Connected Thinking Blog - NACHRI Conferences

Evaluation is Essential -- Early and Always

"Without adequate evaluation to inform us, we are walking in a fog and don't know what we are missing."

That simple premise underlies much of the professional work and personal obsession of Carolyn Cumpsty Fowler, Ph.D., MPH, assistant professor and evaluation coordinator at Johns Hopkins University School of Nursing. Fowler led a two-part interactive session encouraging attendees to think about evaluation as a type of critical thinking that applies to all stages of any project and to realize how evaluation strategies help create effective connections with other people.

Challenges and dangers

Fowler starts with three big challenges often faced with any project: limited resources, non-strategic choices and lack of collaboration. Fowler says that the most important resources are not financial, and that one of the biggest dangers is a well-funded, well-resourced program; too many resources inhibit creativity and introduce complacency that tends to overlook the need for evaluation as a critical part of any program.

Another danger Fowler notes is non-strategic intervention choices. Something may seem like an amazing opportunity or a good idea at the time, but if it doesn't meet the objectives or help reach the end goal of the program, it isn't a benefit. An evaluation of the opportunity before accepting it will tell you it's not a wise use of resources.

Lack of collaboration Fowler calls "silo-sightedness." People and skills are resources that need to be invested to earn interest, she says. if you keep them in your silo they dont earn a return. Connections should be created early and often. For example, common challenges like turf wars can be avoided with proper pre-evaluation. "People don't get engaged in a turf war unless they care about something," says Fowler. Evaluation in advance can lead to collaboration with another passionate individual or organization instead of later conflict.

These three big challenges are completely interrelated and have a multiplicative effect that can be either positive or negative. If you overcome two of the three challenges, it makes it much easier to overcome the third; if you are struggling at two of the challenges, it makes it hard to maintain success on the third.

Evaluate early and always

"The biggest fraud that has been perpetrated on our community is the idea that outcomes evaluation is what matters," says Fowler. "If you are not evaluating until outcomes, it is often too late to change anything."

Evaluation is needed throughout all phases of a program: planning, implementation and outcome. "Evaluation incorporates formative evaluation--this is my total obsession in life," says Fowler.

Problems will happen with every project -- that will be part of every outcome evaluation -- but evaluation used during planning and implementation increases your ability to influence the outcome.

Evaluation before the program gives you a sense of the terrain and the context you are entering into.

Fowler outlines five "need to know" formative phases: pre-project, start-up, implementation and project modification, maintenance and sustainability, and replication and policy. Each of these stages should be thought about in advance and each can benefit from the thought-work leading up to it.

Key concepts

Concept 1: "The connections you create in the program design phase are critical to achieving outcomes." Strategic connections are "planned, tactical, calculated, deliberate, premeditated, considered intentional associations we form with others."

Concept 2: Before we can create strategic connections, we need to ask a lot of questions. It isn't always obvious what we need to know or why we need to know it. Asking questions is a large part of evaluation and planning -- it helps us understand the communities we are in and the communities we can collaborate with, and this can extend beyond just the obvious circles of relationships and influence.

Fowler reminds attendees that "community is not a geographic place; it is a shared place of being." And a part of resource development is recruiting the right people to share that place. All connections must prioritize relationships, and all connections must be evaluated.

Fowler shares a couple of favorite quotes to help illustrate these key ideas:

• "If the first button of one's coat is wrongly buttoned, all the rest will be crooked," Giordano Bruno (1548-1600).
• "The first step towards getting somewhere is to decide that you are not going to stay where you are," John Pierpont Morgan (1837-1913).

What types of connections are necessary for you to have a successful program? How could evaluation help you to maintain and strengthen your connections?

Tools for Influence Mapping

Susan Distefano, MSN, RN, NEA-BC, president and CEO of Children's Memorial Hermann Hospital in Houston, shared some of the resources she uses as a leader and gave examples and tools for attendees, with particular focus on how administrators in children's hospitals within hospitals can have a greater effect on system decision making.

Children's Memorial Hermann Hospital is part of an 11-hospital system. January 3, Distefano's first day on the job, she became involved in a decision to potentially eliminate a service line that would have affected the children's hospital. Her reaction was to use a control-influence-appreciation model of spheres of influence to map out who influenced who at the upper levels of the system, based on the recommendations and insights of her senior staff.

Through a rapid series of phone calls and meetings the various staff members made contact and made their case to the right people to send influence up the ladder to the system decision makers. The effect was to keep the service, but with the measure of reframing specific goals related to patient safety and financial performance to ensure long term viability.

Visit the NACHRI website to view Distefano's Powerpoint slides. Distefano also recommends Nancy Post as a resource for other tools to help sustain leadership skills.

