Editor's note: Mr. Feeley is President and CEO of the Institute for Healthcare Improvement (IHI), probably the most influential organization of its kind. He previously served as IHI's Executive Vice President. Originally from Scotland, he has also served as Director General for Health and Social Care in the Scottish Government and Chief Executive of the National Health Service in Scotland. We spoke with him about his work at IHI to improve health care quality and safety.
Dr. Robert M. Wachter: From working in Scotland and the United States, you've learned a lot about cross-country health systems and how the structure of the system can either promote or get in the way of improvement. Tell us a little about that.
Mr. Derek Feeley: It's one thing to mandate and quite another to implement at that national level. Even recognizing that something must happen at scale, and then making it happen at scale—those are two completely different things. You need to build an implementation bridge to connect them. If we hadn't chosen patient safety as our organizing principle for our work in Scotland, it would have been more challenging. Because how can anyone argue against patient safety as the right thing to do? Like almost all systems in the world, we had some patient safety challenges that we needed to resolve. For example, we had an outbreak of C. difficile, which resulted in the deaths of a number of patients in one of our hospitals, and a major national drive to resolve that got folded into our patient safety program. So there was a burning platform for the work. But to get from mandating the program to national implementation required a whole host of things—some about culture and some about the learning system that we needed to build to make sure that we could deliver.
We talked openly about our values and the competencies that we would need to build; the behaviors that we would need to demonstrate; and the importance of measurement, transparency, and psychological safety. We were building a learning system that had at its core a set of ambitious aims to try to reduce hospital standardized mortality by 20% and harm by 30% across the whole country within a period of time. We were using the plan-do-study-act model for improvement. We deliberately built capability to apply that method and imported and developed evidence-based interventions from IHI's 100,000 Lives Campaign. Then we fostered this spirit of collaboration that brought the teams together, enabled them to learn from each other, and tried to do this in a way involving all of the stakeholders from delivery system leaders to the Royal Colleges to anybody else who would come to the table to work with us.
RW: As I think about that story, it strikes me that there are a huge number of lessons. One is that as you take centrally controlled organizations and push them to meet targets or to improve quickly, there is a great risk that they will bypass a lot of the steps you talked about. Not understand the need for transformation, for culture change, for collaboration, and just instinctively go to mandates because they're feeling pressure to get it done. How do you prevent organizations from instinctively doing the wrong thing by forgetting these messy stages that are central to getting the work done?
DF: You have to require the messy stages. This wasn't achieved overnight. As we started this work in Scotland, we had a tradition of performance management, setting targets, and then following up insistently to ensure that those targets were being delivered—without, frankly, a huge amount of thought to how we were going to do that. The first thing that we tried to do was to be clear about the fact that this was not a target. We were setting some ambitious aims in order to change our system. We weren't going to performance manage against these targets in the traditional sense. That maybe sounds like semantics, but actually it was much more than that. It was about trust building. It was about creating a sense of ambition and momentum, but giving people the tools that they needed to make the changes we were asking them to make. And we were giving them the training and support they needed in order to be successful.
The second thing we did that turned out to be important was to engage people in a dialog about the changes. Even though that didn't result in a significant amount of change to the interventions that we were seeking to apply, it was really important that people felt that these were their changes. They'd had an opportunity to introduce their lived experience of trying to make this improvement. They'd satisfied themselves that we were applying the best science that we could, and frankly, that someone had come and asked them about how we might make these evidence-based changes even more impactful. There was some time and negotiation involved, but it was well worth the effort.
The third important aspect was to get our system leaders on the same page, all stressing how this was one of the most important things that we were doing. For our administrative leaders, that was a change. Because in our previous culture of performance management, they were accustomed to hearing that meeting the targets and achieving the financial balance were the most important things, particularly in our cash-limited system. Now they were advocating for quality and safety. Without their willingness to be powerful advocates in their delivery systems, we wouldn't have made the progress we made as quickly as we did. Those three things helped us in our transition to this new way of working.
RW: Taking over IHI, a unique and in many ways iconic organization, what did you see as the biggest challenges and what worried you the most when you became CEO?
