How a CEO learns

As you can tell from this blog and elsewhere, we are pursuing a very strong quality and safety agenda at BIDMC. Our progress to date has been good, but we have a long way to go. It is very satisfying and helpful for me to get to know people around the country who are doing the same, as we learn a lot from one another.

An example. Every time I hear Jim Conway from IHI give a talk, I learn something or am reminded of something important. He recently helped us during a joint retreat of the boards of BIDMC and our community hospital BID~Needham. The focus was the role of the board in governing quality and safety, a topic I have covered here earlier, but dealt with so much more effectively by Jim.

And then yesterday, he and I were making presentations at a different kind of meeting, and he repeated some of themes raised at our board retreat. He reviewed the lessons learned by the Dana Farber Cancer Institute in the ten years following the tragic death of a patient from a chemotherapy overdose. As a CEO, it helps me to hear these things again and again to really have the lessons from others' experiences sink in and to help consolidate my own thinking, and I am always grateful for the opportunity. Here are some highlights, in shorthand, without Jim's eloquence.

Key points about a culture of safety:

Based on trust, human rights, repentance, and forgiveness.
Patient and family centered.
Supports staff, enabling and motivating the highest levels of performance.
Acknowledges the high-risk and error-prone nature of health care.
Ensures individual and shared acceptance of responsibility and accountability.
Encourages and facilitates reporting and open communication about safety concerns in a fair and just environment.
Ensures that organizational structure's processes, goals and rewards are aligned with improving patient safety.
Learns from errors.
Shares stories.

And here are key points about actually implementing change. The theme is for the leadership of the place to force a kind of creative tension based on seeing what we want to the organization be -- our vision -- and telling the truth about where we are -- our current reality. That creative tension can only be resolved in two ways: (1) raising the current reality towards the vision, or (2) lowering the vision towards the current reality.* Of course, we aim for #1! (By the way, this involves particular challenges in academic medical centers, where the role of the CEO is somewhat different from other types of organizations.)

How you cultivate this creative tension over time:

Benchmark against the best practices.
Search for opportunities to be humbled.
Learn from the tragedies of others.
Keep patients and direct care staff "in the room", i.e., engaged in evaluation and decision-making.
Conduct critical risk assessments.
Story telling and learning.
Constantly look for trouble.
Be transparent.
Get information to those who need it to drive change.

I particularly like the idea of "constantly looking for trouble." Here's how you do it. Ask the staff on the floors the following questions:

What's keeping you awake at night?
What's your favorite work-around?
What kept you from giving the kind of care you want to give?

The folks in the room yesterday were slightly taken aback because an inherent characteristic of this approach is its transparency. In particular, your activities, flaws, and failures are open for the world to see. And they raised issues of the inappropriate portrayal and use of that information by those on the outside seeking commercial or political gain. Jim and I pointed out that there were some risks along those lines but that, for the most part, our ultimate constituency -- the public -- wants hospitals and doctors and other caregivers to succeed and believes in their good intentions. Transparency is consistent with maintaining that trust and indeed reinforces it because it sends a message that the organization is willing to hold itself accountable.



*This is based on the work of Peter Senge at MIT.