Excerpt from the Compass Clinical Profile in Healthcare Leadership “Building a Will to Quality,” featuring  Maureen Bisognano, CEO of The Institute for Healthcare Improvement (IHI).

Dr. Cary Gutbezahl(CCC): As the Board members get more exposed to these areas, they develop a certain degree of sensitivity to the complexity of the organization, and, as you mentioned, the high degree of interpersonal connection that’s so important in providing healthcare services. But if they don’t have a clinical background, how do they develop the comfort of being able to actively participate rather than just be led by the people they interact with?

Maureen Bisognano (MB): Great question. I think what it means is that there is a different conversation about quality. In the past, and still in many places, I see quality reports that are these red, yellow, green scorecards … which are static in time. There can be any number of dead patients in the green boxes. I mean, there is no definition of what’s green, what’s yellow, and what’s red.

So, it’s having an executive team that’s comfortable moving away from that static scorecard in time and really beginning to explain what ventilator pneumonia is, what a central line infection is, and how many of these complications are actually eradicable and how many are not.

THE COURAGE  TO TALK ABOUT THE HUMAN IMPACT

But, it begins with the courage of an executive to say, “Let’s talk about this patient who got an infection.”

Five years ago infections were perceived as being a normal complication of care. Some patients were vulnerable, some were not. We certainly didn’t attribute individual performance of a clinician or a unit to the cause of that particular complication.

But we know better now.

I was in a meeting where the Board was talking about a young man who was admitted with trauma and got a central line infection. In the beginning of his hospitalization, this young man, a father of several children, was expected to be in the hospital for several days. Instead, he was in the hospital for a several weeks and ended up having to go to a nursing home for some months.

So now we’re getting to it—the hard questions that need to be asked.

QUESTIONS OF REAL IMPACT

What’s the impact of that complication in human terms on that family?

What’s the impact on that person who lost his job as a result of the infection?

What’s the impact of that complication in terms of the finances on the hospital?

What’s the impact if Medicare and other payers stopped paying for the additional cost of the complication?

What does that mean in terms of this case?

That leads the Board to ask the next question, which is:

How many times does that happen each year?

… which gives them a dollar figure in the hundreds of thousands, or maybe millions of dollars, that they will lose in revenue as a result of this complication.

What would you need to fix this problem?

That discussion hopefully leads to creating the will within the organization to see the gap in performance, where they stand, and how best to close the gap. They will most likely need some improvement capability. That might mean making an investment in an improvement course or sending an Improvement Advisor off for the training.

What it also really means is change. It might mean buying different supplies or reorganizing processes.

When the Board actually sees the human cost and the dollar cost of these complications, they become literate very quickly in understanding the meaning of ventilator pneumonia.

WILL, NEW IDEAS, EXECUTION

Dr Cary Gutbezahl (CCC): One of the key things for the Board to do is to create the motivation within the organization to deeply understand, act and finish an initiative.  Finishing is critical if you are going to make a positive change within the organization.

Maureen Bisognano (MB): Absolutely. At IHI, we always say you need three things to improve: will, new ideas, and exquisite execution skills.

It starts with building will, and I do think that’s a part of the Board’s role. When I meet with Boards or executive teams, I ask these four will-building questions.

1. How good are you?  Do you really know?

Are you reliant on a static red, yellow, green scorecard, or are you looking at data over time in a balanced scorecard view?

2. Do you know where your variation exists?

Why ask this? Because within that average number that Boards always look at, hides exceptional performance. The average hides both good and bad performance—exceptionally good and exceptionally bad sometimes.

When the Board starts to look at that variation, it gives them real insight into what the role of governing is. To remove that variation, you need the poor performers learning from the better.

3. Where does your organization stand relative to the best?

Often they have no idea.

They look at their own performance, but they don’t know that there is a gap between what they are seeing on their quality data and what the best are doing within their county, system, state, country or around the world. That gap can be profoundly moving for Boards.

4. Do you look at your rate of improvement over time?

I could give any hospital in the United States—any adult hospital—their mortality data since 1998. Many of them think they are improving. But … when they actually look at their data, they might not be. They may be flat, or could be improving dramatically.

It’s looking at performance over time that is so critical for Boards.

