In Conversation With… Maureen Bisognano
Approach to Improving Safety
Setting of Care
Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about IHI's efforts to improve health care on a global level.
Dr. Robert Wachter, Editor, AHRQ WebM&M: When you allowed yourself to be extravagant, [in the beginning] what was your greatest dream about what IHI would accomplish?
Maureen Bisognano: Our first mission was to improve safety in hospitals in North America. As we began to make some progress in that area, our mission has expanded from safety in health care to the Triple Aim (better care, better health, lower per capita costs), and our mission now is improving health and health care globally.
RW: One of the early things you did was team up with industry to look for lessons from outside of health care. As you have observed this world over the last 20 years or so, what lessons do you think are really powerful, and—when people in health care say, no, we're not like FedEx or not like the airlines—which do you have real sympathy for?
MB: I am increasingly out in the field and looking to these other industries for new lessons in safety. Let me just give you a couple of examples of the new way we're thinking at IHI about safety. Our goal statement is that by 2018 we will have accomplished new levels of safety across the country, including whole–system safety, looking at safety in the community, safety in primary care, and especially integrating safety across a patient's journey. We're also looking at developing new ways for leaders to think about leading and driving safety in their organization, and looking at new measures of harm.
Recently, we convened a group of health care quality leaders to visit NASA and to see whether there were new lessons that we could learn. One of the first things that they saw at NASA was a big map on the wall dedicated to looking at the continuum of a Space Shuttle—from bringing it to the launch pad until its safe recovery and landing. They look at every near miss, every event, and every safety problem along the continuum. My vision is that when we start to look at safety like that over a year of care for a patient, or over a continuum journey from pre-hospitalization to full functionality at home, that we're going to have a much different view of the improvements we still need to make.
RW: When you started at IHI, the organization was small and the worlds of safety and quality were also small. It was well before the publication of the IOM reports on safety and quality. Improvement was not yet on the radar screen of health care in a major way. How did the work change when To Err Is Human came out and all of a sudden it became a big national and international issue?
MB: To Err is Human was issued when we were at one of the IHI National Forums in Orlando. I can remember the buzz in the meeting when people were both threatened and a little frightened to know about these kinds of safety lapses. It shifted the conversation at the Forum immediately to the transparent display of the extent of harm in the system and really created a whole lot of energy. Leaders began to recognize that they had a role to play. Board members began to seek out IHI and say, "Are we alone in seeing quality problems in our organization?" And, "How do we best deal with them?" We also saw energy from frontline physicians, nurses, and pharmacists who came together to work in multi-professional teams to solve these problems. It was a shift from a sense of seeing events as only very rare lapses to seeing the whole system. And that whole system view propelled a lot of action.
RW: I can also imagine that internally, IHI went from something of a mom-and-pop operation to something that needed to scale up. So how did you maintain the energy and passion of your people as you got bigger and the demands on you became so much greater?
MB: Our strategy from the start has always been to use leverage to spread good ideas. The first step is innovation. Every 90 days we convene small teams of people who take on intractable problems in health care. They still look outside the industry, much as we did in the early days. They look at best practices within the industry. They create technical briefs and theoretical hypotheses that we test in the field. The Triple Aim emerged from looking at problems in a new way. For example, we're now looking at safety in ambulance services and in pre-hospital care. We're also looking at transitions from hospital to home. And we're looking at using data to predict problems and to prevent them. In all of these cases, we have teams that go out and look at best practices.
We recently visited the New York City Police Department and looked at how they predict crime, and use data to put police officers where crime is about to happen. We watched them analyzing everything from the temperature, to activities that were planned and recognized, to little things that were popping up. Their sense of both reliability and resilience was amazing. We then went to the North Shore–Long Island Jewish Health System and looked at their command center, where they have a team of people watching a moving map of Long Island. They know down to the zip code what nationality and what age and what kind of health problems exist in each neighborhood. They're also watching weather and events, and they're able to put an ambulance in neighborhoods before the 911 call comes in. I do believe that this way of using data is going to be a powerful driver for safety in the future.
