1. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl HRO Mindful Organizing in an Intensive Care Unit Fourth International HRO Conference April 20 & 21, 2011 Twitter: @StrangeShirine #HRObytheDutch #InterveningWithPassion

2. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl What can you expect in the next 3 minutes? 1.Situation: An Intensive Care Unit 2.Intervention Strategy: negotiating and experimenting 3.Results: To what question is HRO an answer? #HRObytheDutch #InterveningWithPassion

3. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Situation 24 available beds 8 doctors Teaching hospital: fellows and doctors in training 130 nurses (that are not all ‘die hards’ anymore) The question is not anymore: ‘can we keep the patient alive?’, but ‘when do we add limitations to the treatment of the patient?’ ICU as an important ‘player’ in the hospital: a better ICU means the possibility to do more complex churgeries Introduction of telemedicine #HRObytheDutch #InterveningWithPassion

4. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Situation This ICU: is regarded as one of the best in the Netherlands keeps innovating and experimenting with new techniques with the doctors and nurses that started this unit 30 years ago #HRObytheDutch #InterveningWithPassion

5. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Question to the change accompanist We are the best ICU in the Netherlands… Our knowledge is more than up to date… Our protocols are precise… Our equipment is state of the art… And still, we think we can do better… It has something to do with how people interact and we do not know how to improve that… #HRObytheDutch #InterveningWithPassion

6. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Situation Issues are: We have 24 available beds, but due to a shortage in nurses, we never are able to open more than 18 The results of the Employee Satisfaction Research were alarming: employees are not happy to work here at all Recently two patients died, which could probably have been prevented. Because of this, docters and nurses are restless. Some of them feel that they are to blame #HRObytheDutch #InterveningWithPassion

7. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Situation A few examples of the nightmare ICU: 1.The suddenly instable patient 2.The departing patient 3.The patient with or without limited treatment 4.De nurse dressed as a civilian 5.The new equipment 6.The silent fellow #HRObytheDutch #InterveningWithPassion

8. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl What can you expect in the next 3 minutes? 1.Situation: An Intensive Care Unit 2.Intervention Strategy: negotiating and experimenting 3.Results: To what question is HRO an answer? #HRObytheDutch #InterveningWithPassion

9. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Intervention Strategy Step 1. Closing the mental contract Intake with the board of directors Intake with the 8 doctors Intake with the middle management  Is everybody in? And with what expectations? Negotiating meeting with doctors and management  What result do we want to accomplish together by introducing HRO? #HRObytheDutch #InterveningWithPassion

10. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Intervention Strategy Step 2. Creating shared references and shared sense of urgency Starting meetings with doctors and nurses Nightmare and Dream ICU Practicing in dialogue instead of discussion Practicing in seperating observation, interpretation and judgement Creating experiments Meetings with doctors and managers Leading the ICU: who decides on what? #HRObytheDutch #InterveningWithPassion

11. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Intervention Strategy Step 3. Learning by doing experiments Experimenting = possibility to make mistakes and learn from them Doctors and nurses work together in experiments Self organizing without the help of management Manager as coach of the experiment group Practice to not simplify: reflecting and evaluating #HRObytheDutch #InterveningWithPassion

12. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl The HRO experiments Shared references 1.Explaining protocols 2.Knowledge quiz 3.End of life 4.Talking blamefree about a situation Redundancy: 5.Time-Out 6.Vliegende keep 7.Blamefree evaluation of the day Respect for expertise: 8.Walk a mile in my shoes 9.Frisse blikken spuien 10.Telling stories Focus on operations: 11. To what question is this an answer? 12. Think of your hat, stay on your seat #HRObytheDutch #InterveningWithPassion

13. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Intervention Strategy Step 4. Collective Sense Making Reflection meetings and evaluation meetings Practice not to simplify Acting AND reflecting Meetings with doctors and managers Coaching the experiments Explaining, sensemaking and being resilient ‘Think of your hat and stay on your chair’ #HRObytheDutch #InterveningWithPassion

14. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Intervention Strategy Step 5. Anchoring HRO Three gangs that keep HRO alive: Content Patterns in interaction Leading HRO starting meeting for new employees Three rounds of HRO experiments each year #HRObytheDutch #InterveningWithPassion

15. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl What can you expect in the next 3 minutes? 1.Situation: An Intensive Care Unit 2.Intervention Strategy: negotiating and experimenting 3.Results: To what question is HRO an answer? #HRObytheDutch #InterveningWithPassion

16. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Results Informed culture: Dialogue instead of discussion Observation, Interpretation, Judgement Checking assumptions Focus on mistakes: I am a human being and do not have to be perfect I am not alone Sometimes I just don’t know Not simplify: No jumping to conclusions and solutions Acting AND reflecting CreatING shared references on f.e. protocols and on end of life decisions #HRObytheDutch #InterveningWithPassion

17. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl Results In short: Doctors and nurses together: -Determined what can be improved in this ICU concerning quality of care, patient safety and cooperating -Created experiments to constantly improve -Used their experiences in the experiments to introduce new ways of working that improve alertness of doctors and nurses and therefore improve patient safety #HRObytheDutch #InterveningWithPassion

18. Strange | Strategy and Change Shirine Moerkerkenwww.shirine.nl To what question is HRO an answer? HRO is not an answer to creating an even more perfect ICU It is an answer to creating more alertness between doctors, nurses and docters and nurses in working together. So that they can deal with unexpected events Mistakes will still be made, but doctors and nurses will notice weak signals early and will give strong responses to that weak signals. And that creates better patient safety #HRObytheDutch #InterveningWithPassion