GETTING THE BOARD INVOLVED IN QUALITY CARE

Dr Cary Gutbezahl (CCC): Thank you for joining me. In our work with a lot of hospitals that have problems with Centers for Medicare and Medicaid Services (CMS) citations, one of the most common findings is failure at the governing body level to oversee and fulfill conditions related to the governing body. We find that a lot of the Boards struggle with getting involved in managing quality patient care. Your organization, the Institute for Healthcare Improvement (IHI), has done a lot of work to get Boards involved in this area. We’d like to discuss that.

Getting the Board involved creates certain risks for the CEO, especially those who haven’t really been that involved in managing quality because they are focusing more on other aspects of their jobs. How can the Board begin the process in a way that encourages the CEO to take the risk and drive the hospital toward better clinical performance?

Maureen Bisognano (MB): That’s a great question. I was speaking at a Governance meeting on the state of quality care in the United States—where there are defects and great opportunities for improvement. I remember being approached by several of the Board members afterwards who came up and said, “I feel really badly for you because you have to work in these terrible places.”

I don’t think they realized that their places were in the same boat.

OPENING THE QUALITY DOOR

I also understand the risk that an executive would be taking to open up this door when in the past, many non-clinical Board members have assumed that their organization’s care is high-quality, and that the board’s primary responsibilities are confined to  finance, acquisitions and building projects.

But, we have to open that door.

What we do at IHI is begin by talking with the Boards generally about how quality compares in the United States. The members of the Commonwealth Fund State Scorecard Team now work out of IHI’s offices. We’ve incorporated these staff and their research into IHI so that hospital executives can have data that take a look at how states compare with respect to quality, or how the U.S. compares with other countries with respect to quality.

The Reality of U.S. Healthcare: Higher Costs–Lower Quality

If I were a hospital CEO again, I would first orient the Board members by beginning to show them data at a national level that show the problems we have in the U.S. healthcare system. In other words, the U.S. system costs substantially more money and yet our quality outcomes are not as good as those in other countries.

So, if you begin at a national level and compare the U.S. system to other countries’ health systems, then at the next meeting you could move on to talk about how states vary in their approaches to quality.

Quantifying the Quality Gaps

Again, going on to the Commonwealth Fund website, you can take a look at a particular state and how it compares. What the website does is quantify the gap between any two states to say, if we were to move the performance of the State of Massachusetts to the national best, how much money could we save in avoidable re-admissions? How much money could we save in preventable hospitalizations?

So, I think you’re right. A lot of Boards are still not in touch with what quality means and looks like in their organizations. If you do that, you’re orienting the Board to the fact that there are gaps in quality at a state level. If a hospital CEO gives me a call, we can prepare a report card that shows how the hospital compares on quality from a number of different Perspectives.

Then the CEO can have a conversation with the Board about the gaps.

DOWNLOAD “BUILDING THE WILL TO QUALITY” COMPASS CLINICAL PROFILE IN HEALTHCARE LEADERSHIP

 In “Building the Will to Quality Care,” Maureen Bisognano shares practical and aspirational concepts about Board leadership and engagement to help drive a healthcare organization’s progress to dramatically improve quality care and outcomes.  Ms. Bisognano reveals unique ways healthcare leaders can radically improve, even revolutionize the current healthcare delivery system by;

• Getting the Board on board – great things happen when the Board gets intimately involved in the quality care of patients
• Discovering the patient journey – the complexity, processes, problems and opportunities
• Having the courage to talk about the human impact of mistakes and complications
• Understanding how values-based decision-making is the foundation of quality
• Will, new ideas and exquisite execution – the three things absolutely necessary to improve quality of healthcare.

“Changing and improving healthcare all starts with will—the will to seek out and act on new ideas; the will to be values-based decision-makers; the will to close the knowledge gap between the front office and the front line; the will for exquisite, flawless execution; the will to discover the patient’s journey.  The will to quality care.” – Maureen Bisognano, CEO, The Institute for Healthcare Improvement

DOWNLOAD your copy of “Building a Will to Quality Care,” PROFILES IN HEALTHCARE LEADERSHIP.

RELATED

A Fine Choice: Profile in Healthcare Leadership – Features Peter S. Fine, FACHE, President and CEO of Banner Health.

