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Voices for Safer Care

Insights from the Armstrong Institute

Organizational and Cultural Change

Doctor Who?

One of the most exciting things about working in patient safety and health care quality is that it’s not solely about advancing science or applying performance improvement methods. It is also about the excitement of being part of a social movement that is changing the culture of medicine—putting patients at the center of everything, sharing errors in the hopes of preventing future ones, and confronting hierarchies that stifle communication and innovation.

Kate Granger, a physician in the United Kingdom who is living with terminal cancer, has tapped into that sort of enthusiasm in a big way. Last summer, reflecting on a recent hospital admission, Granger remarked in her insightful blog that some members of her care team never introduced themselves when approaching her. She wrote:

As a healthcare professional you know so much about your patient. You know their name, their personal details, their health conditions, who they live with and much more. What do we as patients know about our healthcare professionals? The answer is often absolutely nothing, sometimes it seems not even their names. The balance of power is very one-sided in favour of the healthcare professional.

She asked that health care professionals make a pledge to introduce themselves to every patient that they meet, and share the challenge with others across the National Health Service. Thus was born a movement that went viral, aided by the Twitter hashtag #hellomynameis. More than five months since her post, there is a steady stream of tweets every day. Some clinicians wear lanyards with the hashtag, a show of support and a reminder to introduce themselves. Last week, NHS Employers released a video celebrating the #hellomynameis campaign.

More than anything, introducing yourself to patients is an issue of providing compassionate care. But it is also a patient safety issue. We know that faulty communication so often lies at the root of medical errors. How many adverse events might be prevented if all clinicians introduced themselves, making them more inviting to questions and concerns?Read More »Doctor Who?

A blueprint for high reliability

Ensuring that patients who take beta blockers receive their heart medication before and after surgery is a best practice to prevent future problems. A workgroup at The Johns Hopkins Hospital is one of 40 teams across JHM focused on delivering such best practices.

Across health care, organizations constantly struggle with the challenge of achieving patient safety and quality successes on a large scale—across a hospital or network of hospitals. Too often, they are doomed at the start, because staff don’t even know what the goals are. In other cases, staff have limited capacity to carry out improvement work and few resources available to help them. Subpar performance is allowed to continue without any accountability, assuming that they know how well they are performing in the first place.

At Johns Hopkins Medicine, we are proud of an effort that has not only improved patient care, but has also provided a blueprint for how we can tackle any number of challenges in improving patient care—such as eliminating infections or enhancing the patient experience—across complex health care organizations.

Last week three hospitals within Johns Hopkins Medicine were recognized by the Joint Commission as “Top Performers” in patient safety and quality, for consistently following evidence-based practices at a very high level. Those hospitals—The Johns Hopkins Hospital in Baltimore, Sibley Memorial Hospital in Washington, D.C. and All Children’s Hospital in St. Petersburg, Fla.—benefitted from an organization-wide approach that enlisted local teams in problem solving, directed core resources to support those teams, and made units, departments and hospitals accountable for their performance.

Read More »A blueprint for high reliability

A method to the mystique

A few months ago, I posted about the pleasure of meeting Horst Schulze, a former Ritz-Carlton executive who created his own ultra-luxury hotel chain based on many of the principles he employed while working for the Ritz-Carlton. It was clear to me that the hospitality industry has something to teach health care about what it takes to create a culture of service excellence, and what it truly means to treat employees and staff with the utmost respect.

For that post, I only heard about Ritz-Carlton; I now got to experience it. As part of the Baldrige Executive Fellowship Program, I spent two days in January with the Ritz-Carlton in Pentagon City. Aside from hearing from senior leaders how they maintain excellence, I lived the Ritz-Carlton experience as a hotel guest.

Read More »A method to the mystique

Leadership qualities for a patient-safety turnaround

In recent years, Parkland Memorial Hospital in Dallas, Texas has faced intense media scrutiny and government investigations into patient safety lapses. As the hospital searches for a new CEO, the Dallas Morning News asked me and other experts to answer the question: "What kind of leader does Parkland need to emerge as a stronger public hospital?" Below is the column, re-used with the newspaper’s permission. While it is focused on one hospital, the themes apply broadly. The type of leader that I describe is needed throughout health care.

