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

1. Leading for Safety: Thoughts on Structure, Culture and Governance March 4, 2011 Debbie Barnard, MS, CPHQ Victoria Inn Winnipeg, Manitoba

2. PresentationOutline • Introduction • Reflections on Governance/Leadership, Structure/ Infrastructure and Culture • Case Study • Table Top Discussions • Report Out/Reflections • Closing Comments

3. 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”

4. 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

5. Are we up to it

6. Case Study: Dana-Farber Cancer Institute FROM TO Errors are everywhere Excellent, not perfect Great care in a high-risk environment Principles of fair and just culture, guidelines, algorithms, flow sheets • Errors are rare • Everything’s great • Great care • Made it up as you go along

7. Case Study: Dana-Farber Cancer Institute FROM TO Moral duty, risk on nondisclosure, transparency Great systems, great staff Board, C-Suite, Chiefs, Chairs drive the work • Risk of disclosure/ confidentiality • Great staff, poor systems • QI, RM, Safety staff drive the work

8. Case Study: Dana-Farber Cancer Institute FROM TO Actively engage Actively engage, nothing possible without them Partner with patients and families • Keep the board out • Keep doctors out of QI and RM • Deliver care to patients

9. Case Study(Think Differently- video)

10. 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

11. 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.

12. 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.

13. 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.

14. 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

15. 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.

16. Culture

17. “Every enterprise has fourorganizations: • 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

18. Scope for Leaders • What is the meaning of organizational culture? • How to measure organizational culture? • How to build/change organizational culture?

19. Tribal Wisdom of Healthcare 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

20. Structure/ Infrastructure

21. Low Level of Detail High Viewing the Organization as a System: Linkage of Processes at appropriate Level of Detail Source: L. Provost, Senior Fellow IHI

22. Planning for Improvement Source: L. Provost, Senior Fellow IHI

23. 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

24. Execution of Improvement Work in Organizations Projects ? Division or Department Level ? Whole Organizational level Source: L. Provost, Senior Fellow IHI

25. Execution Structure Organizational Level (whole system) Sub-system Level Sub-system Level Sub-System Level Project Project Project Project Project Project Project Project Source: L. Provost, Senior Fellow IHI

26. Table Work and Discussion

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”?

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

29. Structure & Infrastructure 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 How can this approach support your team to connect structure, strategy and improvement? Does your quality infrastructure require any changes to improve how quality improvement work gets done?

30. Report Outs • Observations & reflections from your group’s discussion • Your contribution to the “Ten Powerful Ideas for the Future Now”

31. Closing Video