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Lessons from the Frontlines CCS/CCHA NICU Improvement Community of Practice In collaboration with CPQCC Paul Kurtin, MD Our Reality!

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lessons from the frontlines

Lessons from the Frontlines

CCS/CCHA NICU Improvement Community of Practice

In collaboration with CPQCC

Paul Kurtin, MD

our reality
Our Reality!

“When an ever increasing amount of information has to be squeezed into the relatively constant amount of time each of us has at our disposal, the span of attention necessarily decreases”

social anthropologist Thomas Eriksen

high reliability organization
High Reliability Organization
  • Preoccupation with failure
  • Reluctance to simplify interpretations
  • Sensitivity to operations
  • Deference to expertise

We are faced with an overwhelming amount of information

What we pay attention to filters and limits the information we have

We then use that limited information as the basis of our decision making and action


How do we maintain continuing alertness

We can forestall catastrophic outcomes through mindful attention to ongoing operations


There are always surprises, but we ignore or discount contradictory information

  • Mindlessness is more likely when people are distracted, hurried, or overloaded. To deal with production pressures people ignore discrepant clues and cut corners
  • Also occurs when people feel they can not act upon their concerns

Continuing efforts to update actions and expectations by always checking if new information fits current expectations and plans

sustaining mindfullness
Sustaining Mindfullness
  • Create a climate where it is safe to report and question assumptions
  • Conduct incident reviews soon after the event
  • View close calls as sign of potential danger not success
  • Maintain situational awareness of current practices and changes in those practices
  • Make knowledge about the system transparent and widely known (process measures)
sustaining a culture of safety
Sustaining a Culture of Safety
  • Reporting culture: protection of people who report
  • Just culture: acceptable and unacceptable behaviors
  • Flexible culture: adapt to changing conditions; system endangered until proven safe
  • Learning culture: seek out and adopt best practices; don’t explain away contradictory evidence
sustaining focus
Sustaining Focus
  • Develop and implement tools to assess and share adherence to standardized approaches
  • Build decision aids into the process. Make it easy to do the right thing.
organizing for quality
Organizing for Quality
  • Relatively small number of similar challenges with a potentially large number of solutions
  • Must address all common challenges
  • Must find local answers that are appropriate contextually
  • Must build these solutions into ongoing improvement processes
six challenges
Six Challenges
  • Organizational culture
  • Structural processes
  • Political processes
  • Organizational learning
  • Emotional processes to engage people
  • Technology and infrastructure to support improvement
six challenges14
Six Challenges
  • Structure: committees, roles, data monitoring, QI training
  • Politics: What’s in it for me?
  • Culture: key to sustainability, mindset about quality
six challenges15
Six Challenges
  • Learning: both accumulate and pass on new knowledge. Key to sustainability
  • Emotion: quality as a ‘cause’, social movement
  • Infrastructure: reliably deliver quality, safe care everyday
non sustainability
  • Structure: Fragmentation
  • Political: Disillusionment
  • Cultural: Evaporation (gains vanish)
  • Education: Frustration as skills and knowledge don’t keep up with goals
  • Emotion: Loss of energy
  • Infrastructure: Too hard to do
  • Solutions may travel poorly because of context, most broadly defined
  • Solutions must be home grown, bottom-up
  • Solutions lay in effectively connecting the right people, the right leader, the right tools
  • Solutions in relationships among processes, among people (micro, meso, macro, system)
  • Structure: Put in place
  • Culture: Build team ‘work’
  • Politics: Deal with conflicts
  • Learning: Learn from mistakes
  • Emotion: Share passion for being the best and being for the kids
  • Infrastructure: Avoid distractions of high tech solutions

“Organizing for quality is about fallible people who keep going… Quality is human and organizational, not technical or mechanical.”

Patient care quality = Qsystem

Qsystem = Q1 + Q2 + Q3…(the quality

within each microsystem +

the quality of the hand-offs

between microsystems)

  • Long-term philosophy: the right processes will produce right outcomes
  • Add value to the organization by developing people and partners
  • Continuously solving root problems thus driving organizational learning
Learn and Learn about learning.

Generalisable scientific knowledge; organizational context; measurement; improvement modalities; execution

Be the best at getting better

our reality23
Our Reality!

Everyone in healthcare really has 2 jobs when they come to work everyday: to do their work and to improve it!

Paul Bataldan, MD