When Nick Restrepo, MD, Vice President of Medical Affairs for Winchester Medical Center in Virginia, tapped funds to take colleagues to the annual IHI Forum for shared learning and to build collective commitment to better patient care, he fundamentally changed prevailing attitudes toward safety and quality and launched an innovative approach to building leadership capacity.
Mary Jane Kornacki: I’m here at the IHI Conference in Orlando, Florida, the 28th Annual Forum. I’m speaking with Dr. Nick Restrepo and Dr. Howard Green. Howard Green is the Chief of Anesthesiology at Winchester Medical Center and Nick Restrepo is the VPMA at Winchester Medical Center.
I understand that there a number of people here from your organization and that you have a process whereby you gather in the evening and you review what you’ve learned throughout the day. Why do you do that?
Nick Restrepo: I first came into this job 6 years ago, and one of the recommendations made by other medical executive leaders throughout our organization — throughout the country — was the value of the IHI Forum. When I came the first time, I only brought a couple other people. We came basically to see what it was like and to see what the meeting had to offer, and we realized the tremendous amount of potential in terms of leadership development for physicians and coming to understand the need for and the process by which one migrates toward a high-reliability organization.
Our organization was fortunate enough to have money left by a physician who had passed away dedicated and earmarked toward physician medical leadership development. I have taken that money that comes under my direction with our foundation and used the earnings of that money each year to fund bringing physicians, physician leaders in particular, to the IHI. We’ve grown from a small group of four or five to this year, we have a total group of 22, about 18 of whom are physician leaders in our organization, and it’s all funded through the generosity of one of our late ER physicians.
It has been a key vehicle in team development and physicians getting to know each other outside the workplace, coming here and having a common experience and also establishing common goals and understanding the manner in which one can achieve those goals collectively.
One of my beliefs is that if you come to a conference like this, you have a responsibility to make value of the conference. And there has to be a return on investment, for a lack of a better term, and the best way to do that is to share what you learn. We’ve used a variety of formats, and what we typically do each evening after the day is have a little bit of time for exercise and then we gather for a debriefing. The debriefing is structured primarily around what did you learn today that we could take back that would help us move the organization forward, this year with regard to harm and engagement.
Regarding harm, everybody’s asked to include the normal things you think about and also include things like readmissions and other forms of harm, mortality or preventable deaths and hospital-acquired infections, etc., as well as engagement focusing on physician engagement, nursing and other staff engagement, building from that for patient engagement.
We have a discussion each evening with flip charts, and we write down those things we learn that we can then take back and implement as an organization. We have a follow-up meeting when we get back, and then people develop projects that over the course of the year are performed to improve the organization, to help us move forward.
Howard Green: Nick is leaving an awful lot out here, which he won’t say about himself, but I will. Six years ago, nobody at our hospital was talking safety or quality. Absolutely nobody. I knew nothing of it. The first year Nick came to this thing, he’s told me more than once, he came back to Winchester very discouraged because he recognized what we were up against and how little structure, little framework [we had]. Essentially, he was all alone, and so Nick really single-handedly determined to do something about that. So now here we are 6 years later and everything has changed.
He’s built this cadre of physicians and administrators who are all on the same page about where we’re going, what we’re trying to accomplish, and we have made enormous accomplishments in 6 years. I could go on and on and on about the number of safety initiatives Nick has instituted at our hospital. The single piece of evidence to me that is most striking is that our serious safety event rate has decreased month over month for 2 years. That’s not subjective. That’s an objective measure of where we’ve come, and it’s because of Nick having the vision.
Another thing: That money was just sitting there untouched for many years, and it was Nick who realized we could make really good use of that. The physician who left that money, I think he would be very pleased to see how we’re using it today.
Kornacki: Nick, you came to the [IHI] meeting, but was there a moment when you thought, “We have to do this differently, and I have to get more people here”?
Restrepo: Yes. Let me just backtrack a touch. I had been in practice in the community for 15-1/2 years, and I, like every other physician there, believed we were in a pretty good place, and I continue to believe we were in a good place. But I didn’t realize just how much better we could be, and so the lightbulb that went off was that when you come to meetings like this, or other sorts of medical meetings or health care improvement meetings, you see what could be, and you become less satisfied with what you are at that point in time and realize that if you grow things you have the ability to do better for your patients, your community, the clinicians who are caring for the patients.
Probably the one talk that moved me the most was a talk by Dr. Gary Yates and Dr. Mark Chassin here in terms of high reliability. At that point, 6 years ago, for me it was the first time I heard about it, but it was some of their earlier work. They continue to give a version of that talk with some slightly different presenters. The ability and the need for creating reliable systems in health care as a responsibility to the patients and the staff — because there’s a lot of trauma that takes place for the staff when they’re involved in an adverse health care event — that struck me. I don’t know if I was all alone when I got back, but I certainly did not have the partners that I currently have with the physician engagement.
Where they’re moving the organization forward at this point is a sustainable model. If I were to leave and go to some other place or just disappear, the critical mass of leaders is there so that this is going to live on. I think that has been a very important gift that this meeting and Dr. Gephardt’s donation has resulted in for our community really ongoing.