RW: One of the sea changes in the work that you do is that we have gone from largely analog to largely digital industry in the last 5 years. How much of that do you see as an enabler? And how much of that do you see as an impediment, as we hear about glitchiness around new IT systems?
MB: I was talking to Charles Vincent, a safety expert from England, about this. We were looking at this NASA map, and we were saying that, in some ways, the use of electronic systems is an enabler, obviously. It's going to call to our attention things that we may have been blinded to in the past. But we also do see the downside and the errors that pop up. To me, leading safety in this day and age is the perfect marriage between technology, using data for prediction, reliable systems, and resilience. The resilience is a key ingredient that we haven't focused on yet enough in the safety world. It's that ability to talk to a patient and to see what the data or even the vital signs wouldn't show you—that there is a need that requires your attention immediately. So adding that sense of resilience to the reliable systems and the data systems, I'm hoping, will be a big step forward for us.
RW: Partly using the Global Trigger Tool that you developed, a number of studies had disappointing results about safety over the last 10 years, including some that showed it had not improved. That could be a bummer, and it could also energize you to work harder or to work differently. What was it for your organization?
MB: Well, when you walk into the IHI office, because I'm Irish I picked an Irish adage that hangs on the wall. It says, "When you come upon a wall, throw your hat over it and then go get your hat." That's basically what we think here. There are walls. What we're seeing is, in a sense, disappointing. Why is it so difficult to spread a safe practice across health care systems? Why is it so challenging to spread it even within a single health care organization? Yet at IHI, we can throw our hat over the wall, and we are continuously energized by going out and developing new ways to measure and improve safety. The excitement of developing new models, learning from other industries, and working with people from across health care who are so inspired to improve gives us the energy we need to continue.
RW: How do you deal with this issue of project burnout, particularly people feeling like they have been working very hard at these things and it's just one thing after another after another?
MB: At IHI, we believe three elements are necessary for improvement. The first is building will. When someone is tired, when they implemented change and they haven't seen dramatic results, or when they find resistance in their peers or they find problems in the supply chain—when they come up against those walls, I believe it's our obligation to help them to see the end result. And that is to tell the story of the patient. Often I think when we have a team that's demoralized or tired or overloaded by too many projects, the sense making that can come from telling a story and combining that with data is very powerful. Whenever I go out and talk with health care leaders around the country, I often start the session by interviewing a patient. That conversation then resonates throughout the whole course of the meeting. People will be referring to the patient by name, and they will be talking about barriers that they never saw. It's that sense of putting someone at the bedside, so to speak, and understanding the human cost of harm as well as the organizational or the financial costs, that gives people the will to come back up and start again.
RW: One of the things that it seems that you and IHI have focused on is not only telling the story of the patient but getting the patient and caregivers and family members involved in the process of improvement. What have we learned from trying to do that?
MB: I think we've put a human face on a problem. We put a sense of the continuum there that we didn't have before. One of our fellows last year is a wonderful hospital administrator who I interviewed some years ago. His name is Gilbert, and he is in a wheelchair, paralyzed from a gun injury. When I interviewed Gilbert in front of several hundred leaders, nurses, doctors, pharmacists, Gilbert talked about how wonderful his caregivers were, and how he loved the idea of being able to connect to his medical records from home. And he loved the ability to make an appointment electronically and to track his medical records on his cellphone. And Gilbert told me about his wheelchair, which has the latest technology, so lightweight that he can get it into his car by himself. I asked, "Does anything ever go wrong?" And he told me about what it's like to get a flat tire.