DF: There's a huge amount of IHI that I only want to nurture and grow. I see my role there just as a gardener, if you like. It's about making sure that the sense of purpose and mission and the strong values that Maureen [Bisognano] and Don [Berwick] created before me are only enhanced. In the spirit of continuous improvement, we wouldn't be a credible improvement organization if we didn't take our own improvement seriously. We're working on a number of important things. The first is around trying to reach more people. For a small not-for-profit organization, IHI has been impactful in terms of the number of people that it reaches. The Open School is a good example of that, with now millions of courses taken by hundreds of thousands of students in 84 countries across the world. That's fantastic. But it gives us a platform to reach even more people. I want to see IHI reach more of the clinical workforce. I want to see IHI reaching into communities to do the work on improving health that we need to do. There's a twinkle in my eye about IHI reaching out into patient populations to try to give patients some knowledge of improvement science and methods that would help them to be partners in their own care. Reach is a priority for us, and we're working very actively on that just now.
When I look back at the Crossing the Quality Chasm report and the six dimensions of quality that were identified back then, the one in need of greatest attention is equity. We are actively innovating and prototyping around how we could apply what we know about improving the other dimensions of quality through the application of improvement science to reduce equity gaps in health and health care. There is a strong connection to that, to some of the work we want to reinvigorate around patient safety in that the feeling is that patient safety needs a reboot; it needs reenergizing. Part of that is about how we think about harm when we're thinking about patient safety. My argument is that we've been too narrow in our definition of harm. Absence of equity is harmful to patients. Similarly, an absence of dignity is harmful to patients. We need a recalibration of what we think of as harm.
There is an argument that we should use some of the recent media commentary to spark a debate about where are we headed with patient safety, and we cannot let that debate just be about the numbers. I'm conscious that there is a range of perspectives on exactly how many people die as a result of medical error. Whether the number is 98,000 or 400,000, it's too many. Let's figure out what we can do at the same time as we're having the debate about exactly how many. There's some fatigue and perhaps even complacency around patient safety that we need to change, and I want IHI to be part of that change.
RW: As I hear you describe the directions, I wonder about the challenge of scope creep and the balance between being ambitious and being appropriately focused. You talk about broadening definitions of quality and safety, reenergizing safety, and looking more at equity. That's an enormous agenda, and one that involves a scope far greater than IHI began with.
DF: Well, I rarely make any apologies for ambition. I'm probably not going to start now. The key to this is in IHI focusing on our core strengths, and we have four that we can contribute toward this. The first is innovation. IHI has been and will continue to focus much of its attention on innovation. So how do we harvest, find, and develop those ideas, but with an intent to implement at some level of scale? That bridge between idea and implementation needs to continue to be part of IHI's contribution to this work.
The second thing we're able to do is convene. Our neutrality around some of these issues helps us to get the right people in the right room to have the right conversation with the right kind of tone and positivity, with a solutions bias. We can and should continue to convene, whether it's small groups of experts or thousands of people at our Forums. We might even want to think about how we could convene even larger numbers using virtual media.
The third thing is partnering. We need to be finding likeminded organizations to join us in this work. I am very much in the spirit of worrying less about competition and worrying more about finding collaborators that we can work with. Because you're absolutely right, 160 people at IHI just aren't going to tackle that agenda that we laid out. It's not feasible unless we find partners. There's a piece of work that we're convening in the health field called 100 Million Healthier Lives with 800 partner organizations signed up. We're learning about how to create a coalition, how to empower a community, and the importance of socialization of ideas.
The fourth is driving results and applying improvement science and methods in a deliberate and diligent way to secure those results. IHI ought to focus on those four things where we bring value and leverage: innovating, convening, partnering, and driving results. I'm entirely comfortable that leaves a lot of space for other organizations to be part of achieving some of those ambitions. I'm really intentional about leaving space for other organizations to contribute, and I'm open to any such partnership.
RW: One of the dominant themes of IHI's work over the last 20 or 30 years has been a joyfulness that the leaders have had, the zeitgeist of the conferences. You clearly have that, and Maureen and Don did as well. Yet as you hinted, a lot of providers are burned out and a lot of people working in this space are burned out. How do we reclaim the hearts and minds of people?
DF: That's true, and without seeking to add to that ambitious agenda, we're incredibly interested in that at the moment. Indeed, you will increasingly see further work around what we call joy in work coming out of IHI over the next few months, because our sense is that joy in work is more than the absence of burnout. It's like Antonovsky's definition about health being more than the absence of disease. So too is joy in work more than the absence of burnout. On the other hand, when we talk to people about this, they identify a chasm between the current state and joy in work. So our theory is that we ought to try to bridge that. With help from people like Steve Swensen at Mayo Clinic, we have been trying to think about what those steps to joy in work might be. Our theory is emerging.