Profiles in Healthcare Leadership: An Interview with Jim Anderson – Features Jim Anderson, retired CEO of Cincinnati Children’s Hospital Medical Center

ABOUT PROFILES IN HEALTHCARE LEADERSHIP

Compass Clinical Consulting’s Profiles in Healthcare Leadership are the result of interviews with transformational leaders in today’s healthcare industry— men and women who have demonstrated courage, ingenuity and the hard work needed to create dramatic, measurable and sustainable improvements in their hospitals. They challenge assumptions, see things differently and enable remarkable breakthroughs. These leaders freely convey insights that we all can use to improve the way we deliver healthcare, and in the process, give us new ideas on how to make better American hospitals.

• The chance to apply their specialized skills in a different setting
• The variety of traveling and living in different parts of the country
• The satisfaction of being treated as professionals whose opinions are valued and respected
• The opportunity to take on tough challenges with support from experienced people.

CURRENTLY LOOKING FOR:

• Directors of OR
• Directors of ED
• Quality & Compliance Professionals with TJC or CMS Surveyor Experience
• Physician and Nurse Leaders

If you are interested in working as an interim healthcare executive or clinical director, call Cathy Sarky, Recruiting Manager, at (513) 241.0142, or email talent@compassgroupinc.com. You may also upload your resume here.

Excerpt from “Profiles in Healthcare Leadership: An Interview with Jim Anderson”

Jim Anderson was CEO of Cincinnati Children’s Hospital Medical Center from 1996 to 2009. In all measures, the hospital’s success and growth under Jim’s visionary leadership was extraordinary.

THE EXTRAORDINARY COMMITMENT OF PATIENT AND FAMILY-CENTERED CARE

Q: In the well-known report on “Pursuing Perfection: Improving Family-Centered Care for Cystic Fibrosis Patients,” you directly confronted CCHMC’s fairly average record of treating this disease and then did some extraordinary things to fix the problem. This was a wonderful example of how you were improving care by encouraging a culture of transparent openness. Being a corporate lawyer and CEO for 24 years prior to coming to CCHMC, did you have reservations about this openness, this possible risk? Can you share the inside story behind this transformation?

Jim Anderson (JA): When you try anything new, there are always risks. Always worries. The experience could end badly—but it could also end wonderfully. Innovation and transformation require risk—and not just risk-oriented thinking, but also well planned action and execution. I came to the conclusion that transparency was truly an
essential aspect of patient and family-centered care—a new ideal to strive for.  That the cystic fibrosis (CF) project by the way, was not painless. There was pushback. But we plunged forward with the belief that we were doing the right thing.

First, we exposed the situation and the data at a meeting of patients and patient family members. Our team revealed that  we were not one of the top hospitals for the treatment of CF. At the time we did this, sharing data that suggested under-performance was not common at most hospitals. There was too large a threat for legal action. But because we were encouraging a culture that honored transparency, we got the families and patients  involved in fixing the problem, even asking the patients and families how they perceived our level of care.

Once we put the issue on the table, our team came up with a set of promises to the patients and their family members:

• We will preserve your child’s lung function better than any other organization.
• We will get the care you need regardless of race, age, gender, education or ability to pay.
• We will protect your child from harm related to our care.
• We will allow you, as parents, to be involved in the care as much as you desire.
• We will respect and value your time.
• We will optimize your child’s nutritional status.

This type of commitment and transparency is extraordinary— some might even say risky. But the results were spectacular:

• The percentage of cystic Fibrosis (CF) patients under the 10th percentile for weight dropped from more than 40 percent to less than 25 percent.
• More than 95 percent of patients received flu vaccines that first winter, compared to an estimated 40 percent prior to the new program.
• Compared with less than 50 percent in the three years prior, 85 percent of the patients now receive a quarterly respiratory culture.

Q: A conflict arose with one of your most experienced CF doctors. He thought his method of treatment was the best, but the results didn’t support that.  How do you handle it? when one of your very best and most experienced doctors tells you he’s doing the best they can, and it can’t be done any better?

