Berwick at the National Forum

#IHI09 Don Berwick's opening address is always a highlight of the IHI National Forum, and with good reason. He not only presents the latest and best about quality and safety improvements but also places those advances in the context of the broader health care environment.

Much of today's talk was about how to overcome the "tragedy of the commons", the natural inclination of people to ignore the externalities associated with their actions. The original formulation of this was set forth by Garret Hardin, using the example of overusing a common grazing area.

Don noted,

Like the villagers, rational health care stakeholders are eroding the common good simply by doing what makes sense to each of them – separately. In the short term, we each win. But, in the long term, we all lose. We lose the Triple Aim: better care for individuals, better health for populations, and lower per capita cost, all at once.

Name any stakeholder – hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ group – every single one of them says, “Oh, we need change! We need change!” But, when it comes to specifics, every single one of them demands to be kept whole or made better off. “Don’t stop my sheep; stop his.” So everybody draws on the Commons, the herds grow, and the Commons fails. If you don’t increase your herd, you’re a chump. And, who wants to be a chump?

Drawing on the work of Elinor Ostrom, Don stated the necessary conditions to offset those inclinations in a community of interest and pushed the attendees to action:

Here is my challenge. I challenge us to end the Tragedy of the Commons in health care. I challenge us to prove Garrett Hardin wrong.

It isn’t easy. Positive collective action, even in small communities, and especially in health care, is fragile. It could all just fall apart. But, it can work. I know it can work because, sometimes, some places, it does work.

But, I’m very mindful of who you all are. You are doctors and nurses tending patients, operating managers trying to keep 6 West going or clear the waiting lines. You’re QI directors coaxing the operating room into using a checklist, or executives getting ready to tell the Board some bad news. And, I think, you’re wondering, “What can I do from my limited perch to govern the Commons better? I’m already over my head.”

I am really not sure. But, I have a strong feeling that it can – it has to – start with you. Command and control solutions seem weaker every day, and Elinor Ostrom’s brilliant explorations suggest that, in many contexts, higher authorities simply can’t do the job. Maybe someone smart enough and courageous enough in Washington can write a few rules that change the odds.... But, the odds of real reform, “re-form,” remain zero – the Commons is doomed – unless the action is closer to home – closer to you. So, drawing on Elinor Ostrom’s work, here’s are some ideas to start chewing on:

1. Understand your health care Commons. Understand its limits and boundaries. Understand who can and does draw upon the common pool of resource, and who it serves.
2. Adopt an aim. Here’s one: Over the next three years, reduce the total resource consumption of your health care system, no matter where you start, by 10%. Do this without a single instance of harm, rationing of effective care, or exclusion of needed services for the population you serve. Do it by focusing not on the habits of health care as it is now, but by focusing on what really, really matters....
3. Develop, fast, because there isn’t much time left, your own institutional structures – the ones you will need for local rule-making to better manage your Common Pool Resource. Do not wait for external rules to be made, or to change; do it yourself. One such structure might be, for example, a Community-wide board – the collection together of all the health care Boards with shared stewardship of the whole.
4. Develop, fast, because there isn’t much time left, monitors, so that you can track the use of the common resource, and find out who is sticking to the rules you write, and who is breaking them.
5. And, when people do break the rules – opportunists, free riders – create undesirable consequences for them, if you can, and ways to isolate them, if you cannot. Collective action is very fragile. You will need militia.
6. Identify and address conflicts early, often, and with confidence. Conflicts will be frequent and legitimate, and they will demand wisdom. The social capital – the commitment to protect the Commons – has got to trump these conflicts.
7. Expect and offer civility. This is the foundational transactional rule for effective, collaborative management of what we hold in trust.... Respect is a precondition.

He closed with this thought:

My friends, we can spend our days ahead fighting for our piece of the pie. We have plenty of role models for that. But, that’s for summer camp and the schoolyard; not for here. Not for this real and fragile world. Not for the Commons. Not when there is only one pie, and it is all we have and all we will ever have, and it is in our hands to preserve, not just for us but for our children and our grandchildren. We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us, but those rules will be less wise than the ones we can write, and those tablets will be, not our salvation, but weights upon our spirit. It is a very tough choice. Get everything we can? Or respect everything we have been given?

Poster Session at IHI

#IHI09 Sometimes you have to travel far to meet someone from home. Here are Faye Holder-Niles and Linda Haynes from Boston Children's Hospital offering a presentation at the IHI National Forum poster session, where dozens of teams offered stories about quality and safety improvements in their institutions.

Faye and Linda presented a summary of a primary care team approach to advising families and treating children with asthma. Using a combination of interventions (e.g., counseling about drug dosages, HEPA filters for vacuum cleaners, rodent control measures), they dramatically reduced the number of asthmatic incidents for the children in several of Boston's neighborhoods. A subsidiary benefit was a huge reduction in the number of emergency room visits. (Check out those charts behind their heads on the poster.)

Nice work by our neighbors across the street from BIDMC!

Joanne and Emily at your service

#IHI09 Many thanks to Joanne Healy and Emily Crites for organizing the logistics at the IHI National Forum. Everything went incredibly smoothly as the IHI "blue shirt" team took good care of 5000 people on site over four days in Orlando.

