Wednesday, March 21, 2012

Our aim is 100%. Short of that, we are at zero.

The power of transparency, as I have noted, is that it provides creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
MIT's Peter Senge explains this more fully in his book The Fifth Discipline:

[T]he gap between vision and current reality is . . . a source of energy. If there was no gap, there would be no need for any action to move toward the vision. Indeed, the gap is the source of creative energy. We call this gap creative tension.

Imagine a rubber band, stretched between your vision and current reality. When stretched, the rubber band creates tension, representing the tension between vision and current reality. What does tension seek? Resolution or release. There are only two possible ways for the tension to resolve itself: pull reality towards the vision or pull the vision towards reality. Which occurs will depend on whether we hold steady to the vision.

Paul O'Neill, the former CEO of Alcoa, expands on this by noting the importance of aspirational goals for an institution:

By aspiration, we mean goals that are set at the theoretical limit of what is possible. For example, zero nosocomial infections, zero medication errors, zero patient falls, zero work place injuries for all employees, zero wasted time spent hunting and fetching, zero duplicative or repair work for things not done correctly the first time, i.e., lab work or imaging studies.

Setting goals at theoretical limits sharpens the understanding of the size of the opportunity relative to current performance. Benchmarking against national averages or even better performers can create the illusion of success or satisfaction with “good enough.”

Those leading a hospital, and those governing that hospital, working in cooperation with the medical staff, need a score sheet that reflects these principles.  I came across one lately that exemplifies these values.

Christina Aeh RN, BSN, director of patient safety at Southern Ohio Medical Center, explains:

Our dashboard is set up for perfection--all or nothing. So we are either 100% or 0. We have added the word "never" within each indicator so that we can measure 100%. "100%" means we had zero incidents that month for that indicator. Wherever you see a "0" we had a failed case or event that month.

Here's what it looks like:

 And here is an excerpt that includes the incidence of central line infections:

I like the simple elegance of this, but some of my readers will be uncomfortable with the SOMC methodology and score card.  But can I say nicely to you that it is none of your business?  Each hospital needs to figure out the best way of holding itself accountable.  The purpose is not to draw comparisons between hospitals.  As I have noted:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

So the key is to create a dashboard that reflects your hospital's audacious goals, that is broadly visible to everyone, and that works to focus the efforts of your medical staff on the priorities they have identified.  By the way, the dashboard will change over time, with redesign resulting from the communal learning that occurs in your hospital.  Don't worry if some metrics drop off and others are added. Don't worry if you change how you keep track of things.  Such changes are the sign of modesty and learning.

But you need to get started.  Now.  People's lives hang in the balance.

1 comment:

Anonymous said...

This post reminds me of the whiteboard in the ICU hallway of a hospital to which my mother was admitted about a year ago. It had various parameters such as falls, CLABSI, etc. all written out on the y axis with month on the x axis. Trouble was, it hadn't been filled in for at least 5 months. What is a family member to make of that? And what message does that send to the staff? Nothing good, for sure. I wrote a letter to the CEO (about several other issues also) and got an apology and excuses back from the ICU director; non-reassuring.

I agree with you - just get started first, because that's where the lives are saved. But also find a meaningful (not advertising) way to communicate it to your patients and visitors, and keep up with it for crying out loud.

Parenthetically, if I write a letter to the CEO, I don't like getting back a reply from the ICU director. This makes me think some admin assistant opened it and directed it to the department mentioned, and the CEO never saw it. I bet Paul didn't handle things this way at BIDMC.

nonlocal MD