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Appendix C. High Reliability Organization Learning Network Operational Advice From the Cincinnati Children's Site Visit

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Overview
Organizational Transformation
  Creating a Shared Vision for Transformation
  Identifying Essential Elements for Transformation
    Leadership
    Institutional Infrastructure To Support Transformation
    Rigorous Measurement
    Transparency
    Accountability and Alignment
  Summary on Organizational Transformation
Building a Business Case for Quality and Organizational Transformation
  Engaging the Chief Financial Officer
  Building the Business Case
  Use of Evidence-Based Care
    Effective Discharge Planning
    Reducing Ventilator-Associated Pneumonia and Surgical Site Infections
  Summary of Business Case Issues
Specific Improvements Toward Organization Change
  Emergency Department
  Pharmacy Redesign
  Codes Outside the Intensive Care Unit
  Computerized Work Orders
  Surgical Site Infections
  Safety of Handoffs
  Neonatal Intensive Care Unit
  Transitional Care Area
  High Fidelity Simulation Center
Lessons Learned
Acknowledgements
Contact Information

Overview

This appendix summarizes practical suggestions on how to transform an organization by creating an infrastructure for supporting improvement initiatives geared toward making the organization more reliable. All ideas reflected in this document were suggested by representatives of Cincinnati Children's Hospital Medical Center and other healthcare systems attending a site visit as part of the AHRQ-sponsored High Reliability Organization (HRO) Learning Network.

Cincinnati Children's is a world-class facility, with an endowment of more than $1 billion, more than $900 million in research contracts and grants, and a history of innovation that includes a Robert Wood Johnson Foundation (RWJF) Pursuing Perfection grant. As a prestigious children's hospital, Cincinnati Children's attracts 50 percent of its patients from outside its service area.

Participants in the site visit were interested in how Cincinnati Children's is transforming itself into a national leader in quality improvement and safety initiatives, as well as how its efforts could be adapted to different systems.

This document synthesizes the site visit discussion to answer several key questions about organizational transformation toward high reliability:

What does it mean to transform a hospital using high reliability concepts?
How can an organization build a business case for organizational transformation and quality?
How has the broad commitment to organizational change been translated into specific initiatives to improve patient care and the patient experience?
What can be learned about how process redesign efforts can drive organizational transformation?

The discussion of these questions relates specific activities and initiatives to a framework for high reliability organizing. In addition, specific examples are provided to help illustrate the tangible impact of a commitment to organizational transformation. Finally, by focusing on change processes and not just end products of improvements, other systems can understand the processes that led to Cincinnati Children's improvements and be better able to take these insights and create processes that will work in their own systems.

Other materials that were shared at the site visit, including slides from the presentations and other examples of improvement materials, are available on the HRO Learning Network extranet and from AHRQ and Delmarva staff.

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Organizational Transformation

Although Cincinnati Children's has been nationally prominent for many years, the organizational commitment to fundamental improvement is less than 10 years old. When Cincinnati Children's received the RWJF Pursuing Perfection grant in 2001, it lacked a comprehensive quality improvement strategy or clear understanding of where its improvement efforts should be focused. The IOM report Crossing the Quality Chasm provided a conceptual framework for the organization to think about its quality improvement efforts and aspects of care in which improvement could occur. While Cincinnati Children's has made great progress on its transformation journey, key leaders from Cincinnati Children's strongly emphasize that they are still on the transformation journey and believe that improving reliability will be a continuous process.

This section addresses two key questions one would ask when starting to transform an organization into one that provides highly reliable, high-quality care:

How can a vision for transformation be created?
What key components need to be addressed as the transformation process begins?

