L eading for Safety: Thoughts on Structure, Culture and Governance
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Transcript of L eading for Safety: Thoughts on Structure, Culture and Governance
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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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