JA: You handle it with compassion—and persistence. Our doctor had been practicing for 30 years and truly believed his methodology was the best. He stuck by this belief until the fourth or fifth data set from that project validated a different approach. While he was convinced that he was producing good outcomes, the metrics convinced him that the outcomes could be better. At first, the doctor believed the metrics were wrong.  It’s a matter of professional respect to get the metrics right. The numbers have to support the actions—the treatments and the results. Eventually, we all have to follow what the numbers indicate; at the end of the day costs count.

If we are going to be data-driven, our organization must be supremely capable of generating good data. We have PhD statisticians who compile, analyze and review the data so that when they sit down with the doctors, the conversation moves very quickly to the quality of the data. You need credible data when you have difficult conversations about medical protocols. The data must be at a level that is appropriate and acceptable. Providing good data is one of the ways CCHMC supports our medical staff, our patients and their families.

The CF doctor was almost in tears when he finally realized that what he had been doing for decades was really only putting us in the 20th percentile.  And, you know, it was crushing.  I mean it would have been to me, it would have been to you or all of us. After confronting the story the data told, he said, “Well, I need to do things differently.”

We did.

And the results changed dramatically.

Now CCHMC is in the top 10% of all CF hospitals. And despite this improvement, we’re still not happy. We want perfection. Getting better relies on having solid, data-driven process improvement that ultimately impacts our medical protocols.

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Excerpt from “Profiles in Healthcare Leadership: An Interview with Jim Anderson”

Avoidance of conflict is neither healthy nor productive when the conflict is over serious differences of opinion. Conflict avoidance does not reflect an understanding of conflict or an appreciation of the potential benefits of well-managed conflict.

What is Conflict?

In many health care organizations, conflict is seen as a destructive force that interferes with teamwork and getting things done. That’s because in most organizations, conflict is expressed with anger and aggressive or resistant behaviors. Conflict originates from not getting things done the way one believes it should be done. Let’s call it a self-situation mismatch. The expressed emotions have given conflict a bad name.

There are two types of conflict. The undesirable and too familiar type of conflict is called relationship or affective conflict. Relationship conflict is a conflict based in dislike and distrust. It has a strong emotional component and manifests itself in disrespectful behavior, both verbal and actions, which result in non-productive and disruptive interactions.

The other type of conflict is called task or cognitive conflict. This type of conflict originates from differences in perspective about understanding. Studies show that groups that generate task conflict and manage it well, perform better than do groups that have little task conflict.

Why is this true? Advocates frequently get carried away by their enthusiasm for a solution and overlook important issues. Sometimes, people don’t know what they don’t know. Finally, habits tend to produce the familiar solutions even when the familiar is inappropriate or ineffective. That’s where task conflict can be helpful.

Task conflict can illuminate the overlooked issues, identify biases, and the sources of differences of opinions. When teammates view problems differently, the group explores the definitions, assumptions, logic, and biases that underlie the differences of opinion. In addition, oversight of important contextual factors may be identified and remedied. In effective teams, other teammates participate in the discussion to raise questions and defuse the emotions of the discussion, and provide additional insights. Ultimately, a robust discussion yields a better solution and stronger commitment to the agreed upon plan of action.

What happens if you don’t manage task conflict well?

It is likely to degenerate into relationship conflict. That’s why most of us avoid generating any type of conflict. We are weary of relationship conflict and fear that we cannot control the genie after it has been released from the bottle. Unfortunately, by giving up conflict altogether, we run the risk of missing the opportunity to correct planning deficiencies that originate from flawed thinking of individuals and diminish the benefit of collective minds.

Hospital senior teams are well positioned to engage in cognitive conflict. Hospital leaders are experienced executives who have distinguished themselves within their professional scope of work. Unfortunately, this means being successful within one of the hospital’s professional silos. It is extremely rare for executives who work their way up the hierarchy to gain experience in another organizational silo. How often do physician executives work in Finance? How often does a finance person work in radiology or nursing? Professional training and licensing are significant impediments to developing cross training.

Yet, the education and experiences of a physician, nurse or financial executive produce different points of view. More importantly, it produces different values, different assumptions about causation and possibilities, and meaning attached to beliefs. These differences can produce arguments but if managed properly, disagreements can produce insights.

Engaging in Constructive Conflict

The first step towards constructive conflict is to create the right climate. First, provide education. People will need to become aware of the two types of conflict. They must be trained to develop an appreciation of the potential value of task conflict, while recognizing that relationship conflict does not need to follow.

