“Being the best at getting better” is the focus at Cincinnati Children’s Hospital Medical Center. “It matched our recognition that we were not doing as well as we thought we were doing when we began to actually look at the information,” says Uma Kotagal, Senior Vice President for Safety, Quality, and Transformation at Cincinnati Children’s. “If we are not the best, we can certainly be the best at getting better, and then we will be the best.”
Kotagal sat down with Amy Compton-Phillips, Executive Vice President and Chief Clinical Officer for Providence St. Joseph Health and Lead Advisor for the NEJM Catalyst Care Redesign theme, to discuss how Cincinnati Children’s created a culture that focuses on delivering broad-based change at pace and at scale, rather than one change at a time. “This idea of being transformational, aspirational for children and their families, was part of the beginning,” says Kotagal. “I would say our culture is collaborative, it is optimistic, it is transparent, it is aspirational, it is patient centered, and it is scientific.” Read or listen to the interview below.
Amy Compton-Phillips: This is Amy Compton-Phillips with NEJM Catalyst, and I’m here today with Dr. Uma Kotagal, who is from the Cincinnati Children’s Hospital, [where she] spent many years as the leader for Quality and Transformation, as well as the Director of Health Policy and Clinical Effectiveness, and was elected to the Institute of Medicine in 2009.
Uma, I’d love to have a conversation about how you created this culture at Cincinnati Children’s where you really focused on being the best at getting better. You didn’t focus on how to deal with change, one change at a time, but you actually worked to make the entire organization focus on delivering broad-based change at pace and at scale. So what can you tell us about the culture at Cincinnati Children’s, and how you made that happen?
Dr. Uma Kotagal: Amy, thanks so much for the opportunity to chat with you about the work at Cincinnati Children’s. I would start with the statement: being the best at getting better. That was coined by Lee Carter, our former Chairman of the Board, and it matched our recognition that we were not doing as well as we thought we were doing when we began to actually look at the information. Lee said, “Well, if we are not the best, we can certainly be the best at getting better, and then we will be the best.”
So this idea of being transformational, aspirational for children and their families, was part of the beginning. I think I would describe the culture at Cincinnati Children’s first. We are a pediatric institution and that brings a whole lot of smiles. We’re working with children who are always teaching us, so I would say our culture is collaborative, it is optimistic, it is transparent, it is aspirational, it’s patient centered, and it is scientific. We are an academic medical center; we spend a substantial portion of our effort trying to generate new knowledge that transforms outcomes for children.
Compton-Phillips: That’s great, and what did you do to create that culture, because at least in visits that I’ve had there, people don’t live in fear of the next new initiative, they embrace change and they’re constantly seeking ways to improve. So how did you create that? What did you put in place to make it happen?
Kotagal: When you look back, it’s interesting what has happened, and telling the story is important. I think we began with agreeing that we could do better. That was a big deal between the Board, the senior leadership, the research leaders, that we were not doing as well as we could, and that really came from our work in cystic fibrosis where we found, as we looked at the data, that we were not in the top third of the country as we thought we were, but we were kind of in the middle to lower third.
That really shook us because it was the first time we had looked at data that had been available for a long time, but looked at it very openly. We began to use patient stories and videos. We made a video in which the parents of the children with cystic fibrosis told us how bad it was and what their perspective was, and we cried in the beginning when we saw these videos because they were this dissonant with our view of how great we were. But that really gave us the impetus to move forward.
We agreed that transparency caused trust and vice versa, and we agreed that patients needed to be at the table. That setting of “no, we’re not the good, we could be the best at getting better, let’s use the patients and stories and let the patients be at the table to help us” moved us I think . . . it was hard, but it moved us from many small, small, small projects to really thinking about, what is the big thing we’re going to do?
We also agreed that we would fail sometimes but that was okay, and that was part of the transparency part. So we could say to the Board, “We tried these three things and it didn’t work, or our numbers haven’t changed,” and the Board responded by saying, “We’re there, it’s okay, keep going.” So there was no fear when we had the transparency happen.
We also agreed that action was needed and that we should be really acting instead of discussing and talking and talking. And the quote that Jim Anderson, our CEO at that time, would use was to “Get started before we were ready.” So not to wait until it was perfect and then say, “Okay, we’ll get ready now.”
One of the important things we did in consultation with the Institute for Healthcare Improvement was to start on a set of system-level measures. This was an important way to focus us on the whole system transformation. We had about 100 people in the room, parents, some kids that were in college that had been our patients, and they told us what was wrong with the system. And out of that we crafted a set of domains and a set of measures to be able to say, “These are the big dots that we were going to move.” And as you expect, those were whole system measures in the areas of safety and flow and outcomes, and patients’ experience in engagement and things like that.
So we’ve been working off of that big-dot approach for now a long time, and under that big dot a whole portfolio of projects that enable you to move the big dot. It’s a little different from having a lot of projects and hoping that moves the big dot, if you will, so that’s a difference in our approach.
