CASE STUDY
Healthcare System Increases Patient Safety and System Integration
Challenge
A complex, ten-hospital, multi-clinic healthcare system was committed to improving its Patient Safety record, inspired by the Institute for Healthcare Improvement’s “100,000 Lives” Campaign. The challenges were that each facility was accustomed to doing its own thing, with little integration or collaboration among them, no accountability for reporting specific safety issues, and little if any sharing of best practices.
The senior leaders knew that to become a more efficient and collaborative system – and improve Patient Safety – they had to up-level their clinical protocols in a well-orchestrated system-wide fashion. They had to make it both expected and safe for physicians and nurses to openly discuss adverse patient events and transform key areas of practice. They did not have the systems, behavior, culture, or mindset required, and had no track record for making a system-wide transformation.
Solution
Being First designed a strategy and guiding principles in collaboration with the HR executive, senior physician and nursing leaders, and the internal Organization Development practitioners. A key strategy was to staff a change leadership and project structure that represented all ten hospitals and major clinics. They created a Campaign Leadership Team, selected Campaign champions and teams for each of the regional hospitals, and established six initiative teams for the six practices they were implementing.
Guided by Being First’s Change Leader’s Roadmap Methodology, the leaders created inspiring principles to shape the effort, determined their priority initiatives to meet the “100,000 Lives” campaign requirements, and used their network of Campaign champions and initiative teams to create an engaging approach. This included lots of cross-boundary dialogue to orchestrate the tailoring, training, piloting, implementation and reporting strategies for all sites.
Once launched, Being First coached the Campaign Leadership Team and champions throughout the following year to support their implementation.
Once the leaders shifted their thinking from “cover up and embarrassment” to “do what’s best for patients and the system,” they modeled this new mindset for their management ranks and workforce. In addition, their guiding principles became major forces influencing the transformation of their culture and behavior.
Results
- Reduced Adverse Events – Implementation of the safety practices across the entire system was successful, with a significant reduction of adverse safety incidents over each of the next several years.
- New Best Practices, e.g., a monthly system-wide conference call on Patient Safety, on which the leaders reported challenging incidents and collectively explored how to address them and improve their practices further.
- Increased speed – faster implementation even while engaging more people than usual.
- Lower cost - they reduced resource requirements and duplication of effort.
- Acceleration of System Integration -- Due to the shift of mindset, behavior and culture, the leaders realized they could collaborate to successfully implement enterprise transformations.
- Increased buy-in – they achieved deeper and faster buy-in across the entire system due to the enthusiastic support of their Campaign champions.
- Increased change leadership capability – they succeeded magnificently while also providing developmental opportunities for their leaders.
- Their next wave of change – process integration - went even better.