I've been in health care for 30 years, and I never thought about a wheelchair getting a flat tire. He said that he calls his physician who writes a prescription for a replacement tire. They send it to the durable medical equipment vendor. They send it out to find a company that has the right tire. And when it comes back in, the assistant calls him and tells him his replacement is there. I asked him how long does that take? He said 3 weeks. Again I was floored because I had never thought about that. I asked what happens during the 3 weeks? He said that he has to pull really hard on the flat tire side, which causes his muscles to spasm, which means he needs to take pain medication, which means he cannot work. What matters to Gilbert is that he can go to work. But nobody had ever seen the whole of his experience. Each person worked at his or her own little piece, but nobody could see the cost in productivity terms, or medication terms, or pain terms, or visit terms, or unnecessary work. One of the nurses jumped up from the audience and said, "I got a flat tire last night. I called roadside assistance, and I was on my way again in an hour." And she said to Gilbert, "Next time, I'll get you a spare tire." I said, "No, you can't fix it for Gilbert. You have to fix it for everyone." I think that's so often what we do, frontline providers fix it for the patient in front of us and don't surface the issue to see that it's a system problem.
RW: That's an amazing story. I'll raise a couple of tensions that you and the organization sometimes find yourselves in the middle of. One is the no blame versus accountability tension—the safety field was founded on the principle that it's largely about good people trying to do the right thing and the system doesn't work very well—yet there is this need for accountability and there are a few bad apples out there. How do you navigate that?
MB: To me good leadership understands the difference between the two circumstances you just described. I do believe that most people are absolutely in this field to help, and in one of the most challenging workplaces that you can find. It's physically demanding, it's emotionally draining, and it's intellectually challenging. But people come to work every day to do their best job. That said, there are a few bad apples. An effective leadership system will deal with those so that the others can surface issues without blame and get those systems fixed. It's like Gilbert's wheelchair. If someone cannot surface that issue safely, or someone can't say that he doesn't have the supplies he needs, or that he's gotten the wrong medication, then they won't. But to me it's a leadership system to define the two approaches and to get the call right.
RW: Another fundamental tension in the field is what level of evidence do we need before we say one should do this? That's probably different at the level of an individual hospital versus an organization like yours that has a huge international reach. When IHI says we should do something, people generally jump up and try to do it. There have been issues over the last decade trying to figure out how you draw the line about the level of evidence required for action. How do you think about that?
MB: There's a formula that I walk around with in my head. It was based on some researchers in England named Pawson and Tilley. Their research said that C + M = O. Context + Mechanism = Outcome. In other words, the culture and context matter, the leaders matter, and the mechanism is the change concept—it's the ventilator bundle or the safe way to give a particular medication. Hence, the theory was that if you understood your culture and you had a mechanism that you could try that the C + M would equal O.
My modification of this formula says C + M + QI = O. I believe leaders need to take an idea like a ventilator bundle or an idea that they see is perhaps worth testing in their organization, and we'll never have enough research to know that this can be implemented in every context reliably to produce a certain outcome. For me quality improvement is about leaders understanding their local context, it's taking the mechanism that has some credibility and it's paying very careful attention to that outcome so that you're watching every day or every week—in this particular ICU is this mechanism producing this outcome I predict? If not, then quality improvement would say you keep making local adaptations or modifications. It's a learning system more than anything that is going to help us to decide when and how to implement a certain recommendation.
RW: When you took over IHI from Don Berwick, you did one of the hardest things in management and in leadership and did it extraordinarily well. I'd love to hear how you replaced an icon.
MB: Well, it's an interesting question. I mean, who would want to replace Don Berwick to give a plenary? But I always had this vision that I would walk across the stage in his shoes and then give the plenary and then walk across in my high heels to exit the stage. I think the symbols are really powerful. He was an icon, he still is. So I developed a transition plan. I set out three goals for the first year. They were in my head and I didn't talk about them. I had three goals in my head and I had a huge transition wheel in the office. It was about 8 feet wide and it was a wheel that every single person who touched IHI was represented on. The board of directors, the finance team, the clinical team that's doing work in Malawi, the patient safety team that was out working in Scotland. Every person who walked through the office could see themselves on the wheel. And I said we have three jobs to do here. We have to tell the story, to make sure that people understand that IHI is still vibrant and relevant. We have to hear people and keep them very connected. And we have to produce results. People would come in and write on the wheel, "This is what I will do." But I think it was the sense of engagement and energy that helped people over that transition.