Parkland rebuilding ‘at the speed of trust’

Public hospitals such as Parkland are a public trust, serving the community's health needs by providing safe and effective care to a population that lacks alternatives.

Major shortcomings in the quality of care provided at Parkland have eroded that trust. Now trust must be restored. The community is counting on it. It's literally a matter of life and death.

Parkland's board is searching for a new CEO to lead this journey. The CEO's task will not be easy: Resources are tight, resident supervision is insufficient, staff morale is low, systems need updating, and preventable harm is far too common.

History may provide some guidance. Historian Rufus Fears notes that great leaders - leaders who changed the world - have four attributes: a bedrock of values, a clear moral compass, a compelling vision and the ability to inspire others to make the vision happen. Parkland needs one of these great leaders.

The key values of the next CEO should be humility, courage and love -- and these values must guide the leader's behavior. Parkland will not be able to improve unless it acknowledges its shortcomings; this will take humility. Yet Parkland is a great organization with a rich past and bright future. The leader must honor the past and look forward. The leader must be able to live with the paradox of being humble yet confident.Read More »Leadership qualities for a patient-safety turnaround

Putting a little Ritz in health care

Recently, I had an enlightening encounter with Horst Schulze, who led Ritz-Carlton Hotels to national awards and has since opened his own hotel chain, Capella. Hortz gave an informal presentation to members of a program that I’m taking part in, the Baldrige Executive Fellowship, and we continued to talk afterwards. Capella has five ultraluxury hotels from New York to Singapore, and all have been recognized as tops in their region. Horst spoke to us of a culture of excellence. He knows—he has built such a culture time and time again. Excellence does not occur by chance. It requires clear goals and a system.

Horst explained that to be great, everyone in the organization needs to know the goals, in order of importance. For Capella, the goals are 1) keep existing customers, 2) add new customers, and 3) optimize the spend of each customer. Every employee not only needs to know the goals, but they need to know the behaviors to achieve them. The Capella employees ensure a warm welcome, compliance with and anticipation of guests’ needs, and a fond farewell.

All employees are required to know service standards. Twenty-five of them. One of them states that you are responsible to identify and immediately correct defects before they affect a guest—for example, getting customers food when the restaurant is closed. Defect prevention is key to service excellence, just as it is to delivering safe health care. Another service standard states that when a guest encounters any difficulty, you are responsible to own it and resolve the problem to the guest’s complete satisfaction.

Capella has standard processes for everything—how to submit defects, how to resolve them. And they trained staff in the goals, the behaviors and the processes. Each hotel, every morning is required to have a huddle at which all staff attend. They review the goals for the company and read one of the behaviors, called service standards. Every day they read a different one. They cycle repeats every 25 days.

If a manager did not do this, Horst said, they would be fired.

Read More »Putting a little Ritz in health care

What health care can learn from corn milling

Some of the best ideas for improving health care come from outside our field. For example, we’ve adapted cockpit-style checklists from aviation to improve teamwork and communication on our clinical teams. We’ve turned to performance improvement methods from manufacturing to reduce waste and defects in care delivery.

A recent experience reminded of the value of seeking ideas and inspiration from elsewhere. As I wrote in an earlier post, I was among 15 executives from various fields who toured Cargill through a fellowship run by the Malcolm Baldrige National Quality Award Program. On a visit to Cargill Corn Milling, among the largest of the gigantic company’s 75 business units, I heard a story with unexpected parallels to health care. Cargill officials told us that their nine plants used to compete against each other. Often, two or more of their plants would submit bids to the same customer, usually with different prices. This self-competition was inefficient, didn’t meet customer needs, and cost them market share and revenue. Something needed to be done.

The Cargill leaders recognized that they needed to organize themselves around what they provide to customers (i.e. their product lines) rather than their geographically based plants. And that’s what they did. The three main product lines were human food products (largely sugar), animal feed, and fermentation such as ethanol. Rather than having each plant compete against each other, they worked together to meet customer needs.

