1. Leading for Safety: Thoughts on Structure, Culture and Governance
March 4, 2011
Debbie Barnard, MS, CPHQ
Victoria Inn Winnipeg, Manitoba

2. Presentation Outline Introduction
Reflections on Governance/Leadership, Structure/ Infrastructure and Culture
Case Study
Table Top Discussions
Report Out/Reflections
Closing Comments

3. Our Promise to Patients/Residents
Safety – “not harming people with our care”
Effectiveness – “matching science to care”
Patient centeredness – “nothing about me without me”
Timeliness – “avoiding needless delays”
Efficiency – “Avoiding waste”
Equity – “Closing the gap”

4. “The current care systems cannot do the job. The chassis is broken.
IOM Report 1999 & CAES 2004
“The current care systems cannot do the job. The chassis is broken.
Trying harder will not work; we must change the systems of care.”
Source:

5. Are we up to it

6. Case Study: Dana-Farber Cancer InstituteTO
FROM
Errors are rare
Everything’s great
Great care
Made it up as you go along
Errors are everywhere
Excellent, not perfect
Great care in a high-risk environment
Principles of fair and just culture, guidelines, algorithms, flow sheets

7. Case Study: Dana-Farber Cancer InstituteTO
FROM
Risk of disclosure/ confidentiality
Great staff, poor systems
QI, RM, Safety staff drive the work
Moral duty, risk on nondisclosure, transparency
Great systems, great staff
Board, C-Suite, Chiefs, Chairs drive the work

8. Case Study: Dana-Farber Cancer InstituteTO
FROM
Keep the board out
Keep doctors out of QI and RM
Deliver care to patients
Actively engage
Actively engage, nothing possible without them
Partner with patients and families

9. Case Study (Think Differently- video)

10. Governance & Leadership
HOT TOPIC!
Boards on Board – IHI 5 Million Lives
Effective Governance for Quality and Patient Safety - OHA Regional Programs 2011
CPSI Board Resources & Toolkit

11. What Does the Evidence Tell Us?
Outcomes are better in hospitals (organizations) where:
The board spends >25% of its time on quality and safety.
The board receives a formal quality measurement report.
There is a high level of interaction between the board and medical staff on quality strategy.
Vaughn T, Koepke M, Kroch E, et al. J of Patient Safety. 2006;2:2-9.

12. What Does the Evidence Tell Us?
Outcomes are better in hospitals (organizations) where:
Senior executive compensation is based in part on quality and safety performance.
The CEO is identified as the person with the greatest impact on QI, especially when so identified by the QI executive.
Vaughn T, Koepke M, Kroch E, et al. J of Patient Safety. 2006;2:2-9.

13. Six Things That Boards Can Do
1. Set a specific aim to reduce harm this year and make an explicit, public commitment to measurable quality improvement (e.g., reduction in unnecessary mortality or harm).
2. Select and review progress towards safer care as the first agenda item at every board meeting.
Get data on harms and hear stories; put a “human face” on data.

14. Six Things That Boards Can Do
3. Establish and monitor a small number of organization-wide “roll-up” measures that are updated continually and are transparent to the entire organization and its customers.
4. Commit to establish and maintain an environment that is respectful, fair, and just for all who experience pain and loss from avoidable harm.
Patients, their families, and staff at the sharp end of error

15. Six Things That Boards Can Do
5. Develop the capability of the board.
Learn how the “best in the world” boards work with executive and MD leaders to reduce harm.
Set an expectation for similar levels of education/training for all staff.
6. Oversee the effective execution of a plan to achieve the board’s aims to reduce harm, including executive team accountability for clear quality improvement targets.

16. Culture

17. “Every enterprise has four organizations:
the one that is written down,
the one that most people believe exists,
the one that people wished existed, and
the one that the organization really needs.”
NHS Building & Nurturing an Improvement Culture

18. Scope for Leaders What is the meaning of organizational culture?
How to measure organizational culture?
How to build/change organizational culture?

19. Tribal Wisdom of Healthcare
When you discover you are riding a dead horse, the best strategy is to:
Beat the horse --> it may rise from the dead
Change riders --> it is clearly the rider’s fault the horse is not moving
Appoint a committee --> if more people look at the horse , it may not be really dead .
Arrange to visit other sites--> See how they ride dead horses
Lower the standards: make dead horses acceptable

20. Structure/ Infrastructure

21. Viewing the Organization as a System:
Linkage of Processes at appropriate Level of Detail
Level of Detail
Low
High
Source: L. Provost, Senior Fellow IHI

22. Planning for Improvement
Source: L. Provost, Senior Fellow IHI

23. Can you build a house without a frame?
Committees
Technology Supports
Databases and IT systems that communicate
Reporting System
Human Resources
Orientation & Competency Programs
Source: L. Provost, Senior Fellow IHI

24. Execution of Improvement Work in Organizations
Projects ?
Division or Department Level ?
Whole Organizational level
Source: L. Provost, Senior Fellow IHI

25. Execution Structure Organizational Level (whole system)
Sub-system Level
Sub-system Level
Sub-System Level
Project
Project
Project
Project
Project
Project
Project
Project
Source: L. Provost, Senior Fellow IHI

26. Table Work and Discussion

27. Governance & Leadership
1. What do you think the leadership team did at DF to create their “to state”?
2. Leadership for improvement is difficult; what do you find most challenging in your organization?
3. What are some of the key strategies that the board and leadership team can do to “walk the talk”?

28. Culture
What’s at least one successful strategy or tactic you can share from your organization’s improvement journey?
Pretend you are coaching a new leader, how can you help them to begin to use a system view of their organization as a way of creating a new culture?

29. Structure & Infrastructure
How do you think the leadership team at DF began to redefine their processes so that they could view their organization from a whole system perspective
How can this approach support your team to connect structure, strategy and improvement?
Does your quality infrastructure require any changes to improve how quality improvement work gets done?

30. Report Outs Observations & reflections from your group’s discussion
Your contribution to the “Ten Powerful Ideas for the Future Now”

31. Closing Video