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Creating a Shared Vision for Transformation

Cincinnati Children's spent a significant amount of time defining what transformation should mean for its organization. These discussions led to the conclusion that achieving organizational goals requires more than a series of incremental performance improvement projects. Instead, the vision for transformation emphasized:

The need to focus on large-scale organizational changes that are linked directly to the strategic plan. Particularly given Cincinnati Children's size, the only way the organization as a whole could be transformed was through aligning strategic planning with the investments being made in safety and quality improvement.
Goal setting for systems based on 100 percent performance and 0 percent defects. Leaders agreed to establish these perfection-oriented goals even when it was not clear whether those goals were achievable. They reasoned that these standards of excellence were the only way to avoid accepting errors and defects that were inconsistent with the organizational mission.
An emphasis on creating transparent processes for sharing successes and failures with internal and external customers. To build a foundation for a culture in which ongoing improvement was the norm, Cincinnati Children's accepted that almost every process in the system could and should be better and that leaders needed to talk about what they were learning as they attempted to improve these processes. By creating extremely high standards, the leaders made it easier for staff to discuss failures and opportunities for improvement because the failure to achieve something extraordinary is not anything to be embarrassed about. But high standards also made it more difficult to remain complacent, even in systems where performance was comparable to those of their peers.

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Identifying Essential Elements for Transformation

Like other organizations who have committed to major change, leaders at Cincinnati Children's view transformation as a continuous process that requires persistence. A mantra that senior leadership has used to avoid "over planning" was to "start before they were ready"; this coupled with setting audacious goals has helped them begin the transformation process more quickly.

Cincinnati Children's leadership has found it useful to think about the following five elements as key focus areas for their journey:

Leadership.
Institutional infrastructure, organizational alignment, and resource investment.
Rigorous measurement.
Transparency.
Accountability.

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Leadership

Leadership at the system and unit levels has proven to be essential for jump-starting and sustaining organizational transformation. Cincinnati Children's identified three leadership essentials that help to clarify how leaders drive organizational change:

Leaders must own the process of creating the culture and focus required for transformation. It is up to leaders to help others clearly understand priorities. Leaders also have to model the transparency and accountability that transformation requires. Perhaps most important, leaders are responsible for ensuring that staff can succeed in their improvement efforts and for sustaining the positive outlook that encourages people to continue trying to make changes successful even when progress is slow. Each example of major change within a unit reflected the efforts of a leadership team who exhibited these characteristics.
Leaders must remain united. A key success factor at Cincinnati Children's is support for transformation from the entire leadership team. This process did not happen immediately. Key leaders, including the chief financial officer (CFO), only gradually bought into the commitment to a quality-based transformation of the organization. Over time, some leaders who remained uncommitted to transformation left or were replaced by others who were supportive. As the commitment to transformation grew, it became easier to attract and retain leaders committed to transformation. Now that transformation is central to organizational culture, there is a consistent senior leadership response to complaints related to the transformation: "This is how we work, and this is now part of your work." Although this response might have been inconceivable or highly risky 5 years ago, unity among leaders now enables Cincinnati Children's to respond to complaints in ways that help to drive organizational transformation.
Leaders are more effective when working in teams. Many improvement projects have a team leadership structure that brings complementary skills and influence to a project and may include a physician, nurse, and sometimes an administrator. This structure is used for several reasons:
- It helps to avoid the perception of winners and losers, which can lead perceived losers to withdraw from the improvement effort. Problems owned by the physician and nursing staffs are much more likely to be solved in ways that are supported and sustainable for both groups.
- It fosters a breakdown of the traditional cultural barriers between physicians and nurses and leads to an atmosphere where everyone recognizes the contributions of multiple staff types. Transformation requires a culture that rejects hierarchy and embraces relevant expertise. By creating leadership teams, Cincinnati Children's is modeling the type of culture required for all types of staff to feel that their insights are valued and that their warnings of potential risks to patients will be taken seriously.
- It creates more favorable conditions for stimulating enthusiastic physician engagement and involvement. In some hospitals, physicians are regarded as obstacles to quality improvement, and those perceptions create resentments that lead to self-fulfilling prophecies. Cincinnati Children's works extensively to provide resources and expertise that will allow its physicians to help lead improvement efforts. Each Clinical System Improvement Integrating Team is led by a physician and a nonphysician. In this capacity, physicians work collaboratively to help develop and lead initiatives that improve systems and processes. The net effect of this effort is a growing number of physician leaders who can provide valuable perspectives and ideas required to drive the transformational goals that have been established.

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Institutional Infrastructure To Support Transformation

Having a well-developed organizational infrastructure is key to efforts to achieve organizational transformation. Typically, infrastructure is equated with technology and information systems required to support an organization's mission. But when Cincinnati Children's began its transformation, it defined infrastructure development more broadly. This section addresses infrastructure at two levels: support infrastructure and technology infrastructure.