PIV Infiltrate Measures/Collaborative Meetup

Are you interested in PIV infiltrate measures/collaborative? Meet at 5:45 PM on Tuesday 3/15 in Harbourside Foyer in front of Salon C to discuss.

How to Become a High Reliability Organization

"On August 16, 2010, we hurt a child in our operating room and three days later he died. It was a terrible, terrible event. It destroyed the family forever and destroyed many of our staff. It was completely preventable. ... It helped open our eyes that we still have a long way to go," says Steve Muething, M.D., assistant vice president of patient safety at Cincinnati Children's Hospital Medical Center.

In a packed session, Muething shared his experiences with, ideas about and advice for helping create a high reliability organization (HRO). By his own admission, Cincinnati Children's is not yet a HRO, but they are working hard to become one and have learned a lot of lessons along the way.

What is a high reliability organization?

There is an entire field of science around HRO theory. It is prominent in engineering (aviation, automobiles, nuclear power, etc.) and some other fields, and has a small but growing body of work in health care. Several potential definitions have been offered for HRO as it applies to health care, including "no preventable deaths; no preventable serious harm."

In Muething's vision, in a high reliability children's hospital, two outcomes would be that families would feel safe and staff would clearly know their roles and feel empowered and safe. He believes that 90 percent of what is needed to be an HRO is "already under our control."

Journey towards high reliability

A journey to reliability involves several levels of improvement. Process design can help achieve the first level of HRO.  Reliability culture takes it up exponentially on the HRO curve.

For Cincinnati Children's the journey started with changing the reliability of their systemic processes. They worked to develop standardization and process reliability, building improvement capability. This starts by defining standards and working to achieve 95 percent or better reliability in areas like number of catheter-line association bloodstream infections and ventilator-associated pneumonia. These kind of standard improvements are saving lives every year.

Focus on mindfulness

Cincinnati Children's is one of several children's hospitals who are flipping their evaluation (Nationwide Children's Hospital is another example) and focusing on patients harmed as a way of helping keep staff from becomming self-satisfied with their improvement. Right now, Cincinnati Children's is seeing 24 patients a month still suffering from one of their preventable metrics. In addition, the hospital is seeing a patient serious harmed by negligence or failed protocol every 21 days on average. Making these numbers public is helping change culture with a focus on failure as an inspiration to continuously strive for improvement.

As part of being on the front line, you need to be aware of all harm, but also aware of all risks -- continuously. Harm reduction needs to be owned by the front line. And when something goes wrong, it is important to find the cause.

Leadship in an HRO needs to focus on high functioning teams and microsystems; daily and shift huddles to keep everyone aligned; multiple improvements need to be going on simultaneously; a just culture must be developed; management must be predictive rather than reactive.

Error prevention requires behavioral training and ongoing reinforcement. Situation awareness is essential; 95 percent of high risk situations can be identified in advance, but it takes a culture open to discussion to raise the necessary warning flags and precautions.

Part of the work at Cincinnati Children's is collaborating with the eight children's hospitals in Ohio to put aside their fierce competition in the interest of protecting patients. The hospitals are working together on safety initiatives, sharing their results, and seeing improvement together.

It's a long journey

Muething says that the patient death on August 16, 2010, was the result of a hundred little things that no one would have ever expected to contribute to the outcome. One person was a few minutes late coming in, one wasn't as familiar with a particular piece of equipment being used ... the little pieces added up.

"We are working to implement systems where we are always ready and always safe," Muething says. "This takes implementing standard operating procedures; assuring competency of every single person involved; getting the little things right every day; empowering every person involved to own safety."

Muething firmly believes that the journey of improvement is a personal story. Every person must be involved and invested in the change. "I now believe my most fundamental job as a pediatrician is 'don't hurt me," Muething says.

Muething strongly recommends Weick and Sutcliffe's book "Managing the Unexpected," as a valuable resource for organizations interested in becomming HROs.

How is your hospital becomming more transparent? What ways are you changing your hospital culture to improve safety, reliability and patient care?

Strategies for Building Corporate Alliances

In two consecutive sessions, Philips McCarty, founder and managing director of Cause Innovation, shared strategies for building and sustaining a children's hospital corporate alliance program. He started with the context that "Corporations today really want to see metrics behind what they support. They are asking how the dollars they are investing are providing payoff in the community."

McCarty defined four elements of authenticity in defining corporate alliances: measureable  sales and impact, employee engagement, relevant connection with consumers, and missions- and value-based. Authenticity should be key to all relationships your hospital has with outside organizations.

McCarty advises hospitals to start with 10 questions to consider the feasibility of building corporate alliances with your hospital.