College drop-out does good (and well)

#IHI09 Marshall Ganz was the keynote speaker at this morning's plenary session at the IHI National Forum. As co-chair of the event, I had the privilege of introducing him. See biographical details here. An excerpt: "Marshall entered Harvard College in the fall of 1960. In 1964, a year before graduating, he left to volunteer as a civil rights organizer in Mississippi." And thus began a lifelong career in movement building. (He eventually, 28 years later, went back to conclude his degree.) Before getting into lessons learned, Marshall explained what it was like to be involved in the early days of the civil right movement in the South.

Marshall summarized five practices that constitute leadership for change, which I summarize very briefly here:

1) Using storytelling to enable people to act together for change. "Narrative is how we learn to make choices, to understand the world affectively. Stories teach us how to act under uncertainty. We need to learn how to tell stories purposefully."

2) Building relationships. "Create a mutual commitment to a common purpose. Association makes the whole greater than the sum of its parts."

3) Creating an organizational structure based on team leadership rather than individual leadership. "Establish clear norms of behavior for the teams."

4) Translating shared values into action requires a focus on a few strategic objectives. "How to turn what we have into what we need to get what we want. Good strategy flows from commitment. Commitment puts us into a place where we have to figure it out. Use the resources we have, not the ones we don't. Don't buy in to conventional notions.

5) Actions to be real have to be real, concrete, and specific, with measurable results. "It matters what we count. There has to be a connection between metrics and strategy. Does the strategy move us towards the goal and increase our capacity to work together, and are people learning and growing as a result of the effort?"

Session E11 at #IHI09

Yell Eureka if u c this!

That is a message to the attendees at the session (a repeat of the one below) I am now conducting at the IHI National Forum, entitled Using Social Media to Pursue Quality and Safety. I have asked them to keep their Twitter search open for the meeting hashtag, #IHI09, as an illustration of how quickly information can flow through the social media.

This post is timed to go up at 11:25 am, just after the session starts. My blog posts automatically are fed to Twitter, and the hashtag will ensure that this post is collected by Twitter in the National Forum collection of tweets. The first person in my session to notice the tweet and yell "Eureka" will win a prize.

In the session, I will present our journey at BIDMC in the use of social media in encouraging our programs in patient safety and quality. This all started with some posts on this blog about central line infections, ventilator associated pneumonia, and hand hygiene. We discovered two things from those posts. First, the world would not come to an end if we disclosed clinical outcomes from our hospital. Second, the public presentation of these data acts as a stimulus to quality and safety improvement in the hospital. It serves to hold ourselves accountable to the standard of care we strive for.

Following publication on this blog, we moved to doing the same in a more expanded way on our corporate website. Here, you can see some of the same quality metrics, but you also see the full survey conducted by the Joint Commission when they came to accredit our hospital. Why? Well, the Joint Commission has important things to say about how well we run our place and where we should make improvements. How better for everyone in the hospital to see those things than to post them on the company website?

Each hospital has to decide for itself what degree of transparency is appropriate and comfortable, but as noted by John Toussaint here at the National Forum, it is an essential component of a culture of continuous process improvement. Social media can help spread the world.

Added later: The picture above is of the winner of the prize at this session, Mark Trahant. Congratulations!

Session D11 at #IHI09

Yell Eureka if u c this!

That is a message to the attendees at the session I am now conducting at the IHI National Forum, entitled Using Social Media to Pursue Quality and Safety. I have asked them to keep their Twitter search open for the meeting hashtag, #IHI09, as an illustration of how quickly information can flow through the social media.

This post is timed to go up at 9:40am, just after the session starts. My blog posts automatically are fed to Twitter, and the hashtag will ensure that this post is collected by Twitter in the National Forum collection of tweets. The first person in my session to notice the tweet and yell "Eureka" will win a prize.

In the session, I will present our journey at BIDMC in the use of social media in encouraging our programs in patient safety and quality. This all started with some posts on this blog about central line infections, ventilator associated pneumonia, and hand hygiene. We discovered two things from those posts. First, the world would not come to an end if we disclosed clinical outcomes from our hospital. Second, the public presentation of these data acts as a stimulus to quality and safety improvement in the hospital. It serves to hold ourselves accountable to the standard of care we strive for.

Following publication on this blog, we moved to doing the same in a more expanded way on our corporate website. Here, you can see some of the same quality metrics, but you also see the full survey conducted by the Joint Commission when they came to accredit our hospital. Why? Well, the Joint Commission has important things to say about how well we run our place and where we should make improvements. How better for everyone in the hospital to see those things than to post them on the company website?

Each hospital has to decide for itself what degree of transparency is appropriate and comfortable, but as noted by John Toussaint here at the National Forum, it is an essential component of a culture of continuous process improvement. Social media can help spread the world.

Added later: The picture above is of the winner of the prize at this session, Dan Henderson, Health Justice Fellow, at UConn School of Medicine. Congratulations!

Welcome reception at IHI

#IHI09 Shannon Mills, Community Manager for IHI, was on hand at the IHI National Forum to help people learn about the IHI Open School. Rebecca Vellejo and a colleague from the University of Kansas were explaining about the National Database of Nursing Quality Indicators. Lucille Skuteris joined a colleague to give information about Joint Commission Resources Consulting. Monda Shaver and Susan Lautner were marketing the Healthcare Facililties Accreditation Program, a competitor of the Joint Commission. And a new nanofiber product produced by a company called Vestagen Technical Textiles was on display, complete with a demo showing how it repels fluids.