The first place to start may be by asking providers what matters to them. What are the pebbles in their shoes? What is preventing them from having meaning and purpose in their work? The second is to try to understand the impediments to joy in work that apply locally, because we have observed that this is a very contextually sensitive issue. Even in the same hospital, you can have a joyful ward where people feel motivated and engaged and are really performing at their optimal levels right next door to a ward where morale is low and people are feeling disenfranchised and burned out.
The first step is to create the sense of shared responsibility. Simply pointing at the CEO of the health system or the medical director and saying, "It's your job to create joy in work" is unlikely to be successful. This needs to permeate the whole organization, and then people can use validated approaches. But our fear is that they leap straight to choosing an approach without asking what matters, understanding the local context, or building the shared responsibility at all levels. We're hoping we can deploy that kind of approach, and we expect to be able to bring what we've learned about how to realize improvements at scale to this work.
RW: Recognizing there is no magic bullet, when you see that ward where the culture is great and the people seem to be happy and joyful in their work, and then you go next door and it's just the opposite—are there one or two things that typically are present in the positive ward and not present in the one that's having problems?
DF: Very often you see people who are committed to improvement, who understand that they're trying to improve care for patients. There is a sense of shared purpose. Secondly, there is an openness in those wards. There is a feeling that it's safe to speak openly and to contribute, which is often missing in units or wards where there is an absence of psychological safety. The third thing is a sense of teamwork. People feel as if they're part of a team. They have strong and positive relationships with the people that they work with. They have ways to manage and make sense of conflicts and they feel as if they're part of something.
RW: I've been thinking a lot about technology for the last few years. If you think about the state of IHI when Don Berwick founded it, there was relatively little technology in medicine. It wasn't a particularly important player in the improvement space, the measurement space, or the change space. Now the US has gone from primarily a paper-based system to primarily a digitally based system. How does that change the nature of IHI's work?
DF: It's part of the cultural dimension I talked about. The conversation we've just been having about burnout connects with some of the demands that technology is placing on practitioners. Technology also has a real potential benefit in helping us to build a continuous learning system. It can help us to both collect and learn from defects and successes. It can be a part of how we apply best evidence. But we are starting from a perspective where, at the moment, the negativity around some of the cultural dimensions overshadows some potential from the learning system. We have a group of 40 or so organizations in IHI's Leadership Alliance, and they have been working to think about making EHRs more like smartphones. I do feel somewhat for the EHR vendors in that community, because I think what they get from health care currently is a multiplicity of perspectives on what it's really going to take to build systems to support safety and quality. We would be well advised as a community to try to get our collective acts together and speak with one voice around what is it that we really need from technology, and specifically from the EHR, in order to support our core business—providing high quality care for patients. I welcome and respect the leadership that you've been showing around some of that. There's a job to be done and IHI can help around convening systems, securing the collective voice, and gaining some synergy around our requests and our messages in terms of what we want.
RW: For folks who've never been to IHI headquarters, can you describe the vibe there? What it feels like to be in that office and maybe in particular the contributions of the physical space?
DF: It's open plan gone wild really. No one has any space that is their own, including me. I share an office with six other people, which is just fantastic. It enables the kind of conversations that we need to have as an organization and enables some of that innovation and convening that I talked about earlier, inside the organization as well as outside. When Don moved us to this current space, the atmosphere he had in mind was that of a newsroom. He wanted to create that kind of interactive atmosphere where people could have conversations across their work surfaces and meet in an open plan environment. That's exactly how it feels. There's a constant hum around the place. There's a buzz that's just really generative of ideas and new thinking and really works for us as an organization. We're an organization that thrives on that kind of conversation.
The other thing that contributes to the feeling in the organization is that it's largely a young organization. I raise the average age quite significantly! Those people bring a real vibrancy and curiosity that helps to create the kind of organization that it is. The third thing, it's an organization that really takes its values seriously. We write them on the walls, we revisit them, and we have them on our coffee mugs. I guess most organizations could point you to a set of values that they subscribe to, but we really mean and believe what we say in our values, and that's why one of the first things you see when you walk into the office is a description of those values. We try to make it meaningful for the organization.
There's something about the way in which we use the space. There's something about the kind of people who share a commitment to our mission who are drawn to us and our relative youthfulness and energy. And there's something about our strong sense of ourselves as an organization. That also goes to being clear about what we're not the best organization to do. Having a strong sense of yourself doesn't imply anything other than humility on our part. One of those values is around generosity, and we would want to have partnerships and conversations and share our learning with anybody who is interested in having that conversation. The best way to experience IHI's culture is to come to IHI.