Resolve

As our biking group celebrated New Year's eve somewhere in the Atlas Mountains, the usual question arose as to each person's resolution for the coming year. I demurred from saying mine publicly because it seemed a bit pretentious to say, "I'm going to save some lives." But as I thought about it upon returning, I realized that my job as CEO of a Harvard-affiliated hospital requires something of that magnitude. Not that I am a doctor, but I am in a position to influence not only what happens at BIDMC but also, by example and advocacy, other places throughout the world. The same is true for the other clinical and administrative leaders of our hospital.

We can document that we have saved hundreds of lives at our hospital during the last few years by a full and sustained commitment to quality and safety, front-line based process improvement, and transparency. I hear from many of my readers that the stories you have read on this blog and our actions in this arena have changed the way in which you have thought about your own institutions and your practice of medicine.

Yet, when I was in London for the Risky Business conference and asked an audience of 300 people how many of their institutions would have disclosed the existence of a wrong-side surgery throughout their hospital and more widely -- in an attempt to learn broadly from the error -- fewer than ten people responded positively.

As our doctors, nurses, and administrative leadership team speak out at conferences throughout the world, they hear lots of questions, but the one they hear most often from the middle management of other hospitals is, "How can I get my CEO/Chief of Service/Board of Trustees to support me in the kind of culture change you have achieved?"

It is very hard for nurse managers or other mid-level staff people to steer from behind. For one thing, they are very busy doing their day-to-day work. For another, hierarchical organizations do not always respond kindly to suggestions from within the organization.

A physician friend of mine recently wrote with a hard-hitting analysis of this situation:

This is probably the worst time in history to try to advance a patient safety agenda given recent federal legislation, HIT meaningful use, Medicare and all other pressures preoccupying the profession. Nonetheless, it must be done and fast -- but may necessitate a different strategy. Many people working on this are special but far too nice and earnest.

Jim Conway has said:

"It is imperative that the top leaders in quality and safety assemble NOW, and collectively develop an aligned agenda that will allow us to realize our goals. And, in the process, they have the humility to shut up, listen, and learn from other industries that have figured it out a long time ago. We must stop the endless unaligned agendas and we must develop a common language and approach."

While he is absolutely correct, the crux of the problem as I see it is that changing culture is the only permanent fix, but will take so long, as does any major culture change, that it's impracticable given the scope and urgency of the problem. Right now the profession just doesn't see it as their problem and, given the political environment mentioned above and the fragmented nature of medical leadership, we must look to cultural education for the long term, not the immediate fix. They're just NOT PAYING ATTENTION, because they don't HAVE to. There are no consequences.

Therefore the only short term solution I see is one that mandates compliance in some way first, while working to change culture underneath. So the usual weapons of CMS, Joint Commission, legislation, etc. are the only way to achieve anything in the time frame needed.

So that brings me to people in your position. You have an opportunity to get these guys together and add some of those passionate e-patients and maybe get some real "sticks" (opposed to carrots) put in the Joint Commission standards to mandate change sooner rather than later. I can tell you in the community hospital world, which is quantitatively most of the world, this is all that administrators, and therefore reluctantly doctors, respond to.

Culture change and the long process of education will be the eventual answer, and there should be a specific agenda for that, too, as Conway indicates. But, as one of the previously unconverted, I can attest that it takes immersion, much repetition, relationships with "converted" people whom you trust and can ask questions, and time to "get" it. It certainly did me, and I count myself as a case in point.

That my friend might be right is hard to hear. Why? Because regulatory approaches, no matter how well intentioned, tend to lack finesse and often cause people to work on the wrong problems. They are certainly necessary, but they need to be informed by people on the ground.

Perhaps, as my friend suggests, the people on the ground will come from the burgeoning movement of patient advocates. At the IHI Annual Forum, we helped bring together a group of patient advocates. They and others have the potential to form a core group to move things along. But, the passion of these folks may also be their Achilles heel. To be effective, they will need to figure out a way to retain that passion but to make room for the kind of compromise among themselves that allows a political movement to grow. Other advocacy groups have done this in the past -- e.g., in civil rights and environmental protection -- but those movements were also characterized by periodic internecine battles. That is something to avoid here.

Meanwhile, back in the C-suite, what's the role for me and other CEOs who wish to move this agenda along? Clearly, we must resolve to retain and expand our role as local champions for quality and safety, front-line based process improvement, and transparency in our own institutions. As heads of academic institutions, we should resolve to offer stories of our experiences to people in other hospitals, to help create a mutual learning environment. As industry leaders, we should resolve to encourage hard-hitting and effective regulation to move along a recalcitrant profession. And, we should resolve to develop the humility to trust that the patients have an important role in all this. We should invite them in, make them feel welcome, and shut up and listen when they show us a better way.