Feasibility 10 -- Assessing Your Corporate Alliance Opportunity

1. Are your development, hospital and board leadership open to cause marketing and corporate alliances? Do you know in what context?
   This can be a tricky area in almost any hospital, especially with legal departments. It's a gray area and it looks like it is becomming even grayer rather than more clearly defined. Cause marketing has immense potential but also has some risk as brands ally together.
2. Are key physicians in key areas of expertise/department/pillars open to aligning their programs with corporate partners?
3. Do you have internal corporate leads you can access/approach for cause marketing and corporate alliances? Do you know in what context?
   Without any initial leads, it is challenging to get started. Once started, it is much easier to add additional corporate alliances. The connections of your board members can be key if they are willing to be involved.
4. Are the medical department/pillars open to working together on cause marketing and corporate alliances? OR would any alignment have to be pillar-specific?
   This needs to be about the hospital as a whole and it can be hard when one department doesn't want to share with other departments.
5. Do you have a strong regional brand or exceptional national research in key, consumer-friendly departments/pillars?
   Number one message to take back to your organization: "We must conduct brand research." It costs money, but it is worth the investment.
6. How well do key areas of development work together: major gift officers, direct mail, event production, sponsorship, marketing communications, PR?
   Siloing can be one of the biggest detriments to any successful development or cause marketing outreach.
7. Is development marketing and outreach separate from clinical marketing? If so, how well do they work together?
8. Do you have any event, advertising or human resources that can be leveraged in support of a cause marketing program? Do you know in what context?
9. Do you have the resources to devote someone, or part of someone, to creating a formal program and conducting research for the next 18-24 months?
   This is an initiative that seldom realizes immediate results; building relationships and formalizing any relationship takes time, and you need to plan in advance for that timeline.
10. Does your institution have the legal skill and/or resources to devote to supporting a formal corporate alliance program?

After determining feasibility,the following tools and resources need to be in place to start building relationships:

Tools and resources

• Guidelines and criteria -- This is an essential place to start. You should have guidelines and criteria in place that support your mission. It helps you know when to say no and when to say yes and invest your time and resources into building a long term relationship.
• Process charts -- Know what approval process is in place, know what you should give back in return, and what assets should be leveraged to help this alliance happen.
• Define your assets -- Know what you can promise and deliver (website, events, etc...) and know what you can't control (public relations results, celebrity presence, etc.).
• Coroprate alliance task force -- Bring people together from different departments to support the plan and implementation.
• Legal process -- A templated approach often works best. Start with a basic outline and let the legal team have buy in.
• Research tools -- When you develop your arsenal for corporate alliances, know what your resources are and where to go for additional information.
• Target lists  --Decide who you will approach, think about what that will look like, and what criteria are considered.
• Flexibility -- No matter how many tools are in place, you have to have room for flexibility because corporate alliances are never black and white.

After you have the necessary tools in place, McCarty provided four key questions to consider before solidifying any corporate alliance:

• Does the partnership serve the mission of the hospital?
• Is the allaiance a productive use of resources?
• Does the alliance threaten the hospital's credibility among those it serves?
• Does the alliance weaken the hospital's brand reputation among those who support it?

Ideas for the future

Corporate alliances are part of a long-term development and brand-building strategy and need the support and integral involvement of development as well as public relations and communications. This provides consistent strategy as well as a safety net if anything goes wrong. The cooperation is necessary for long term success.

McCarty also provided advice for long-term relationships. Think about all relationships as they might exist over time. Sometimes it is worth starting with a small committment with a corporation with a strong brand with the expectation of growing that relationship over time. With all relationships, it is worth regular reevaluation to determine if a partnership still makes sense; corporations change over time and there may come a point where your goals and mission diverge and a particular alliance no longer makes senes. It is okay to end a relationship if it doesn't support the mission of the hospital.

McCarty also gave an exhortation to attendees to network together. Sometimes corporate alliances can make sense at a much larger scale than a single hospital, and it is to everyone's benefit to share resources and relationships with one another.

Visit the NACHRI website for more information on McCarty and on the sessions he presented. You can also visit McCarty's blog, which offers additional ideas for and examples of successful cause marketing and corporate alliances.

Where is your hospital in building corporate alliances? Who do you partner with and what benefits or challanges have you experienced?

A whale and a firetruck go into a hospital...

It's not a joke but a sincere question: what do you do with a 30-foot whale, a fire truck and countless other diverse objects?

That, and a hundred questions like it, were answered with pictures and stories in a presentation by Bruce Komiske, chief of new hospital design and construction at Children’s Memorial Hospital in Chicago, and Sue Ann Barton, principal at ZGF Architects, LLP.

Children's Memorial is building a new hospital, Ann & Robert H. Lurie Children's Hospital of Chicago, scheduled to open in 2012. The hospital is going to be 1.25 million square feet of space stacked on only 1.8 acres. The 23-story hospital is notable not only for its height, but for its ambition in serving as a place that brings leading cultural organizations and community together. Every floor of the hospital is designed around a theme provided by a local cultural institution. The 30-foot sculpture of a whale is being integrated into the lobby; the fire truck is part of the design of another floor and is a tie to the local fire department based across the street.