RW: You came into the role with a huge and deep experience with the organization but it's probably different to be at the helm. So what have you learned as the leader that you didn't know as second in command?
MB: I would say that the tempo matters. Speed is really crucial right now. Sense making is important. Leaders are asking us all the time to help them think through the big issues, to help them think at the system level. Because as you were saying earlier, so many people are feeling overwhelmed by efforts, by measures, by data, by electronic systems that sense making at the senior level—connecting boards to the senior team and then helping them to strategize so that they have a common and optimistic voice for the staff—has been really important.
RW: The other tension I hear is not only overload, but also—as Gary Kaplan said to me recently—that the board and the senior leadership now are so focused on big picture uber-strategy [mergers, ACOs, and the like], which can lead them to take their eye off the quality and safety ball. Are you feeling that?
MB: We're feeling it; we're seeing it. Don Berwick and a small number of experts from around the world recently served on a commission in England, where we did a deep dive into a situation very much like the one you described where the leaders were focused on the physical plant. They were focused on the finances. They were focused on long-term strategy. And they very much took their eye off the ball of what was happening at the bedside. And devastating things happened. It's a corrosive situation when leaders leave their responsibility for the quality of care and focus only on the big things such that they lack time and attention to the little everyday events (like a unit that doesn't have enough staffing on the night shift, or a unit that has all young new people with inadequate experience to see the problems in a different way). In other words, they might have reliable processes, but they do not have resilience. And that causes failure. Those failures then add up. If people aren't attuned to hearing the voice of the frontline staff or the patients or the family members, devastating things can happen.
So we're very focused on keeping that connection between the boardroom and the bedside tight. We have developed a set of safety practices for board members and for senior members that are really quite powerful. One of my colleagues here in Massachusetts, a CEO of an academic medical center, has a breakfast once a month, and he invites staff who have been a patient at that hospital that month or their family members have. When they come to breakfast, they are sometimes surprised by his questions. The first question he asks is: what rules did you break when you were a patient or your family member was so that you could make your care right? He stands up at a flip chart, and he writes down all the rules that they broke. At first it's a bit daunting because they're a little unnerved by confessing that they broke rules to make care better. But his message to them is (1) I am ready to hear that quality is not as high as its needs to be now, and (2) it's my job as an executive to make it right for every other patient who is not an employee here.
RW: What a great idea! As you envision what IHI looks like in 5 to 10 years, how is it different than it looks today?
MB: We have five major strategies going forward. The first is patient safety. By 2018, we're predicting that we'll be partnering with other organizations around the country, around the world, to produce much safer care. We're predicting that we'll be able to do that by looking at harm in a new way, looking at care problems across the continuum, looking at the journey of the patient, by using data to predict and prevent much as the New York City Police Department is. We'll be looking at working toward harm-free care and linking that to the best care that we can provide, empathy and financial cost reductions included.
We also have four other aims. One is the Triple Aim: IHI's vision that all of us in health care need to move from focus on the experience of care. Also to include the health of populations that we serve and reducing cost per capita. The third area of focus for us is person- and family-centered care. We believe that the more we can get to coproduction of care, the better our care is going to be, the safer it's going to be, and the better outcomes we're going to get. The fourth is new design that will produce better outcomes at lower costs. Here we have some very exciting things on the horizon looking at new ways to care for elderly people safely in their homes. New ways to think about what I'm calling Millennial Medicine—because the young people of the world are not going to be attracted to office visits, and they're not going to wait months and months to get an appointment. They want care by a team that's instant and technologically available. I have some great examples of people who are helping us to design that. The last is new improvement methods. And so we've been continuing to build on the improvement capability. Because as we find the more leaders get the dosing of improvement capability right across an organization, the faster the rates of improvement are.
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