Kornacki: [Howard], if Nick has shown any leadership, how does his leadership show up?
Green: One of the keynote speakers this morning was an astronaut who started and ended his talk with an important thing he’s learned: that small, positive changes are what create sustainable change. That’s exactly what Nick does. All of the safety and quality initiatives that he has begun and we’ve begun, he is constantly tweaking, constantly looking at and saying, “Okay, how are we going to make this thing better?” And we’ve all come to expect that. And Nick never gets depressed, never gets discouraged, at least not that I’ve ever seen.
The astronaut also said — and Nick has also said this to me — “You have to work on the things you can control, fix the things you can control, and don’t worry about the rest until you are able to, until they become changeable.” That’s what he brings, that energy and enthusiasm, to all of us, and it just shows.
Restrepo: One of the things that I have learned — and I appreciate Howard’s compliments — but one of the things I’ve learned by having made mistakes is the importance of involving the people who are actually doing the work to make the changes. I make little tweaks here and there, but most of these are basically informed by the individual who is actually doing the work. So the references [Howard] makes around the safety programs and the different initiatives we’ve done, as a medical leader you have to very much embrace deference to expertise and have the people actually doing the work be the drivers of what you end up doing.
I’ve learned over the past several years through failures that then you go back and you reflect upon why did that not work. If you come up with a great idea and then say, “Hey, do this,” your likelihood of success is exponentially lower than if that idea comes from the people actually on the front line.
Our safety program and all of this is very much informed by and guided by our charge nurses, our shift leaders, from security to environmental services to the lab, and they give feedback and help shape what we’re doing collectively. The important thing that I help do is set a vision and then help somewhat control the tension in the organization relative to those initiatives. If the tension is getting a little bit too low, I’ll do things trying to increase the tension and the urgency. If it’s getting a little bit too high, I try ratcheting the tension down.
I’m very fortunate to currently have a great chief nursing officer at the hospital and a great president of the hospital who help me in measuring those tensions and identifying when it is that we have to move in one direction or another in order to continue moving forward in a healthy manner.
One of the things that I learned through this meeting, and other meetings, especially in dealing with high reliability and other initiatives that organizations have implemented, was to do a daily safety call. A lot of places call it a daily check-in. Ours is a little bit different. Rather than in person, it’s done by telephone. And rather than directors, it’s charge nurses or what we call a charge nurse equivalent for non-nursing units.
It initially started as a 5-day-a-week, 10 a.m. check-in looking back over the past 24 hours’ issues relating to safety that needed to be reported, looking forward in anticipating potential issues, and then follow-up on prior issues reported. When we launched this, we said we were only going to go 5 days a week because we don’t have the same resources all weekend. But the staff very clearly within months said, “No, this is wrong, you have to do this on the weekends.” So 6 months later, we’ve launched it 7 days a week, including the weekends. About a year and a half ago, we went to twice a day, 10 a.m. and 10 p.m.
I host the daytime phone calls during the week, but on the weekends and now on the nights, I have a physician sponsor on each one of the calls. They’re all physicians who come with us to the IHI and have a common understanding of the culture of safety and high reliability and the need to address certain issues in a professional, mindful way. That’s the origin and the history of the call.
Green: It’s been my great privilege to be one of those physician sponsors at night. One of the things that I have grown to see as a strength of the safety call is that it has given the charge nurses a platform. They identify patients of focus. No one is telling them who the patients of focus are. It is coming straight from the nurses, straight from the charge nurses. They escalate those patients of focus to the safety call, and it has allowed them to have a platform to question the plan around a patient. It’s given them the ability and the tools to escalate care — how do we escalate care — all of which is to prevent, and is going a long way to prevent, failures, to plan for failures, to diagnose.
Fairly often [the question] will come up, “Who is really taking care of this patient?” Sometimes on the safety call you realize no one is, and so it’s given [the nurses] a tool to speak up, but more than that, role clarity. “What one physician is responsible for this patient, and do you, charge nurse, have a clear understanding of the plan? Is there a plan?” It’s given them a platform for that.
Kornacki: You said earlier that the safety calls are not all negative. You’re also asked to report on positive things.
Green: The safety call can become relentlessly negative, that this or that bad thing is happening, so Nick will occasionally tweak it. For instance, we occasionally will have Good News Friday, when everyone reporting also needs to give a piece of good news, and that’s been really well received. It’s given the charge nurses a chance to sing the praises of their hardworking and dedicated nurses, and it’s also good outcomes for patients and good family outcomes and those little stories. It all comes down to stories, and those little stories can be really inspiring.
This story was recorded at the Institute for Healthcare Improvement’s 28th Annual National Forum in Orlando, Florida, on December 4–7, 2016 by Mary Jane Kornacki on behalf of NEJM Catalyst. We wish to thank IHI for support of this project, especially Madge Kaplan for her technical advice and guidance. Click here for more Lessons in Leadership stories.