Rowing in the Same Direction

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Rowing in the Same Direction

 

By Jake Luty, MD

Clinical Hospitalist, Faculty Lead of the OHSU HQSC

Disclaimer: I’ve never been on a crew team. I have, however, been in a raft going down thrashing whitewater, part of a team of people who all of a sudden found themselves frantically rowing, trying to get from start to finish without anyone being thrown off the boat. No matter the level of turbulence, both situations strike me as an apt collective metaphor for healthcare improvement teams (of course this metaphor is not new as many sites & sources have clearly laid out this case more eloquently that I).

In an October 2013 Harvard Business Review case study, Michael Porter and Thomas Lee, MD outline a strategy to address the value gap in healthcare - that our system is designed to produce unacceptably low quality at unacceptably high cost. This gap is well articulated in the seminal work from the Institute of Medicine, Crossing the Quality Chasm, wherein they outline strategies to make our care safe, timely, effective, equitable, efficient, and patient-centered (STEEEP for short) – a must read for anyone starting to wrap their minds around improving healthcare. Bridging the gap, Porter and Lee contend, will require agreeing on the goal(s) and then, an integrated strategy for ‘value transformation.’

Their first point (Defining the Goal) is subtle – it accounts for roughly 5% of their article – but it is in many ways the most important. Just like the rowers in the raft (or racers in the ‘shell’), setting the direction emerges as a key first step in a safe and effective journey (so much so that each sport usually includes a member whose sole focus is setting direction and facilitating team mechanics to guide along this shared path). In healthcare improvement, an initiative’s team manager typically starts by guiding the team in the definition of the problem as related to the team’s shared purpose. This shared purpose usually derives from an organization’s interpretation of the ‘STEEEP’ paradigm as it relates to the care gaps most pressing for the population served by that healthcare organization. At OHSU, this is the executive leadership, who defines a common framework to which the direction other managers’ ‘rowing’ is set. Especially in an institution as geographically dispersed as OHSU, setting a common direction via accessible mental models (houses and the like) becomes the first step in integrating everyone’s efforts toward impactful and sustainable improvement. Without adept leaders touting a clear shared direction, racers can find themselves inadvertently working against each other.   

The second of Porter and Lee’s points (Strategy for Transformation) can, should be, and is regularly debated by many, so the fine points are not a focus for this post. Rather, it is interesting how the mechanics of a crew team overlap with the central point of the rest of the review – that healthcare teams’ efforts need to be integrated if we are to accomplish the ‘STEEEP’ aims set out in Crossing the Quality Chasm. More so, they cap their model with the key point that efforts ought to be facilitated by an enabling information technology (IT) platform. These are like the ‘tactics’ of a row team, scripted moves in unison that propel the boat with maximal efficiency. Improvement teams with enabling IT platforms enjoy similar boosts in coordination and effectiveness (websites, online networks, dashboards, etc.). That is the aim of this website and many of the other recent changes in the HQSC – to try out new platforms for coordination around a common goal. To better ‘row’ as an integrated unit.

Expect to see developments in the OHSU HQSC’s IT platforms, especially as they relate to newly developed conceptual models for OHSU’s strategic vision (houses etc.), in the coming months. Our hope is that they help us steer our efforts to ford the quality gap in a way similar to an elite Olympic Rowing team, or at least a bit less like a turbulent rafting team, at times rowing in opposition and at others being flung from the boat entirely.

If you have suggestions about how the OHSU HQSC could do better in our efforts to enable integrated action, or have a reaction/resource/story that you think would inform us on this topic, please start a dialogue in the comments section below.

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On Being and Becoming a Blue Shirt

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On Being and Becoming a Blue Shirt

By Dr. Adam Hoverman - OHSU Preventative Medicine Resident

Attending the Institute for Healthcare Improvement's (IHI) Annual Forum this year I was astonished by the surprising revelations that occurred for me in the several conversations that I had early in the week with the esteemed “Blue Shirts”. Consisting of both a wide range of international volunteers and IHI staff, the Blue Shirts are the veritable glue and stalwart navigators for the 5000+ attendees of the conference. I took every opportunity possible to speak with them in the early moments of the forum as they were collectively preparing, encouraging each other, and bracing for the event tsunami ahead. By doing so, I learned more about the heart of IHI, the spirit of improvement on the most quotidian and daily of scales, and the vigorous commitment to shifting the balance of power in all aspects of an organization and beyond.

