A Conversation about Leadership and Quality with James Reinertsen and G. Ross Baker
James Reinertsen, MD, has worked as a physician, CEO and consultant on leadership, quality improvement and patient safety with leading healthcare systems around the world. What follow are excerpts from a conversation held at a dinner for healthcare leaders during the 7th National Conference on Quality in Toronto this February (2006). Reinertsen is a former CEO of Health System Minnesota and CareGroup, an academic and community hospital system in Boston. He currently heads The Reinertsen Group and leads the Institute for Healthcare Improvement's leadership development sector. The questions are posed by G. Ross Baker, PhD, professor in the Department of Health Policy, Management and Evaluation at the University of Toronto.
Ross: Jim, it's great to have you here at this meeting. I want to start by talking with you about the "100,000 Lives Campaign," which we are calling "Safer Healthcare Now!" in Canada. This work on patient safety has become one of the most exciting initiatives in American and Canadian healthcare and has led to greater energy and levels of commitment in quality improvement than we have ever seen before - more than 3,000 hospitals in the United States and more than 150 organizations in Canada. What is it about these campaigns that has created this energy and commitment?
Jim: My analysis is that three things came together. First, there was a critical mass of impatience. A lot of us have been working at this for a long time. And the Institute of Medicine (IOM) reports galvanized a lot of attention so that people began saying we have to do something about all these needless deaths in hospitals. I was on the IOM subcommittees that produced these reports and we thought that within a short time we would see major effect from the critical attention that was being channelled toward the problem. But the very slow pace with which these recommendations and issues were implemented across the system was increasingly frustrating. This led to growing impatience and there were a vanguard of leaders who were really ready to do more.
The second thing was the convergence of two kinds of evidence. For those that need research results, there was the scientific evidence from the medical literature about the six areas in the 100,000 Lives Campaign. The second type of evidence was the data from real hospitals. I can now show you run charts of mortality rates in ordinary places where implementing these sets of practices has led to a 40% reduction in mortality rates. We were learning not only from the science presented in the medical journals, but also from its application in the field. These two forms of evidence had converged.
The third thing had nothing to do with the evidence or timing. The third factor was the nature of the message. The dark side of the "100,000 Lives," is 100,000 deaths. This had a visceral impact that made it impossible not to sign up. How could you not enrol?
So leaders from 3,000 hospitals, 90% of all the beds in the United States, have publicly made a commitment to do this campaign. That's phenomenal.
Ross: The "100,000 Lives Campaign" target date is June 14, 2006, just a few months away, and the Canadian campaign runs until December 31 of this year. So the key question is: What happens then?
Jim: I call this the June 15 problem. Clearly a lot of people will be in mid-stride. The work won't stop. But some means of maintaining that momentum will be required as I see it, at least in the United States side of the campaign.
One thing that will begin in earnest after June 14 in the United States is the measurement and study phase of the work. I think this campaign is going to be analyzed in many ways. The 100,000 Lives Campaign is a fabulous laboratory for learning because it represents a sea change that has happened in the last year and a half. For example, we are very interested in the leadership factors that will distinguish the hospitals that get 20, 30, 40 and 50% reduction in mortality, from those that get nothing.
Everyone asks, "What's the next campaign going to be?" It's going to be hard to find something with the same focus and visceral grab of these interventions that leave you alive or dead. But I don't think it's going to be hard to find a platform of six more planks that lead to dramatic improvements in care. People have to realize that nothing has ever enrolled this many hospitals and engaged this many people in a leadership role before.
Ross: Your comments about leaders' involvement in the campaign are very important. Many people in this room would probably agree that the leader's job is to lead the improvement of care in their organizations. But there are some who say, "My job as CEO is not to lead improvement, but to represent the hospital or system and make sure it's stable and profitable for my community." What do you say to these people?
Jim: This is a common response. Professional administrators will often say, "I wasn't trained as a pharmacist or a nurse or a doctor. Aren't the finances and the facilities my deal? Aren't the doctors supposed to do that alive or dead stuff? Do I have to go back and get a medical degree?" And the doctors, interestingly enough, will say, "Look, I'm responsible for my patients. That's my professional code. But I can't be responsible for the quality of the whole facility."
When I hear such comments, I think about Paul O'Neill. Paul O'Neill was the United States Secretary of Treasury and, prior to that, the chairman and CEO of Alcoa. O'Neill said, "Leaders are responsible for everything in an organization, especially the things that go wrong." You can't say I did my part, but that other stuff over there is not my responsibility. You are responsible, because you are a leader. I like this view. It's uncompromising and clear. It's not compartmentalized.