People need to be educated about the two types of conflict. People need to appreciate that differences of opinions should not be allowed to degrade into relationship conflict. Instead, differences of opinions should be explored as an opportunity to learn something. In addition, the group needs to foster trust, safety, and emotional intelligence. These considerations are tightly linked because it is difficult for any component to exist without the other two. Without these preconditions, group members are unlikely to be willing to engage in task conflict for fear that relationship conflict will emerge.

The next step is to initiate skills development within defined work groups. These are groups that meet often enough so that lessons learned are remembered between meetings. Start with groups that meet at least weekly. Remind the group of the skills that are needed to manage the balance between the two conflicts. Some groups do well to have a facilitator act to encourage task conflict but alert the group to emerging signs of relationship conflict.

There are several key behaviors that need to be taught and mastered so that a trusting environment is created where conflict can be constructive. First, the participants need to avoid the tendency to evaluate while listening and focus on listening for understanding and appreciation. Then, individuals should delay responding to comments until they have had a chance to think through their comments. Reflection may raise some questions that need to be clarified. Most importantly, reflection can help remove emotion from comments and focus on identifying differences of opinion.

Another challenge for the group is to make sure disagreements don’t derail the progress of the discussion. Someone in the meeting will need to assume the responsibility for identifying when the discussion is becoming too contentious and redirecting the conversation to the matters at hand.

Although busy people prefer developing their skills by doing meaningful work, this can be dangerous when dealing with conflict. A lack of skill in engaging in conflict can result in hurt feelings (relationship conflict) that might be difficult to overcome after it has gotten out of hand.

Ultimately, the benefit of a senior executive team developing conflict management skills will be an organization that produces better plans and achieves better commitment to the plan.

Fear of conflict can commit an organization to a path of mediocrity.

Since meaningful success requires taking chances, are you better off taking a chance on building the capabilities of the senior leadership team or on individual initiatives? The answer is that making your leadership team conflict competent will produce better results from each initiative you undertake. Published research proves it.

There has been much recent attention on the high cost associated with readmissions. It seems clear that the policy makers are seeking to hold hospitals responsible for preventing readmissions. Holding hospitals accountable is a classic example of failed management-thinking in which the absence of facts is filled by assumptions.

WHO IS REALLY RESPONSIBLE?

In my experiences in case management, both in hospitals and in managed care organizations, I have found many reasons why patients are readmitted to hospitals. These include medical reasons (such as a complication or instability of the disease), patient reasons (such as lonely people who don’t want to stay at home alone or patients who don’t want to eat a low-salt diet), and post-hospital care provider issues (such as nursing homes that are short-staffed and want to send “sick” patients back to the hospital). All of these are not single solution problems. The only clear fact is that hospitals are not responsible for causing these problems.

So, how can the hospital be held responsible for all this?

EASY TARGETS AREN’T RIGHT TARGETS

Because hospitals are an easy target and other more realistic solutions are harder to implement or not politically acceptable (holding patients and their families responsible for unnecessary readmissions).

FINANCIAL INCENTIVES LIMIT STAY TIME – AND CARE

The public does not realize that Medicare, under current regulations, does not pay for long hospitalizations. In fact, the DRG payment system creates financial incentives to shorten hospitalizations and creates financial penalties to hospitals that have long hospital lengths of stay. Medicare also wants patients to go home (without home nursing care) rather than to a nursing home. Medicare is no more compassionate than any other insurer.

COMPLICATED RESPONSIBILITIES

Medicare also requires that hospitals provide patients with a list of post-hospital care providers and expects the patients to choose. Hospitals cannot, by regulation, indicate preference to their own home care company. Doesn’t this further complicate the degree of responsibility that a hospital can reasonably assume for rehospitalization?

HOW TO PROVIDE BETTER CONTINUITY IF CARE?

If this unreasonable penalty against hospitals is implemented, Medicare should allow hospitals to refer patients to their own nursing facilities and home health care agencies. This will provide better continuity of care and enable the hospital to be a true health system responsible for providing a wider scope of services to patients in their community.

This is an excerpt from the Compass Clinical Profile in Healthcare Leadership “A Fine Choice,” featuring Peter S. Fine, FACHE, Chief Executive Officer of Banner Health.

