"Be the best at getting better..."

I spent several years working at Cincinnati Children's Hospital Medical Center, whose quality and safety program has set a high bar for children's hospitals (really, for all hospitals).  The story on how Cincinnati Children's came to be known for quality and safety has been covered in a Harvard Business School case study by Anita Tucker and Amy Edmondson, a New Yorker magazine article by Atul Gawande, a New England Journal of Medicine (NEJM) Catalyst article by Uma Kotagal (who played a major role in the hospital's quality transformation) and Amy Compton-Phillips, and a chapter in a book called The Best Practice: How the New Quality Movement is Transforming Medicine by Charles Kenney.  It's a pretty incredible story, and one that I was glad to be a part of, even if only as an eyewitness.  I have brought most of what I learned there to my current hospital.  Cincinnati Children's stated vision is to be the leader in improving child health.  They are fulfilling that mission by helping to lead several national and international quality improvement collaboratives, training the future pediatric workforce, discovering new and innovative ways to cure disease, and perhaps most relevant to today's post, by sharing (either directly or indirectly) their knowledge on quality improvement and patient safety with the rest of the world.  It is an impressive legacy.

The chapter in Kenney's book that focuses on Cincinnati Children's is aptly titled, "The Cincinnati Children's Triumvirate" for three of the key players in the organization's quality transformation - then President and CEO Jim Anderson, Board Chair Lee Carter, and Dr. Uma Kotagal, the Senior Vice President for Safety, Quality, and Transformation.  As with any major organizational transformation, there were several other individuals who played major roles as well, but given that "the sine qua non of quality improvement in health care is leadership", it would be easy to argue that the organization's quality transformation as an organization started with these three.

Lee Carter was a long-standing member of the Board, even after he stepped down as the Chair.  He would challenge all of us, including me, to always be prepared to explain our quality outcomes and safety metrics at every Board meeting.  If there was a major safety concern, he wanted to know about it.  He passionately believed that "you are not the best at everything and can always improve."  It was Lee Carter who came up with the aspirational goal of continuously improving "until we are the best and then we will remain the best because we will be the best at getting better."

There is a reason that John Kotter's book that introduces his 8-step process for leading change is called Leading Change.  Change has to be led by the organization's executive leadership.  Steven Dichter, Chris Gagnon, and Ashok Alexander developed a framework for organizational transformation and published it several years ago in the McKinsey Quarterly ("Leading Organizational Transformations").  Their framework involves three axes, all of which are important and all of which are absolutely essential to the success of transformational change (it's all or none):

1. Top-down direction setting: They emphasize that "successful transformations start with clear, consistent, and ongoing direction-setting initiatives" with leadership setting and clarifying clear priorities, creating energy, and signaling the commitment to change.   

2. Broad-based, bottom-up performance improvement: The "embedded skills, systems, and attitudes" are just as important to successful transformation.  As Dichter, Gagnon, and Alexander write, "One of the biggest challenges to overcome is the widely held management view that 'all we have to do is tell employees what we want, provide some training and rewards, and change will happen."  Organizations need to build the requisite improvement capacity throughout the organization.

3. Cross-functional core process redesign: Any transformational initiative will require an intense look at the organization's key business processes.  Dichter, Gagnon, and Alexander suggest that every organization, regardless of industry, is likely to have three to five core processes that cut across all the different functions (HR, R&D, marketing, operations) that deliver the majority of organization's value to its key customers.  

When viewed through this framework, it's clear that Cincinnati Children's executive leadership team ("the Triumvirate") was leading the change and providing consistent, clear, and focused direction on where they wanted to go as an organization.  Hospital leaders were very open and transparent about sharing outcomes and the results of safety incidents with members of the Board, hospital employees, and even patients and family members.  They established and fostered the requisite culture of safety, and every meeting (at all levels of the organization) started with either a safety report or patient story.  

Just as important, the organization made a significant investment in training the workforce in the "Model for Improvement" used by the Institute for Healthcare Improvement.  They developed what was (and I still believe is) called Intermediate Improvement Science Series (I2S2) for training leaders and employees in the science of improvement.  When I first took this course, I was impressed that some of my fellow classmates were members of the executive leadership team and the hospital's Board of Directors.  In fact, every leader throughout the organization was expected to take the course.  

Lastly, Cincinnati Children's changed several core processes within HR, marketing, and operations that supported the organization's transformation.  Both employee and patient safety metrics were built into the performance metrics for leaders throughout the organization.  They started with system-level measures ("Whole System Measures" in IHI parlance), which focused on safety, throughput and capacity ("flow"), patient and family experience, access, and cost of care.  Dr. Kotagal explained, "These are the big dots that we were going to move...and under that big dot a whole portfolio of projects that enable you to move the big dot."

There are important lessons that we can all learn from Cincinnati Children's.  Don Berwick, a pediatrician, former President and CEO of IHI, and former Administrator for the Centers for Medicare and Medicaid Services (CMS) recommends that healthcare "move from inspection to improvement. Move from surveillance and contingency and reward and punishment, remove from asking people to try harder to asking people how we can help them to learn."  Cincinnati Children's is certainly leading the way in this regard.  What's reassuring to me is that where there is a leader, there are always followers!  So many children's hospitals are on this journey too.  I look forward to what we can do together to transform pediatric health care!