No retreat by the Boards

About a year ago, the Boards of BIDMC and BID~Needham met in an educational and planning retreat to decide on their priorities for both hospitals, one a large academic medical center, the other a small community hospital. The result was a four-year commitment to eliminate preventable harm and to dramatically improve patient satisfaction in the two hospitals.

Today, the governing bodies again met to reaffirm these goals, to learn more about how to achieve them, and to plan their agendas for the coming year. They were assisted by some special guests.

First was Steven Spear, Senior Fellow at both the Institute for Healthcare Improvement and the MIT Engineering Systems Division. I have written before about some of Steven's ideas and research. Here, too, he discussed the manner in which the best complex organizations deal with the problem of how to obtain process improvement. He noted that the first step in improving a complex system is being transparent about what is going wrong because "we need to know it's a problem we need to solve." As opposed to a transactional mindset, in which the emphasis is on making decisions because you assume you know enough to make the right choice, he emphasized the value of a discovery mindset. Under this approach, you have to have humility that an educated guess is not likely to be right, but that it provides an opportunity for learning. You also need to be sufficiently optimistic that you will achieve improvement over time, aided by iterative discovery. In short, the key is "humble optimism."

Spear emphasized that one of the jobs of a governing board of a hospital committed to transparency is to stand by the medical and clinical leadership and staff during the inevitable periods in which there will be adverse publicity resulting from this openness. "Watch their back," he advised.

The next session consisted of a panel comprising doctors and nurses from the two hospitals, focusing on their perspective on the progress towards quality and safety improvement and receiving their advice for activities by the Boards that could support these objectives. They were unanimous in their support for the importance of transparency as a key part of process improvement.

Following break-out sessions in which the Boards and their respective committees planned their agendas for the coming six months, they heard from Lee Carter, former Chair of the Board of Cincinnati Children's Hospital, a national leader in hospital quality and safety. He mentioned the key elements of board involvement in the quality agenda:

-- Pay attention and understand what people on the front line are doing so that they know they are appreciated. Improving quality is very difficult and takes extra work. "You need to let them know that you appreciate them."
-- Encourage transparency. "It is powerful and absolutely necessary. Until you identify what you need to improve you never will improve."
-- Establish and maintain a culture of trust, because without it, you cannot obtain transparency.
-- Measure progress, rigorously and accurately. Quoting IHI's Jim Conway, Lee noted, "Some is not a number; soon is not a time." Quantifiable objectives, with specific deadlines, are key, as is measuring progress towards both the objectives and the timeliness of achieving them.

He left the board members with the following lessons from Cincinnati: (1) We are never as good at something as we think we are; (2) it is very hard work to make transformational, as opposed to incremental, change; (3) we always have slower progress than we think we will, and the board needs to understand that and be supportive; (4) it takes persistence, and the role of the board is to support the attempt and be cheerleaders for the transformation. Confirming Spear, he stated that the board needs to let the clinical and administrative leadership know that "I've got your back" during periods of public scrutiny and the adverse publicity that often accompanies transparency. Finally, says Lee, (5), "After all this, it works" and will save lives and will result in better patient care overall.

About 80 lay leaders left the 12-hour session with a renewed sense of purpose and commitment, enthusiastic in their attempt to improve care not only at their hospitals, but also cognizant that they are partners in a national movement to do the same.