We also agreed that the signs of improvement were critical for this work to be accepted because most people in our organization were interested in generating new knowledge, but [were] not necessarily passionate about reliably accepting that knowledge, and in that pursuit of science, whether it was improvement science or reliability science, or the science of the diffusion of innovation, we could see that most of the answers to what we wanted were in the science, but it was in how we applied it that made a difference. So we focused on that.
We focused on patient/physician partnerships right from the beginning, but we also focused on physician/nurse partnerships — putting nurses and physicians on equal footing in these improvement teams, whether they were microsystem, mesosystem, or big-dot teams, and that allowed the culture of the organization to change, and that brought an enthusiasm and teamwork at a level that was really very, very important.
We also agreed that the pursuit of perfection was critical, especially in areas like safety — that even having one child harmed was not good enough. That led us to much more robust designs — that incremental change — and then we worked a lot on alignment between the micro, macro, and mesosystems, creating transitional structures that enabled us to work together across the system right from the beginning, versus waiting to create them toward the end, sort of as a sustainability plan. We said, “Let’s get started,” and then we didn’t know [what] that would look like 10 years later, but we thought it was a temporary structure, people were comfortable with it, and we used that. I would say a big difference in our work is this big-dot focus on outcomes versus focus on activity.
So a whole lot of stuff, but starting with system-level measures, starting with transparency, agreeing relentlessly that we would focus on outcomes, and having patients and families tell us when we were not good enough.
Compton-Phillips: That’s a great summary. I love the fact that you engaged patients up front. I love the fact that you engaged all of the people providing care in your system together in improvement. It has to make a big difference. I wonder if you could just say a very quick word — because I’m not 100 percent certain everybody knows the terms micro and meso and macro systems — just on what you mean by those levels?
Kotagal: I think what we had when we started was a lot of people doing a lot of work, no data, no results, but everybody happy that they were working hard. Alignment was a big issue for us in the beginning, and capability building was a big issue. We had no knowledge of improvement at all. We were basically researchers, we didn’t know how to change systems of care. We had worked at it and failed a few times, so we created a temporary structure that brought together inpatient, outpatient, periop, home health, and emergency departments that we called our mesosystems, with a physician/nursing lead.
The physician lead was the improvement lead, the nursing lead was the operational leader, and under each of these mesosystems, like inpatient, there might be 30 inpatient units under those, and those would be our microsystems. And we worked on those microsystems, identifying physician improvement leaders, and the nursing director would be the operational leader, and build those partnerships.
So when we had our system-level measures, we could then spend a lot of time back and forth between what I think the Dartmouth folks call catch ball. Okay, this is a system-level goal, are you aligned with this goal? How are you going to work on the goal? Do you have the tools you need? Do you have the resources you need? Do you have the data you need, and do you have the capacity to do the work?
At the big system level, we brought together the leaders of these five areas, which were operationally across the system, with members of the senior leadership team, into a clinical system integrating steering teams that then prioritized and focused and made sure that we were taking the big dots down to the lowest level of the work, but also that we were working across, since the patient journey is not just in the microsystem — we have to work across those boundaries. And having this temporary structure and building this capacity at the same time built this coalition of people who were ready and excited to do this work, but also allowed them to reach out to each other to support it, and allowed us to align our dashboards and metrics from the system-level measures down to the front line.
That clinical structure’s now morphed into its more final structure, which is now called Operational Excellence, so that we are really building integration of improvement in operations but we’re not losing the gains made in improvement because we didn’t build explicit operations. And so that structure was a series of huddles and escalations and so on, and [we] really then hardwired all of the improvement work and the reliability work into a rhythm of daily, weekly, monthly processes and come togethers, if you will, so that people can quickly respond and not allow degradation to happen.
Compton-Phillips: Which is great. Thank you so much for that. And as I think about [it] — because it sounds like an incredibly robust infrastructure that you’ve put together that’s now been able to be sustainable over many years — everything you do means there’s an opportunity cost, so there are some things you could not do. Are there any things that we should be thinking about to avoid if you want to create such a robust learning infrastructure?
Kotagal: I would say some things we did well and I should say some things we didn’t do well. I think what we did well was to sequence the dots that we started with so that not every big dot was activated at the same time, and then to understand that the microsystem of all those big dots came together. The relationship between flow and patient safety, you know — is the location of the patient in the right unit? Is the patient not waiting for an OR because our OR systems are not there?
So we began to try to draw this picture for people of the relationship between safety and flow, between patient experience safety and flow, so that people didn’t see these in silos. That work has been incredibly hard and I would not say that it is over. It’s kind of really hard.
The other thing we didn’t do which we should have done, maybe, and I think we’re going back to it, is we didn’t begin with leaning our processes. And I know some people started that place, which frees up capacity, and that’s something in retrospect that I would think about.
I think what we continue to struggle with, like many organizations, is despite prioritization, alignment, big dots, et cetera, cultures keep getting modified and based on transitions and so on, and so we always have to keep pruning. And it’s amazing how many projects start out that we have to keep pruning. They’re all well intentioned, they all start from a good place: “Hey, here’s a problem, let me solve it.” So I would say that what would keep us [up] at night is this proliferation of ideas, all of which seem good, but how do we keep the discipline of work? And I would give ourselves a decent grade for it, but I think it’s a work in progress.
