Maureen Bisognano asks a lot of them. She asked many questions when she was a nurse, and when she ran a hospital. Now, she asks plenty as the President and CEO of the Institute for Healthcare Improvement, the renowned organization that helps the healthcare industry improve the quality and safety of care.
Leadership in these areas, Bisognano says, has to start at the top.
“Many boards and leadership teams still don’t understand the meaning of these quality measures, in cost terms, and in terms of the impact they have on patients,” she says. “Leaders get a quality report that is red, yellow or green -- self-defined colors that don’t tell them nearly what they need to know When I go to visit a board or a senior team, I ask them four questions to provoke them to think at a deeper level.”
Here are Bisognano’s four questions, with some of her comments for annotation:
**Do you know how good you are as an organization? “It’s knowing this qualitatively and quantitatively, not just in terms of red, yellow or green. Do you hear what patients are saying? Do you have patients at the board meetings? Not just patients who have been harmed, but ones who have had a great experience, because boards need to know where to reinforce quality as well as where to push for better quality.”
**Do you know where your variation is? “Boards and leaders mostly look at averages. So they don’t know if they’ve got some performers in their organization who are superstars and some who are really poor performers. By looking only at averages, they’re tolerating a level of bad performance that they wouldn’t if they better understood variation.”
**Do you know where you stand relative to the best? “Most leaders don’t know the answer to this. They look at their own data and they may not realize that there are other organizations in their state, in the country, or in the world that are doing dramatically different, dramatically better. And that provokes thinking.”
**Do you know your rate of improvement over time? “If you’re looking at static numbers, and thinking that they’re getting better, you may never know what the rate of improvement is. So I suggest to leaders that they always look at the rate of improvement over time.”
As the developers of the Triple Aim, IHI’s knowledge and unique culture encourage and nurture respect.
“At IHI, we are very much a team-based culture and our layout in Cambridge, Mass., reflects this,” Bisognano says. ”Everybody’s working throughout the course of a day on teams, so there’s constant challenge and learning and a great sense of camaraderie.”
Even Bisognano, the CEO, doesn’t have an office of her own.
“In my office, there are multiple workstations and a big table in the middle. So all day long, you’ll hear different conversations taking place. It’s very much a culture where, if you’re in the middle of something, you may need to stay focused on that. But if you’re interested in what your colleagues are talking about, you can turn around and contribute.”
Currently, Bisognano’s office has ten names listed outside its doors, representing a diverse mix of IHI senior executives, Fellows, and Senior Fellows, including the former chief executive of the National Health Service in England as well as the president of the National Academy of Medicine in Mexico.
Bisognano says IHI’s influence is felt in four concentric circles. Every 90 days, the members of the IHI R&D team select five to seven unsolved problems in healthcare to research in an attempt to generate solutions. That’s the inner innovation ring. The second circle is one focused on partnerships with organizations like Premier, Catholic Health Partners, Kaiser Permanente and the nation of Scotland to test out those solutions and demonstrate results.
The third circle is where IHI concentrates on equipping thousands of professionals with improvement skills and capabilities, using the educational vehicles of forums, seminars and webinars. The last, outer ring is all about dissemination, “getting the word out” on IHI’s website, via IHI’s online ”talk show,” WIHI, through blogs and social media, and by actively working with reporters on timely stories for a wide range of media outlets. Thus, the work begun by 130 people in IHI’s offices can reach millions.
“A lot of people know us by the Forum and by the Open School, but it’s a much more strategic and all-encompassing view when you look at us from the inside out,” she notes.
The focus on partnerships is critical, Bisognano says, because IHI wants to help equip healthcare providers with the tools they need to achieve optimal care. And to do that, the care needs to be patient-centered. That’s a mission and a journey that is very personal to Bisognano.
When she was in nursing school, Bisognano’s younger brother (she’s the oldest of nine children) was diagnosed with Hodgkin’s disease at a young age, a disease that ended his life.
“I watched healthcare provide what it could for him. But I also watched what it didn’t do for him, and that was to support him and our family facing this inevitable death,” she says.
She also grew in her own understanding, moving from a focus on what medicine could do, to what the patient wanted. She remembers vividly a day in a Boston academic medical center. The doctors had made their rounds as her brother Johnny grew weaker. One radiation oncologist, though, came back into the room.
“Johnny, what do you really want?” he asked.
“I want to go home,” he said.
The physician didn’t say a word. He came over to Maureen, took her jacket from her, and wrapped it around Johnny. Then he carried Johnny to Maureen’s car.
“I know that doctor broke every rule but he taught me an incredible lesson,” Bisognano says. “I thought my role was to give him encouragement and say, ‘Let’s try another round of chemotherapy.’ But my role was to ask him what he wanted. So when I got him home, I asked him what he wanted. He said, ‘I want to be 21.’ He died about five days after his 21st birthday. Those last few weeks were very meaningful, but very different. He was home, and we had all the family coming around to visit.”
She learned another lesson from Robbie, her sister’s son. Robbie was a perfectly healthy baby, but had a severe allergic reaction to a DPT shot at 2 months old that put him in the intensive care unit for a week. He recovered. At his 4-month exam, the doctor was about to give his 4-month DPT vaccine, when Bisognano’s sister stopped him.
“Don’t you remember what happened the last time?” she asked.
“No, what?” asked the physician.
She explained the reaction, the fear, the long hospitalization. The doctor paused for a moment, then said, “I don’t think the shot had anything to do with it, but I’ll only give him half a dose.”
The vaccine was administered. Robbie was dead within 24 hours.
Like Bisognano herself, her sister had questions.
“My sister asked me three questions,” she remembers. “Why were his records in the hospital separate from the records in the doctor’s office? How did the doctor not know that you don’t give even half a dose if there has been an allergic reaction? And, most importantly, why didn’t he listen to me?”
Those questions have driven Bisognano’s passion and guided her to this day.
“What happened to Robbie changed me. But my sister never sued. Most families who have experienced medical errors don’t sue. They’re looking for recognition and acknowledgment and apology more than anything else.”
One of the themes that Bisognano returns to is that healthcare is so complicated that a team approach is needed, and that one person can’t do it all.
She was with a group of residents recently who had come through a Lean training week.
“The first resident,” she says, “stood up to give his report and said, ‘I was blind to the mayhem. I would come in each morning, do my procedures, and I never saw all the other pieces of what was happening to these patients over the course of 24 hours, or over the course of a treatment diagnosis.’ ”
That light bulb moment is similar to what nurses experience continually, she says. The Top 25 Women in Healthcare include a lot of women who, like Bisognano, got their start in nursing; she believes this view of the sum of the parts is one reason so many nurses have made the transition to the corner office.
“Nurses are taught to see the whole health system, the whole journey of care, and we’re taught to see the family as part of the team,” she says. “I think that broad view of systems helps when you get to an executive level because you’re looking at how to put all the pieces together in a different and more effective way.”