The Journey to An Intelligent and Reliable Organization

1. The Journey to An Intelligent and Reliable Organization Kathy A. Scott, RN, PhD, CHE Regional Vice President, Clinical Services Banner Health

2. The Journey to an Intelligent and Reliable Organization Objectives 1) To have a basic understanding of the following concepts and their application to leadership and the regulatory environment: • Complex Adaptive Systems • Levels of Management for Intelligent Organizations • High-Reliability Organizational Attributes 2) To present a framework for integrating characteristics of intelligent and reliable organizations to guide the work of regulatory experts and State Boards of Nursing.

3. “The idea that organizations fail because of human error is a defense that does not address the real problem- many organizations are just not intelligent”. --Maurice Yolles, PhD Liverpool John Moores University The Journey to an Intelligent and Reliable Organization

4. Leadership Matters Know that Your subconscious beliefs and assumptions Influence your every action or inaction And profoundly impact your organization.

5. Intelligent Organizations Understand that • They are a collection of individuals with freedom to act in ways that are not always totally predictable, and • Individuals’ actions are interconnected so that one’s actions change the context for others. Plsek and Greenhalgh 2001

6. Today’s Healthcare Realities • Intellectual capital drain • Unprepared workforce • Technology and innovation speed • Intergenerational dynamics

7. Today’s Healthcare Realities • Lack of understanding of each others’ roles • Public reporting of outcomes • Mental models that promote individualism and elitism • Continuous change without adaptation • Increasing system complexity

8. Healthcare organizations are complex systems.

9. Attributes of a Complex Organization • Many interdependent and dynamic subsystems • Open system with much exchange of information • Feedback loops that enhance, detract and inhibit information • Operate under systems far from equilibrium-continual change

10. Attributes of a Complex Organization • Subsystems not well and no single agent can know or comprehend actions and effects operating within the whole • Frequent tight coupling • Frequent system delays • Many mistaken assumptions

11. Complexity in the System • Is a result of the patterns of interaction between the elements.

12. Snowflake Elaborate pattern Large amount of elements with minimal interaction Not an open system-no feedback loops Cannot adapt to its environment Human Brain Elaborate pattern Large amount of elements interacting with each other within its structure Many and varied feedback loops Continual adaptation to flow of information/energy Dynamic interactions Complicated vs. Complex

13. Organizational Pathologies • Septic: Overcome by toxins within the system resulting in multi-system failure. • Demented: When organizations forget how stupid they were last week. • Depressed: Organizations marked by disengagement, inactivity, difficulty in thinking and focus. • Schizophrenic: Organizations characterized by loss of contact with the environment and inability to deal with reality.

14. Managing Complexity: The Path Toward Intelligent & Reliable Organizations Coping with complexity is at the heart of management and leadership in the turbulent environments faced today.

15. Intelligent Organizations are Adaptable • Adaptable defined as the ability to manage the complexity (variety) of situations well. • Adaptability relates to behavior and decision making. • Adaptability equates to collective viability--the ability to overcome the pathologies that limit an organization’s capacity to perform operations and operational processes effectively.

16. Adaptation is More than Change Adaptation requires a rethinking of our current ideas and practices to bring about a successful and sustainable alteration in the nature of the relationship between the organization and its environment.

17. Reliability

18. Complex Systems can be anywhere on the continuum of highly reliable to highly unreliable.

19. What is Reliability? • The extent to which a system yields the same results on repeated trials.

20. Six Sigma—One Measure of Reliability

21. One Tool to Move Us Toward Reliability • NCSBN Taxonomy of Error, Root Cause Analysis and Practice (TERCAP) Protocol that identifies multiple contributors to practice breakdown—individual, team, system, environmental.

22. Healthcare’s Reliability Gap • World-class manufacturing dictates defect rates in the 5-6 sigma range. • The airlines are achieving better than 6-sigma range with 0.43 deaths/million. • Health-care measures generally fall into the 2-4 sigma range. Merry & Brown, 2002

23. Healthcare’s Reliability Gap • 44,000 – 98,000 annual deaths from errors in healthcare (IOM, 1999). • Health-care errors are the 7th leading cause of death (Kohn, Corrigan & Donaldson, 1999).

24. State Boards of Nursing Reliability Gap • Assure competent/qualified nurses • Standards of practice routinely met • Timely investigation of complaints or practice breakdown • Standardized and timely administration of discipline • Promotion of standards across disciplines • Protect the public

25. Regulatory Reliability Exercise

26. High-Reliability Organizations

27. High-Reliability Organizations are: • Complex and high-risk organizations that demonstrate fewer than their fair share of failures. • Understand that uncertainty is irreducible and sources of harm are limitless. • Share a common set of attributes and practices.