Compton-Phillips: It must be hard to continue to focus on innovation while pruning at the same time, but it seems like it’s the only way you help create the healthy infrastructure, doesn’t it?
Kotagal: I think that you said it really, really well. Everybody at Cincinnati Children’s wants to innovate. Everybody has a better idea. You don’t want to squash that, but at the same time you don’t want a thousand flowers blooming that can’t come together. And I think that is the role of leadership; it is a continuous process and it requires the senior leadership to be focused and perfectly aligned. We use our five-year strategic plans to really get very good clarity on it, and we’ve gotten better and better at it in the last couple cycles.
Compton-Phillips: Great. Actually that might help answer the next question that I had for you, which is: [there are] huge changes right now in the health care landscape across the U.S. How do you think that this work that you’ve been doing, really for almost the past 20 years, will help Cincinnati Children’s be prepared and ready to lead into this new environment that we have?
Kotagal: I think we are not as prepared as other organizations like Kaiser and other big systems have been, because we have the simultaneous issue of being the community hospital and being the coordinary hospital. The majority of our hospitalizations come from children outside our secondary service area. So we have to do both because our focus on research and generating new knowledge and breakthroughs for children with rare diseases is as important as our focus on community health.
So we’ve been pivoting toward that, I would say in the last four to five years more seriously, and I think the capability building that we have is what’s helped us there: our ability to identify what the right measures are, our ability to take that capacity in the community through patient-centered medical homes, coalitions that we’re building with primary care practices. We have a physician hospital network that needs to get better aligned and is getting better aligned on this big system level–work.
So I would say on a technical level we are quite prepared for it. On a will building level, we are working our way to that. And we are excited because the state of Ohio is moving fast, and that requires us to move fast as well. So in some ways leveraging the market and leveraging what we see coming, and using that as a cause to action just like we did in 2002 — using the CF video to say we’re not doing better, we could do better — is important. So there’s a lot of stuff to pay attention to in the space of being the tertiary and the primary care site.
We have been working in the community space now for about three to four years running a lot of prototypes and understanding what it would take to work in the space. In about a few weeks, June 14, we will launch our All Children Thrive network, which will bring together a focus on the 66 thousand children in the city of Cincinnati, many of whom live in poverty.
Compton-Phillips: I think that shows transparency in action there, Uma. I thought you were going to say we’re completely ready because we’ve been doing this forever, so it’s you practice what you preach.
Kotagal: No. Just scrambling, just learning.
Compton-Phillips: That’s great. It actually does help remind us that better has no limit, and that we all have capacity to continue to improve. But one last question — and you started actually going down this path and I was thinking it was going to be from left field, but it really is the direction you all are thinking — is how do you think that hospitals and health care systems can help participate in creating healthier communities around our areas? It’s not how we were traditionally paid but it’s certainly an area that we all want to move into. So what advice do you have for those of us who are trying to take what has been traditionally a health care system to move into generating health?
Kotagal: I think I would say the same things: the will, ideas, and execution — that is the IHI framework — that evolved from a lot of this work is important. So recognizing that the tertiary coordinary Children’s Hospital also has responsibility for the health of the children in the community would be step one. Recognizing that by ourselves, we are not going to improve the health of children. Especially for children, the contribution of health care to health is relatively small. And for children, we run out of time.
So for me as a pediatrician who used to take care of newborns, I have this kind of burning sense of worry and urgency because we know that if by age four or five children are not on the right trajectory, the work to get them on the right trajectory is much harder. We also know that children in the communities they live in are a much bigger contributor to all of this than health care. So we have begun the community health pillar, it’s a very strong pillar in our strategic plan. We have set ourselves four goals, including metrics around reduction of disparity. We are connecting to key partners in the neighborhood, primary care, school-based health centers, the health department, Place Matters from United Way, the Cincinnati Public Schools. I think being a catalyst again for change for communities, but being a humble catalyst — understanding that the big 100-pound gorilla of health care coming in the community is not the right way to go.
We’re encouraged by our early conversations and that coming together to help all children thrive is a call to action in which we can play a role, but not the leading role — in which there is a place at the table for everybody. So we just started on that journey. We know it will take much longer than the work that we did in the previous 15 years, but we, as Jim Anderson would say, have to get started before we’re ready, in order to change the life [of] children.
Compton-Phillips: You’ve given us food for thought, Uma. Thank you so much for the time. Is there any last thought you want to leave us with today?
Kotagal: I would say that my hope is that everybody focuses on children and helping them thrive as a singular component of shaping the future for this country.
Compton-Phillips: As a parent and a clinician, I couldn’t agree more. Thank you so much for your time, really appreciate it and look forward to conversations again in the future.
Kotagal: Thank you, Amy, for the opportunity to chat this morning.
This interview originally appeared in NEJM Catalyst on June 1, 2016.