Service
Experience
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The
one
FINAL
thing
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Best Care at Lower Cost
Path to a Learning Healthcare System
• Real-time knowledge
– Insight, evidence, design, delivery
– Infrastructure and access
• Engaging patient, family, public, community
– At every level
• Rewarding value
– Incentives
– Quality, cost, safety, service
• Creating a new culture of care
– Leadership (at every level) driven
– Supports, reinforces learning improvement
• Integrating stakeholders:
– Patient, family, public, community,
organizations, healthcare educators,
researchers, delivery staff, state and federal
agencies and staff
https://www.bostonglobe.com/metro/2015/04/03/doctors-need-treat-theirpatients-with-respect/XUuE6oyXGz2dpyVNoRx6LJ/story.html
HSPH J Conway
OAHQ Conference
NOTHING is more important,
in our own practice, with our
team, and in partnership with
patients and families
Disrespect /
suffering is
preventable
harm!
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http://www.iom.edu/Activities/Quality/LearningHealthcare/2012-SEP-06.aspx
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Questions, Comments
“Quality improvement begins with love and vision.
Love of your patients. Love of your work
If you begin with technique,
improvement won’t be achieved.”
4/25/2015
A. Donabedian,
M.D
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