To support this new structure, they set cascading goals in which everyone—from the employee to the plant to the product line—knew what they had to accomplish to meet corporate goals. They changed the incentive structure so that plant managers had greater motivation to ensure the company’s success, customer satisfaction, product line success and their plant’s efficiency. With this reorganization, they weren’t pitted against others at their own company.

As I listened to the presentation, my pulse quickened. I leaned forward anxiously feeling as if I took a double espresso to pull an all-night study session. The parallels between corn milling and health care were haunting.

Read More »What health care can learn from corn milling

Health care needs greater accountability, not excuses

Hand washing

I recently spoke to an executive in the energy industry who had a joint replacement at a hospital in New York. His wound developed an infection, which required four additional hospital admissions and several operations. He asked me about hand hygiene in hospitals. Proudly, I told him that, at Johns Hopkins Hospital, we are at 80 percent compliance with hand hygiene, up from 30 percent not that long ago. I focused on the improvement. He focused on the failures. "So," he said pointedly, "one in five times you do not comply with basic hand washing rules, potentially causing infections—or even death." He asked what we are doing about it.

I told him how we try to learn from the high performers and to improve the poor performers, how we train staff on the importance of hand hygiene, how we report compliance rates to unit teams, how we put pictures of patients with the words “please wash” outside their rooms.

The executive said, "All that is great, but where is the accountability?" In any other industry, there is accountability to ensure staff comply with safety standards, standards that are often much less consequential than hand washing. Other industries help staff improve compliance; they also hold local managers accountable for poor performance. To get results, you must both support staff and hold them responsible.

Read More »Health care needs greater accountability, not excuses

Part II: ISO clinician leaders in patient safety and quality

studentsI recently gave a talk to the American Medical Student Association. The energy in the room was palpable. The students were excited, passionate and hopeful. We spoke about the urgent need to reduce preventable harm and to enhance value, and we discussed that they will need to be the ones to lead these efforts.

Yet, in speaking with them, I had to confront the sad reality that most of them will graduate ill-prepared to lead the improvements of quality and safety our health care system needs. They no doubt will know chemistry, biology and physiology, but they may not know about human factors, implementation science or performance measurement—the language of quality improvement. They will know orthopedics and genetics but they won't know teamwork and systems engineering. They likely know about German scientist Rudolph Virchow, the father of cell theory, yet they do not know John Kotter, the father of change theory whose model for leading change is highly effective and widely used. Without a doubt, these students will need to lead change.

Read More »Part II: ISO clinician leaders in patient safety and quality

ISO clinician leaders in patient safety and quality

SimulationWANTED: Clinicians for long-term relationship to lead unit and department safety efforts. Must be passionate about improving patient outcomes and value, have skills needed to lead these efforts, and enjoy working as part of a team.

Dr. Martin Luther King, Jr., in pushing the civil rights agenda, spoke of the "fierce urgency of now." Recent news reports highlight the fierce urgency of now in health care. The U.S leads the developed world in preventable deaths, as preventable harm continues unabated, insurance premiums have increased 9 percent while GDP remains flat, and investments in health care are crowding out investments in other important areas such as K-12 education. The fierce urgency to improve health care value not only impacts patients and health care providers, but all of society.

There are two main reasons why progress in improving safety and quality has been slow and difficult. The first is the field has largely run away from science, seeking quick fixes rather than deep understanding, focusing on what we do rather than the results we produce. The second reason is that health care lacks the capacity (infrastructure with skilled people) to improve quality and value. Because we have treated patient safety and quality as a project rather than a way of life, we have failed to create the necessary infrastructure to support the needed quality efforts.

If we are to improve quality, we will need to create an infrastructure to support patient safety. It is not surprising that most of the published literature in quality and safety comes from units (such as intensive-care units) that have dedicated physician and nurse leaders; there is someone in place to closely manage the work. Research and experience shows that units with dedicated physician leaders have lower costs, higher quality and better patient satisfaction.

Read More »ISO clinician leaders in patient safety and quality