28. Six Attributes of Highly Reliable Organizations • Learn from feedback • Effective teamwork • Anticipate the unexpected • Defer to expertise • Extra-sensitive to operations • Reluctant to Simplify

29. L earn from Feedback • People continue doing what they do when they are not given clear reasons to change behavior. • People will NOT change their behaviors if they believe that doing so will not make a difference.

30. E ffective Teamwork “To communicate and make decisions with the expressed goal of satisfying the needs of the patient while respecting the unique qualities and abilities of each healthcare provider.” Thomas, Sexton, & Helmreich, 2003

31. E ffective Teamwork • Identify and address “normalization of deviance” • The “destructive spiral of silence”--Rather than remain silent to “preserve relationships,” have the courage to respectfully address the issues and seek new solutions.

32. A nticipate the Unexpected • The precursor to noticing or responding to a situation is anticipating it. • Mindfulness is exhibited through ongoing scrutiny of existing expectations and a willingness to invent new expectations that make more sense.

33. D efer to Expertise • Blend/link hierarchy and specialization • Determine who should be at the table based on the issue and expertise needed • Value diverse points of view • Guard against limiting your view of expertise to roles and/or maintaining your personal identity to your role at the expense of reality

34. “We are like actors who forget we are playing a role. We become trapped in the theater of our thoughts. Reality may change but the theater continues. We operate in the theater, defining problems, taking actions—losing touch with the larger reality from which the theater is generated”. Physicist David Bohm, 1990

35. E tra-Sensitive to Operations • Operations is the performance of the practical work within the organization that produces the “output” of patient care. • Sensitivity requires paying attention to the subtle symptoms and eliminating “hopeful” thinking.

36. R eluctant to Simplify • Understand that interdependency requires new methods of inquiry that are different and distinct from analysis—polarity identification and systems thinking.

37. R eluctant to Simplify • Understand our human tendencies related to problem solving in complex systems: • The phenomenon of delays • Deterioration of planful thinking • Reductive hypothesis • Confirmation bias/disconfirming evidence • Simplify and economize

38. High-Reliability Organizations • Reliability is a multidimensional and multilevel process. • Requires transformational thinking at all levels of the organizations.

39. Polarity Exercise for Reliability

40. Intelligent Organizations

41. Traditional Organizations and Models of Management • Almost exclusively oriented toward profit/cash flow. • The ROI system of indicators is insufficient. • Their measures of success are not holistic and will most likely point precisely in the wrong direction--like measuring the temperature to decide what season you are in.

42. New Models of Leadership • Have a high potential for coping with complexity effectively. • Identify pre-requisites to operational success and sustainability.

43. Framework for Intelligent Organizations Management is a multidimensional and multilevel process—a distributed function at all levels of the organization, with each level/group containing three levels of management: • Normative • Strategic • Operative --Markus Schwaninger, Ph.D Professor of Management, University of St. Gallen,

44. Dimension of Organizational Fitness Logical Levels of Management Legitimacy Normative Management Complexity Strategic Management Effectiveness Operative Management Efficiency

45. Pre-Requisites • Variables at a higher level exert a significant influence on the lower levels.

46. Managing the normative aspects has a significant impact on the strategic management—which exerts significant influence on operations.

47. Normative Management • Relates to Legitimacy—to fulfill a purpose at the service of a larger whole • Goal—Long-term viability and development • Variables include: • Identity and vision • System ethos (openness) • System structure • System culture

48. Normative Management & HRO Culture—Practical Application • Identify the tacit versus spoken values, norms, and assumptions of the organization. • Find ways to recognize incompatible values and strategies simultaneously and buffer their effects. • Support realistic and flexible norms and rules. • Manage deviant behaviors while managing the politics.

49. Normative Management & HRO System Structure—Practical Application Develop a formal structure of roles, responsibilities, and reporting relationships that: • Support the access to and flow of information needed. • Support the vision and desired culture for the organization. • Allow flexibility for bringing the right people to the table as needed for decision-making. • Can be transformed under conditions of change and stress.

50. Strategic Management • Relates to Effectiveness—to do the right things • Variables include: • Core competencies • Customer relationships • Problem solutions • Technological support • Critical success factors • Competitive position • Collaborative position