A short introduction is called for here. Over the past two years, I have shared things with readers of this blog that usually are not made public by the CEO of an organization. I have done so because I think the issues facing hospitals are of sufficient societal import -- i.e., beyond the particular interests of our own hospital -- that they warrant public attention and discourse. Further, I believe that academic institutions like ours have a responsibility to provide educational materials to others, and what works better at that than real time case studies of what we are going through?
In so doing, I show us for what we are in real time, warts and all. This makes us vulnerable to nasty anonymous commenters in the blogosphere, as well as to people who think they benefit from embarrassing us and making us uncomfortable. And, even a few of my board members have said, from time time, "Transparency is one thing, but did you have to post that?" The answer is that this is an experiment in real time, but that I believe BIDMC ends up being a stronger, more effective, more efficient, and more humane organization for having done so.
Here comes the next example, an email I sent out over the weekend to our staff, entitled "Looking for your help." It is self-explanatory. As always, I welcome your comments:
As you can imagine, I've been giving a lot of thought to the events of the last several weeks with regard to the MRSA infections and the lapses found by DPH and CMS in our hospital with regard to infection control. We have already made some changes in response to those findings that should be quite helpful, but I want to draw back a few steps and ask your indulgence to think through the issue with me in a more comprehensive way.
Let me start with a story. I have a friend named Tom Botts, who works with Royal Dutch Shell. Tom and his folks had put in place the world's most extensive safety program for people working on oil rigs. Much to his dismay, two workers went to the wrong part of a rig called Brent Bravo and did something totally contrary to all their safety training and were killed. It would be all too simple in a situation like that to blame the two workers for being inattentive to the safety rules, but Tom and his colleagues did something different. They engaged in what he called a "Deep Learning" exercise and discovered that the problem lay not in well-intentioned people who made mistakes, but in the leadership of the organization for failing to fully understand what it would take reduce the chance of errors.
Here's an example of one of his conclusions:
"A system full of well intended, competent people working world class systems trying their best to meet expectations can produce fatalities."
Probably the most profound learning for me. In the Brent Bravo story, there were no obvious ‘villains’, but rather a number of causal patterns that came together to produce a tragedy. The whole point of Deep Learning for each of my senior leaders and me was to be able to see ourselves in the system and what causal patterns we could have been able to break (if we had a better appreciation for the unintended consequences of our many well intended decisions). Key questions: Am I asking the right questions? Am I curious enough?
(If you would like, you can read other parts of the story and Tom's other lessons on my blog here.)
So, now let's go back to BIDMC. That there were flaws in our infection control procedures and techniques is quite evident from the DPH/CMS report. Let's not deny those. But let's also assume that the well-intentioned and highly trained people in our hospital were extremely unlikely to have made these errors intentionally. As one of our nurses said to me, "There is a difference between knowing what to do properly, and deciding not to do it despite knowing it." And then she said, "I truly believe we are the best hospital here in Boston. That is why I choose to work here. We are open with our mistakes, as that is how we are able to learn and progress. It hurts to see our name slandered, and our reputation diminished over this. Can we do better? Yes. And we are already. Our policies are being rewritten, and our procedures reviewed. This is an issue that is in EVERY hospital. Please don't let this disintegrate further into an atmosphere of fear and punishment. Please use this as a tool for internal review and reflection."
Although we have made a full and complete response to the DPH/CMS findings, we are in the business of continuous improvement here, and I want to see if we can do better still . . . with your help. In the past several weeks, we have seen the power of our joint action in adopting budget and personnel actions that reflect our deepest values of caring and compassion. Our town meetings and chat rooms and emails produced a result that solved a serious budget problem . . . and by the way, brought great national acclaim to our hospital.
I would like to try to do the same here. I don't think large-scale town meetings fit the bill for this exercise, and I also don't think the imprecision of chat rooms and emails would work in this case, either. Instead, over the next several weeks, I will convene a series of focused discussion groups with those of you who would like to join me and a small group of Chiefs and Vice Presidents. Your task will be simple and direct: Tell us what we don't know that we should know to help make it more likely that future quality and safety problems will be diminished. We'll then take what we learn from you and do our best to construct the training, procedures, and infrastructure that will move us along in this journey.
In the next few days, you will see an email setting forth a schedule for these meetings, and you will be able to sign up for one that is convenient for you. I welcome and treasure your participation.