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H&HN Daily

Patient-Centered Leadership and Front-line Quality Improvement

06.28.12 by Maulik Joshi

HRET President Maulik Joshi talks with Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement, about patient-centered leadership, ways to improve health care, and experiences that have shaped her ideas on quality and patient and family engagement.

Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement, advises health care leaders around the world. She is an elected member of the Institute of Medicine and serves on the Commonwealth Fund's Commission on a High Performance Health System. Bisognano is also an instructor of medicine at Harvard Medical School and research associate in social medicine and health inequalities at Brigham and Women's Hospital in Boston. She serves on the boards of the Commonwealth Fund, the ThedaCare Center for Healthcare Value and the Mayo Clinic Health System, Eau Claire, Wis. Bisognano began her career in health care as a nurse at Quincy [Mass.] Hospital, holding positions of increasing responsibility there, including chief operating officer.

Bisognano is the 2012 recipient of the TRUST Award from the Health Research & Educational Trust, an AHA affiliate. She will receive the award July 19 in San Francisco during the Health Forum–AHA Leadership Summit.

Joshi: Patient-centered care is a team sport these days with patients, providers and the public. What role does leadership play in fostering the culture to embrace patient-centeredness?

Bisognano: Having the wonderful opportunity to visit many hospitals and health care centers around the world, I see a vast difference between what I would call patient-centered leadership and patient-satisfaction leadership. At some organizations, leaders focus on measuring patient satisfaction, and when I'm making rounds on floors and talking to front-line staff, the culture is about compliance. At organizations with leaders who truly demonstrate that the patient's voice is more important than anything else, you see a very different culture. It's everything from having a welcoming spirit or a respectful conversation to anticipating and seeking patients' wishes before orders are carried out. In these organizations, I see patients sitting on councils or committees for physical plant design and the like. This culture carries down to the front line with doctors and nurses who offer patients a choice about medications or treatment before they're automatically carried out.

Joshi: You are a strong advocate for engaging and including patients. What professional and other experiences influenced you and contributed to the passion and dedication to your work?

Bisognano: In part, it's been my own experiences in my family and as a caregiver. I started my career as a labor coach. In those days, I cared for many women whose husbands didn't have the choice to be in the labor room. I watched different women's voices being heard or not heard depending on the caregiving setting. That influenced my sense of how the birth experience should be redesigned by the family.

In my own family, several experiences influenced me directly. I'm the eldest of nine children, and my nephew Robby was the eldest grandchild. Robby was a healthy child until his two-month physical. When he received the DPT vaccination, he had a terrible allergic reaction, was in the intensive care unit for a week and almost died. He recovered and regained his strength and vitality. Then when he was four months old, my sister took him for his next check-up. The doctor said Robby was in great health and would get the next booster vaccination and DPT. My sister said, "Don't you remember what happened last time?" The doctor asked what had happened and my sister told him. The doctor thought about it for a while and said [the adverse reaction] had nothing to do with Robby getting sick. He said he would give Robby half a dose, which he did, and Robby died within 24 hours.

My sister asked me questions that shaped my career: Why didn't the doctor have the record from the hospital connected with the record from the office? Why does the hospital keep its records separately? It's the same patient; why isn't information shared across the system? Why did the doctor not know that half a dose was likely as dangerous as a full dose? Basically, that was an evidence-based question. My sister also asked why the doctor didn't listen to her. She did not think her voice would override the doctor's professional opinion, but there is nothing stronger than a mother's voice. If the doctor had listened to my sister, I think her son, my nephew, would be alive today. My sister's questions shaped my approach to thinking about quality and the strong voice every patient needs to achieve his or her life's wishes.

Joshi: What is distinguishing high-performing health care organizations today? With all your work — at IHI nationally, and globally with the Commonwealth Fund — what are your insights?

Bisognano: On one hand, I'm encouraged by the leadership that high-performing health systems are showing. I serve on the board of the Commonwealth Fund and its Commission on a High Performance Health System, and we're unveiling a new report about where we've seen progress in the last decade in U.S. hospitals and where we haven't. I'm encouraged because leadership in high-performing health systems has dived deeply into issues like safety, access, patient engagement and partnership. If you look at all the scorecard results, the areas of focus on high performance, like safety and access, are improving pretty rapidly. But we still are spending almost $2.8 trillion in health care in the United States each year. About 75 percent or more of that is spent on chronic disease management, and those metrics are not improving.

But I am heartened by the fact that when a small group of health care leaders decide to make an improvement in safety, they can. Many hospitals now can go for long periods without a ventilator-associated pneumonia or central line infection. That started with a few leaders being powerfully committed to high reliability, and their work is driving change across the country. We need to exhibit the same kind of high reliability across the system, outside of the doors, before hospitalization and after.

Joshi: What do you think organizations like IHI, HRET and others should do or do more of to help spread some of this work?

Bisognano: Organizations like ours have the opportunity to visit exemplary organizations and see how good care can be. In part, our role is building will by showing the gaps between the best and average performance, telling stories of how leaders model change, and giving people both the data and stories that will give them energy and courage to make changes. The second area is ideas. Many organizations that have mediocre performance are not using the latest change packages or haven't seen the kinds of changes that are so powerful in reducing complications and producing high reliability. It is will, ideas and then execution.

Joshi: Building on that, what do you see as important lessons and advice for building improvement capability today in health care?

Bisognano: Organizations take different approaches. Some use a kind of specialist approach with a small cadre of experts who are deeply trained in improvement methods like statistical process control, Plan-Do-Study-Act methods, Lean or Six Sigma. Those improvement experts are deployed as needed to various units to help front-line staff make changes. Perhaps an even more powerful model is when clinical microsystem staff connect with the leadership teams and learn and spread improvement skills more broadly across the hospital.

When I visit hospitals and have the opportunity to join with clinicians and leaders making rounds, I'll stop by units or departments and ask the unit manager or head of pharmacy, "What are you improving this week?" Some managers will say they are not on a team currently. In other words, quality is still siloed as a function, or a department. They'll get called upon at some point, perhaps to improve a metric. But I'm very excited when I ask that question and the manager pulls out a roster of projects that the front-line staff is working on every single day. People are huddling and talking about what "plan, do, study, act" cycles they can write: How can we improve medication management? How can we improve flow? How can we decrease delays in accessing care? When you observe that kind of capability at the front line, you'll see dramatic improvements in quality across the system.

Maulik Joshi, Dr.P.H., is the president of HRET and senior vice president for research at the American Hospital Association. He is also a member of Speakers Express.

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