First, Karen, was a lovely volunteer who had previously worked in Public Health with director of the NW Region, bordering Cumbria in the UK. Cumbria, she taught me, was an English non-metropolitan county that came into existence in 1974 after the passage of the Local Government Act of 1972. While with the local public health agency she focused on reducing teenage pregnancy, tobacco cessation, and increasing vaccination rates in the region. Her passion was both providing “safe sex” education and services once women in the community were pregnant. Most of all, she shared with me, she did not want them to feel outcast or alone. Many had applied from her organization to attend the Annual Forum and she was the one who was chosen to do so. Following a one day orientation, she said of being a blue shirt, “It made sense sooner than I had thought”; “I felt included in the team” and “I was happy that I was able to contribute.”

Then there was Kush, an IHI Staff working as a Blue Shirt at the Forum this year. He shared with me insights from IHI's inner sanctum in Cambridge, MA where he offered a physical description of the layout of the offices. Being from the East Coast myself, I particularly appreciated when he shared with me that “I don’t get that East Coast feeling at IHI. We’re all on one floor. Walls have been taken down. You can see from end to end from one side. We sit by region. No one has an office.” The spirit of transparency, openness, and inclusion that I have always gleaned from reading and listening to Don Berwick, Paul Batalden, and others was clearly demonstrated in Kush’s further description of the offices when he shared with me that “All conference rooms have glass walls. It's very visible who’s meeting. Even our chief of staff sits with the rest. They take one of the seats with us. It’s a great feel. A simple thing and it follows through in how we all act.” Lastly, the inspiration that is evident in the behavior and accountability among the staff of IHI, also turns out to be evident in the art placed throughout the office, “It’s visible on our walls”, Kush said, “All there for us to read and remember daily. Mindfulness. Transparency. Compassion. Boundlessness.”

In all, from Dr. Berwick’s invigorating keynote on Shifting the Balance of Power to the myriad daily interactions with fellow attendees, colleagues, peers, and mentors, my time at the IHI Annual Forum this year was absolutely humbling and rose far above any expectation of what an improvement conference might hold. I encourage you who are reading this to attend next year, present a storyboard even, and if so inspired, consider joining me in volunteering as a Blue Shirt. Few things exceed the value of learning while doing, and in the end it is the improving while doing that matters most of all.

Please consider learning more, and participating in the IHI Open School and local PSU-OHSU IHI Open School Chapter. Further information can be found here:

Institute for Healthcare Improvement (IHI) Open School

PSU-OHSU IHI Open School Chapter

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'Just Culture' and 'High Reliability' at OHSU & PVAMC

'Just Culture' and 'High Reliability' at OHSU & PVAMC

By Missy LeBlanc MD & Jake Luty MD

Healthcare systems are highly complex networks. They involve multiple interconnected systems that must function together to provide effective care, despite the constant risk for serious and even deadly accidents. Organizations that operate with high efficiency and safety despite these hazards are referred to as ‘High Reliability Organizations’ or HROs. Examples include aviation and nuclear power – both industries are incredibly complex and the stakes are high – mistakes in either setting can lead to catastrophic failures. Given the overlap in intricacy and consequence of errors, the concept of HROs has also been extended to healthcare systems.

In order for HROs to function at such a high level, they must strive for improvement through continual learning and the ability to adapt to an ever-changing environment. One way to achieve such adaptation is continued evaluation and improvement of your delivery system. This is done by adopting a ‘Just Culture’ that aims to balance individual- and system-based responsibility to allow for open reporting, investigation and education based on adverse events and near misses. Instead of responding to all errors with reflexive blame and retribution, it is assumed that even well-intentioned people will make mistakes and the focus shifts to preventing our systems from accommodating similar errors in the future. Such a culture helps us work as a team to improve both as individuals and as a system, maximizing the safety of the care we provide our patients.

OHSU and the Portland VA Medical Center, as healthcare systems striving to become HRO’s, work to create a ‘Just Culture’ by having open reporting of errors and near misses as well as having sites specifically related to the topic, so that we can continue to hone our skills and improve the ability of our systems to provide care safely. These reports are investigated by separate institution-based sub-committees, with resident representation on both sides of the bridge (at OHSU by our HQSC PSI sub-committee), who evaluate the cause of the event and put in place ways to prevent recurrence. Given the focus is on improving the safety of our system, errors of all types and degrees (even near-misses, where the error is caught before harm is done to the patient) should be reported. The road to becoming a HRO and establishing a robust “Just Culture” is long and difficult, but it is our duty to try, we can get there by working together, and there is no time like now!

Do you have a story that demonstrates Just Culture done well? Done poorly? Let us know in the comments section (ensure no PHI is used, this is a common forum) & stay tuned for a follow up post examining the ‘life-cycle’ of a Patient Safety Incident report.