Ross: You wrote an interesting article in Health Affairs recently where you suggested that the 100,000 Lives Campaign may change the burden of proof in medical malpractice suits and help make the fear of malpractice a more positive force for patient safety. Can you tell us more about this?
Jim: In every state in the United States, the majority of hospitals, of all shapes and sizes, have enrolled in the 100,000 Lives Campaign and publicly said this is what they were going to do. They said this because they don't want people to die. That marked an extraordinary moment in American medical history, where the standard of care just took a sudden sharp change in favour of those six practices recommended in the campaign.
In the article I suggest that if you are a hospital leader who has signed on for this campaign, then a year from now, you will no more be able to run your hospital without a rapid response team, for example, than you could run your hospital without sterilizing your surgical instruments or any of the other things that are regarded as standards of care. If you don't, then you risk getting a lawsuit.
Let's take surgical site infections as an example. The plaintiff's lawyer is going to say, "My client had a bad outcome. And we understand that 80% of the hospitals in this state don't shave surgical sites anymore but you do. Your hospital committee minutes demonstrate that you've not been able to confront physicians that want to continue to shave surgical sites and my patient's chest was shaved. Here's your suit. You're not following the standard of care." And you will lose.
At the same time there is a positive side to this situation. Many hospital leaders are now reading and thinking about this argument. Several of the big hospital cooperatives in the United States, like the Voluntary Hospitals Association (VHA), have sent the Health Affairs paper out to all their hospitals and are telling them to read this article. What the paper is doing is basically bringing up the rear of the class.
Ross: Jim, we all know that there are many good people, particularly young leaders, who face a dilemma when they work in an organization where quality and safety goals are not a priority. Do you tell these people to leave these organizations and go somewhere else?
Jim: This is a pretty common problem: the beautiful flower in a toxic waste dump. Or at least that's the feeling that a lot of people have in these situations.
I start by telling these people what not to do. I try to encourage people not to go down the victimhood road - the "if only" road. If only I had a chairman that supported this. If only I had a bigger budget. If only I had a better information system. Instead of taking a victimhood stance, I suggest they take a leadership stance: leaders take the situation they have and they start making something of it.
The second thing I would say is: learn really useful quality improvement skills. Invest in learning skills that will be useful to your organization and to your patients. Go out and learn something about flow management and reliability methods as applied to healthcare.
Then do this: take what you learned and harness your improvement work to existing organizational goals around efficiency and throughput. Look for results that get noticed by people that don't get it. By getting these results, you start to recruit others in your organization with social skills and courage. And you need to teach them.
The best way to spread the results is by telling stories. This is the last skill I would invest in and polish. Become a good storyteller. Collect stories about your results and tell them.
So you don't always have the authority to make things happen, but you do have the opportunity to get things started.
Ross: Jim, you have worked with IHI on many of the "pursuing perfection" organizations. What did they learn from being engaged in the relentless pursuit of perfection?
Jim: One of the things they've learned early on is that they vastly overestimated their improvement capabilities. There were seven organizations in the United States that were chosen from 237 applicants to participate in the [Robert Wood Johnson funded] Pursuing Perfection project. They were considered to be the exemplars of quality and safety. But both they and the evaluators who selected them overestimated their improvement capabilities. I think that's probably lesson one. In order to learn anything you have to recognize what you don't know. So the first thing we learned was that these organizations, despite their accomplishments, still really did not know how to improve.
The second thing we learned was that these organizations thought they were getting a grant to do some improvement projects. What they didn't understand was that this grant was going to be the virus that would transform their organizations. This meant changing their entire organizational cultures. You couldn't accomplish what was required by implementing a few projects. So the leaders of these organizations had to ask themselves: "What does it mean if quality is our strategy and not just a nice thing to do professionally?" Learning how to make this transition was a big part of the overall learning.
A really interesting thing we learned was to frame quality aims, broad and wide around system-level measures - measures like mortality rates, customer satisfaction and harm events per 1,000 patient days - not unit-specific or disease-specific measures, like the percentage of pneumonia patients that get the right antibiotic. That's a nice process-level measure, but you could get that done and a lot of other things could stay the same and you wouldn't have improved the system. You can't get to perfection by making islands of excellence or dabbling around in a few projects. You have to engage in a much deeper strategy.
Ross: Engaging leaders and creating a strategic focus on improving the quality of care are clear challenges for us all. Thank you, Jim, for sharing your insights and your wisdom with us tonight.
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