Support Infrastructure

Initial efforts focused on developing a support infrastructure for improvement that would provide the units and teams working on initiatives the expertise and resources they would need to succeed. This investment supports efforts to make the right thing to do the easy thing to do.

Cincinnati Children's also regarded support infrastructure as essential for addressing quality improvement at points where distinct subsystems intersect with one another. Facilitating improvement and breaking down silos within the system were major emphases. Developing this support infrastructure made it easier for Cincinnati Children's to establish unit and leadership accountability for improvement efforts by ensuring that units and their leaders had the resources needed for them to succeed. The remainder of this section describes in more detail the support infrastructure that was created.

Central to the support infrastructure is the Division of Health Policy and Clinical Effectiveness, which was created to support the needs of the improvement teams. This division has grown to 30 full-time employees, including experts in patient safety, evidence-based care, measurement and analysis, and quality improvement. Rather than hiring clinical experts who had some training in quality improvement or people who really wanted to help improve care processes, Cincinnati Children's has chosen to hire quality improvement consultants from outside the field of health care. Several factors make these consultants unique:

They have established track records of improving processes that give them credibility with the clinicians they work with. Because they do not have clinical backgrounds, they are well suited to ask process and flow questions without threatening the clinical staff. Most of these consultants have a minimum of 5 to 7 years of experience in quality improvement and training in Lean methodology and Six Sigma.
Their role is to serve the teams working on the improvement rather than the leads responsible for achieving the change. This consultative role ensures that ownership of the improvement efforts remains with the units and teams that provide patient care. This approach increases staff buy-in as well as the sustainability of improvement efforts.

In addition to these consultants, the division includes data analysts. Typically, data analysts have master's degrees; a background in clinical or health services research; and competency in precise definition of metrics, study design, internal review board (IRB) processes, and project management. Beyond these skills, the analysts must be able to communicate effectively with clinical staff to define measures, explain results, and support the development of processes for collecting and reporting data in ways that help drive improvement.

Cincinnati Children's support infrastructure also encompasses the budgeting of:

Time for staff training off of their unit on quality improvement strategies.
Resources, such as additional staffing, funding, and enhanced data analysis capabilities, to support staff working on high-priority quality improvement projects and to support the testing of new ideas and innovative practices to determine whether they work and can be spread across the organization.

Technology Infrastructure

Cincinnati Children's has invested a substantial amount of time and money in technology to collect and monitor key clinical and efficiency measures more easily and efficiently. Although it regards these initiatives as critical, a major emphasis has been placed on ensuring that processes are designed well before they are automated.

At present, the organizational infrastructure is the foundation for efforts to monitor performance at the unit and system levels. This allows clinical systems improvement teams, business units, and clinical divisions to be held accountable for improving and sustaining performance measures. This infrastructure also supports the commitment to rapid cycle improvement driven by current and accurate data.

Some participants in the site visit were impressed with the resources available at Cincinnati Children's to help drive organizational transformation, so group discussion addressed similarities and differences between the organization's situation and those of other hospitals. Cincinnati Children's does not believe that additional funding and extra staffing were key to the success of its initiatives, and there are many examples of organizations with a great deal of funding and limited staffing constraints who have accomplished very little. At Cincinnati Children's, there is a clear recognition of ongoing challenges that it must still address, including:

Building capability for widespread use of improvement and reliability sciences.
Creating sufficient time to do improvement work and embedding it into daily activities.
Recognizing improvement work as a legitimate academic pursuit.

Clearly, investments in the infrastructure required for transformation are important, but even organizations that may lack capital for major technology investments can profit from what Cincinnati Children's has learned about how to most efficiently invest in support infrastructure.