When Mr. Fine was hired to lead Banner Health in 2000, the newly-merged system was struggling with the chaos of clashing cultures and the complexities generated by the joined businesses. But, under his leadership, Banner – headquartered in Phoenix, Arizona – is now one of the largest not-for-profit, secular, multi-state systems in the country, generated $4.86 billion in revenue in 2009.

Peter Fine, CEO of Banner Health was in his second year of leadership when Banner’s 2020 Vision Plan was created. He discusses the details of that plan with Dr. Cary Gutbezahl, CEO and President of Compass Clinical Consulting.

Peter Fine (PF): We laid out what we  were going to do for 20 years, making it clear, simple and easy to understand.

2020 Steps to The Future

• Fix It – Turnaround, 2000-2002
• Do It – Performance, 2003-2006
• Grow It – Growth, 2007-2010
• Change It – Innovation, 2011-2015
• Lead It – Industry Leadership, 2016-2020

We spent two years focused on fixing this company, taking it from a losing operation to a financially successful organization. Then we began to plan for the next stage—focusing on performance.

We needed information systems that could gather, arrange and provide the information in a way that would allow us to benchmark ourselves against anybody.

This meant investing in IT systems.

We began to build the idea that we were only as good as the best of the best—not the best with the data. So we began to benchmark.

Transparency Motivates Positive Change

We then took those benchmarks and put them online on our intranet. It was important for every part of the organization to be able to access the data. For example, take inpatient services. The measurements we were using were shared visibly and broadly, so everybody could see. It created a lot of tension, but it got the competitive juices flowing.

Total transparency—it’s refreshing but, make no mistake, it is difficult to manage.

Dr. Cary Gutbezal (CG): So, if you were running a hospital where you were at the bottom of the barrel, with unacceptable outcomes compared to your peer group, everybody knew it.

PF: Yes. That created a lot of peer pressure—pressure to perform, motivation to change. We built this process of total transparency and accountability into the organization. It became part of the fabric of the company.

Accountability Provides Investments for The Future

Accountability produced results that then positioned us to spend a few billion dollars during a three-phase plan to grow the company by first focusing on investments in present campuses and towers—reinvesting in our facilities.

Second, we started building new campuses, or what we call Greenfield projects, that are quite advanced from an IT perspective, incorporating design and technology that have been very well accepted by our patients.

A great example is our new Banner Ironwood Medical Facility and the development of the Cardon Children’s Medical Center, the first new pediatric hospital in Arizona in decades. The third phase was acquisition, with the purchase of another system called Sun Health.

Fix. Do. Grow.

Three one-word methodologies we’ve used to grow our organization so far.

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DOWNLOAD the Compass Clinical Profile in Healthcare Leadership “A Fine Choice,” featuring Peter S. Fine, FACHE, Chief Executive Officer of Banner Health.

THE FIRST FACTOR

The first factor to examine when considering the financial implications of the use of interim hospital executives and clinical directors is pricing. Interim pricing varies considerably, primarily due to differences in the management and support provided to the interims.

On the low end of the pricing spectrum are individual consultants, who perform interim hospital work on their own and generally charge rates that might approximate the internal salary of the position. For this price, a hospital might secure an acceptable interim HR Director, but there would be no company behind them to provide the hospital with support, insurance, immediate replacement if necessary, or access to related resources.

VARIATIONS

Pricing also varies when interim healthcare leaders are secured through firms. Some interim firms price their services low to secure more business. Other firms that deploy interim hospital leaders price their services higher to ensure that the best people are deployed and fully supported by very experienced healthcare executives with relevant hospital experience.

Variations in pricing are often indicative of the skills and experience of individual interim executives or directors and/or the depth of support given to them. Generally speaking, firms that pay their interims and internal support staff well attract and retain the best talent. Lower prices can indicate that a firm has recruited interim hospital leaders who are willing to work for less money, or that the firm is not providing a deep and experienced support staff.

IMPLICATIONS

Though this is not always the case, hospital leaders should carefully consider not only the price of interim healthcare leadership services, but also the implications of that price.

For more information about hiring interim hospital executives and clinical directors, contact Tracie Abbott at (513) 241-0142.