Organizing for Success - Lessons from Keystone
What does it take to organize medical organizations for success? In several previous essays, I have considered aspects of this question. Here I want to explore the lessons learned from the “Keystone ICU Project.” In this study, the investigators developed an assessment of the safety culture of 108 ICUs in 77 hospitals in Michigan. They found wide variation in the perception of the quality of the teamwork around patient safety. After introduction of clinical bundles, they were able to reduce the central line infection rate to nearly zero, and compliance with recommend care for patients on mechanical ventilator improved to 99%. Reassessment showed persistent variation in safety culture, but improvement in all units. We were inspired by these results to install similar processes in our hospital, with good results. However, replication in other areas has proven difficult.
The Keystone Group considered the operational lessons learned and reported this “as a starting point for others to consider when embarking on large scale change.” I do not think this paper has been widely read and wish to do my part to promote its message.
Understand the differences between leadership and authority: cultivate leaders.
The authors point out that leadership is often independent of authority, which typically stems from organizational position. The CEO has positional authority, but may or may not be the leader. They conclude support from organizational authorities is a necessary, but not sufficient criterion for success, which depends mostly on informal leaders.
In collaboratives, changes in practice and adherence to measurement criteria are often led by staff who exhibit strong informal leadership traits. Such individuals share knowledge, (“expert power”) and build consensus (“coercive power”), even though they are not in a job position that provides them with formal authority.
Clearly one of our problems in replicating success has been the difficulty those with positional authority have dealing with the power of the informal leader. Informal leadership is difficult to control and may be difficult to direct, but as the authors point out, if everyone is “sold” on the value of the project, there is no need to control. In our effort to reduce central line infections, those with management authority were motivated by the statewide reporting of the data, and the physician champion was supported by the CMO and the Medical Executive Committee in a rare display of its authority. Working with nursing management, resources were diverted, processes were changed, success was praised, and failure was analyzed, with results similar to that reported from the Keystone Project. Recently, though, the coordinators, who were one of the keys to success, reported they are tired of being viewed as the “bad cops” by the regular ward nurses. This suggests the safety culture has been degraded, at least to the extent the perception reflects “us against them.”
Get both the technical and adaptive work right
The authors define technical problems are those that can be clearly defined and most often have existing solutions, often known to the expert. They acknowledge, though, that technical work may be quite difficult. From the examples given, it is clear that the ideas are simple and the details are complex. In contrast, in adaptive work, the ideas are difficult and the details are usually not complex.
Adaptive challenges are often difficult to clearly identify. Yet the ability to pinpoint and manage these challenges is critical to the success of any improvement initiative. Adaptive work (context) involves changing hearts, minds, and behaviors, and typically takes longer than technical work, since it generates dysequilibrium in existing systems. Individuals who care deeply, but may not have formal authority to mandate change are often the champions of adaptive work. Adaptive challenges share several properties…The people with the problem are the problem as well as the solution. Problem-solving authority must shift from authoritative experts to those required to change their hearts, minds, or behaviors for resolution to occur.
Life is not an experiment
The authors list several lessons, which I have lumped under this heading. First, they recommend aiming for the sweet spot between that which is scientifically valid, and that which is operationally attainable. This was not a problem on our effort to reduce central line infections, but I have seen this commonly in the dialysis unit setting. The medical directors I work with include a significant number who are clinical scientists, and they often have difficulty distinguishing between a clinical study and routine clinical operations.
They recommend matching project goals, objectives, and database design at the outset, and also recommend aiming for high quality, rather than high quantity data. One problem we have encountered is the difficulty in either modifying existing databases, or creating new ones to keep focus on the project. One key to sustaining success is to make collection of the monitoring data easy and “the way we do things here” rather than a special study, soon forgotten.
They point out the dangers of “just doing it,” as the effort may not lead to measurable improvement. Likewise, they recommend trying to minimize the bias in data collection. If the metrics are not clearly defined and measured in a standardized way, there is a tendency to see improvement, where what is really changing is the observer’s perception, often influenced by knowledge that an intervention is underway.