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Rigorous Measurement

Although it is a world-class research center, Cincinnati Children's began its transformational journey with comparatively little data about many important clinical outcomes. Absent such information as well as much research on expected outcomes for pediatric care drawn from the published literature, it was difficult to determine where to focus improvement efforts and hard to motivate units to work on improving outcomes. Recognizing the importance of these limitations, a major effort was made to develop, implement, and monitor an expanding set of process and outcome measures. Several important insights from these efforts to promote rigorous measurement have broad relevance:

Concentrate on developing useful and measurable outcome measures as a main goal. Through its transformational development, Cincinnati Children's has learned that it is more important to measure fewer, yet significant outcomes and resist the temptation to measure too much too soon.
Ask key questions before starting the data collection process:
- What do we want to know?
- How are we going to collect that information in the clinical process?
- What are we trying to show at the end of the data collection?
Hire a manager for data infrastructure, if possible, who will lend credibility to the process.
Establish regular reporting schedules and stick to those schedules, be it monthly, quarterly, or yearly.
Use the information collected to help drive improvement. If information is not used, it is important to understand why so that either the measures can change to ones that are more relevant or the information can be compiled and shared in ways that are easier for people to use.

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Transparency

In a culture that stresses continuous improvement, easy and open access to information is essential. Like other organizations that have embraced high reliability organizing, Cincinnati Children's embraces the belief that open communication is necessary for its transformation to succeed. The following are key aspects of transparency:

Transparency must span all levels of the organization. Holding information about organizational successes and failures at the leadership level often can be counterproductive. If you don't make information available to all staff, they cannot fully participate in rapid cycle improvement. Moreover, in order to motivate staff to change behaviors and give them freedom to think creatively about potential improvements, they need full access to information about what is working well and what could be working better. Once information is shared, the opportunity exists to actually address the underlying cause.
Transparency must include recognition of successes as well as failures. Improvement can only occur if failures are identified and addressed, but building a culture of trust that encourages staff to report failures is difficult. Cincinnati Children's has worked with one unit in particular to increase reliability and celebrate successes. When a near-miss event takes place and a staff member accurately records the event, that staff member is acknowledged for reporting the event. Because continuous improvement efforts will entail both successes and failures, communicating about both is essential for transformation to occur.
Transparency should include patients and families. Sharing information with patients and families can actually alleviate questions and concerns that may arise during the course of care. The key is to ensure that any information shared is presented in a way that is meaningful to the families and is easily understood. Involving families in organizationwide advisory councils and unit-based improvement teams is an effective way of sharing information and soliciting feedback on opportunities for improvement. In some units of systems in the HRO Learning Network, information about unit performance is posted in public locations where it can be seen by patients and their families.
Transparency should occur through multiple media. Reporting information in multiple locations and through multiple media increases the odds that the information will be seen by a larger audience. Cincinnati Children's takes advantage of bulletin boards, computer screensavers, its intranet, and the Internet to share information with staff, patients, and families. Although it is a challenge, the organization has made a commitment to posting information in ways that patients and their families will be able to understand and use.

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Accountability and Alignment

To drive system change, people and units must know what they are being held accountable for, and these goals must be aligned with one another and a range of performance incentives. Developing a culture of accountability for outcomes takes good data and time. Cincinnati Children's has found value in taking the following factors into account:

Recognition and responsibility for outcomes have to be at the unit or division level to make the leaders more aware of, engaged with, and accountable for the initiatives. This requires plausible data at the unit and division level, not just data that are aggregated across the entire facility.
Individual providers must clearly understand and buy into their role and contribution and that they are accountable for outcomes. Discussion at the site visit addressed the issue of whether this is easier or more difficult when physicians are directly employed by the hospital. On one hand, physician employees may be easier to incentivize through bonuses; on the other hand, physician employees who are uncooperative are more difficult to replace or eliminate than physicians with looser connections to the hospital.
Accountability at the provider and all other levels should be embedded into the annual review. Beyond the ability of the review process to reward achievements, embedding performance metrics into the annual review reinforces the importance of performance measurement and quality improvement to the organization. Unit directors and division and department heads should be responsible for delivery system performance metrics because system performance is a key aspect of their responsibilities.

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Summary on Organizational Transformation

Much discussion at the site visit focused on the role that resources play in achieving substantial and rapid organizational transformation. Cincinnati Children's clearly has made a major financial commitment to its organizational transformation. Although resources may have enabled the organization to attempt more transformation efforts more rapidly than would be possible in other systems, they are convinced that the success factors relate to the dimensions noted previously. Although resources are essential, leadership, support infrastructure, rigorous measurement, and accountability are the keys to maximizing available resources in support of transforming the organization.

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