Staying focused on the goal is difficult, both in terms of data, and in terms of the individuals and teams trying to make the necessary changes. Discouragement will occur, and progress will “stall.” When conflict occurs, as it will, there is a need to get back to the patient, or what they termed a “laser sharp” focus. They also used a variety of written forms, checklists, and tools to facilitate effective, patient-centered communication.
They point out, though, that there may be conflict between physicians and nurses, as when a checklist is used. The nurse keeping the list may have to call a halt to the procedure if a step has been skipped. In essence, the nurse has to tell the doctor what to do or not to do, as opposed to the usual circumstance which runs the other way. In our case, the lines are most commonly placed in the radiology department by the same group of physicians. Since the physicians know the checklist, and are committed to its importance, they see the nurse as simply a reminder, which allows the interaction to be stripped of any resemblance to a power struggle. The nurse is not telling the doctor what to do so much as she/he is reminding the doctor he/she did not do what she had intended.
Resources are too scarce and the need to improve is too great to support quality improvement activities that are inefficient or ineffective. Project coordinators should strive to make certain that frontline wisdom is respected and reflected in the work; that resources needed to conduct the work are part of leadership’s commitment to participate, a commitment that must be honored; and that the impact of each intervention is measured in a manner that will allow the industry to understand whether clinical outcomes improved and whether patients are safer because of our efforts.
I stated earlier that we have had difficult extrapolating from our success reducing central line infection rates to other projects, but have perhaps not been clear as to why. I think the central problem has been the difficulty separating the technical from the adaptive work. We had the technical solution to the problem available—we had the Keystone Project tools and processes available, and had a willingness to use them. However, we did not appreciate all of the adaptive changes necessary. We relied on our expert, perhaps too much, to provide the formal leadership and guidance, and did not systematically cultivate informal leaders amongst the cadre of bedside nurses. Since most of the adaptive work has to be done at the bedside, this was a serious failure, and limits our ability to both sustain success and to translate our success to other initiatives. We had an institutional preference for the technical and an aversion to the adaptive as too vague and too “touchy-feely.”
We have also been averse to investing informal leaders with authority. Those with authority tend to become anxious with a perceived “loss of control” when the prospect of letting the informal leaders loose arises. What is overlooked, of course, is the fact that all organizations at all times have informal leaders. As I tell my nurse managers, if they do not lead and do not choose to reward the informal leaders who are committed to the organizations goals, they will indeed lose control of the unit to the most negative and resistant personality on the shift. The issue is not to withhold power, it is to distribute it effectively.
Physicians have the same issue—they need to understand the need to cede some authority to the nurse at the bedside. Many become anxious at the thought without ever considering that the nurse is the one who makes most of the initial observations, and in the ICU setting, the accuracy of her assessments and her ability to initiate standard orders is often the key to success. (See discussion about Opting In versus Opting Out strategies.) A smart physician will recognize the value of empowering the well trained nurse to be his “physician extender” for the time needed to solve a patient’s problem. The flip side, naturally, is the nurse has to be willing to “stick her neck out” and volunteer an opinion. I think too many of our physicians and nurses are trying to stick with the usual roles, and too many of those with positional authority are not willing to back the nurse, who is employed by the organization, when the doctor won’t go along.
Can we change? Of course. The real question is what is the motivating force needed to overcome the normal resistance of individuals and the natural elastic recoil of organizations that revert to the “usual and customary” way of doing things as soon as the project is over. I do not think these issues and questions are peculiar to my hospital or to my colleagues. In the end, then, the important question is not can you change, but will you?
31 July 2014
 Pronovost PJ , Berenholtz SM, Goeschel C, Thom I, Watson SR, Holzmueller CG, Lyon JS, Lubomski LH,Thompson DA, Needham D, Hyzy R, Welsh R, Roth G, Bander J, Morlock L, Sexton JB. Improving Patient Safety in Intensive Care Units in Michigan. J Crit Care 2008;207-21. doi: 10.1016/jcrc.2007.09.002.
 Goeschel CA, Pronovost PJ. Harnessing the Potential of Health Care Collaboratives: Lessons From the Keystone ICU Project. In Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol.2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug. Accessed 27 July 2014 at http://www.ncbi.nlm.nih.gov/books/NBK43708/?report=printable.
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