"I met with the CEOs of 20 of the major cultural organizations in Chicago. We had a simple proposition: out theme is 'what makes chicago special,' we want to borrow two of your most creative people to help with the process," says Komiske. Every organization, from the zoo to the museums to the ballet, chose to get involved. The goal was to engage the community of cultural institutions of chicago in the design process. In the end 125 people from 20 different organizations were a part of the artisitic planning committee for the look and feel of the hospital.

The presentation includes amazing pictures of the designs, but also provides a look at the layout and some of the innovative elements that were necessary to do so much with so little real estate. The best way to experience this is to let the pictures speak for themselves. Visit the NACHRI website for a .PDF of the presentation, and visit the Children's Memorial Hospital website for videos and more information about the new hospital.

An inside look at "Best Children's Hospital" rankings

Avery Comarow, health rankings editor at U.S. News & World Report, and Murrey G. Olmstead, Ph.D., associate project director and director of methodology at RTI International, shared the back story, present state and future goals of the annual Best Children's Hospital rankings put out by U.S. News & World Report. RTI International, a non-profit contract research organization, began contracting for the magazine rankings in 2004.

The magazine started it's best hospital rankings in 1990. For the first few years, the surveys were reputation-based only. In 1993, hard data was added to 12 of the specialties; pediatrics was not one of them. Hard data didn't come to the pediatric category until 2007. In 2008, children's hospital rankings were broken out by subspecialty for the first time in six specialties; four more specialties were added in 2009.

In 2006, the decision was made to add hard data to children's hospital rankings. Comarow says they found that adult hospitals were altering their behavior to help ratings as part of their marketing. "With children's hospitals, we were pushed to develop metrics that help encourage hosptials to improve care."
At the time, there were few tools available to help parents select pediatric hospitals. Quality metrics lagged approximately a decade behind adult hospitals. And U.S. News & World Report decide it was unwilling to wait for agreement on hard data standards to come from within the pediatric community, so they worked with RTI and NACHRI to develop valid measures for quality.

In the first year with data added, 70 percent of pediatric hospital scores were still based on reputation. That number has dropped to 35 percent, and is continuing to drop as more and more evidence-based measures are being reported.

The focus now is on enhancing the rankings and methodology. "We are now on the fifth year of the new children's hospital rankings, and we are working on continuing to improve our survey to include more robust and transparent measures," says Olmstead.

He outlined some of the current challenges:

• Trying to be comprehensive vs. trying to keep burden reasonable is a challenge. It takes an amazing amount of time for hospitals to respond to these surveys. Using similar measures from year to year will hopefully make repeat surveys easier for hospitals.
• As a counterpoint, the amount of change to the survey the past few years reflects the immense changes that have been going on in children's hospitals and that is unavoidable.
• Keeping participation high is a challenge because of the workload involved.
• Keeping current with the work at NACHRI and the National Institutes of Health that can potentially be transferable to this project.

"The major thrust of this particuclar journalistic enterprise is our audience: we want to benefit children and their families. To the extent that hospitals use the rankings and methodologies to make that happen more efficiently is wonderful, but that's not our primary audience," says Camarow. "We just want to recogize those hospitals that are doing things the best. We are not marketing to children's hospitals; we are marketing to the families of children."

What has your hospital experience been with completing the U.S. News & World Report survey? What would you change if you could?

Dr. Ben Carson shares how to THINK BIG

Dr. Benjamin Carson Sr., M.D., professor of pediatic neurosurgery, Johns Hopkins School of Medicine, helped set the tone for the Creating Connections conference by sharing stories from his own life and passions, and his personal philosophy of "THINK BIG," an acronym which you can learn more about on his website.

One of the most renouned neurosurgeons in the world, Carson gave a broad disclaimer for his comments: "It is virtually impossible these days to talk to a large group of people without offending someone. It is not my intention this morning to offend anyone ... but if I do, I'm not going to apologize for it. I am not a big fan of political correctness. The emphasis should not be on unanimity of thought or unanimity of speech. It should be universal respect, especially for those people you disagree with."

Carson gave an overview of his personal growth and development, starting with a challenging childhood that never diminished his lifelong desire to be a doctor. An impoverished upbringing in Detroit was part of a much longer story arc that has taught Carson to THINK BIG about the world and about how people can use their brains and their talents to make the world a better place.

Carson's stories are all about the long term view. "I can spend 10-15 hours operating on a child and they might get 40-50 or more years of life. I like getting a big return on my investment," Carson says.

Carson's career has had several landmark conjoined twin separations that helped establish his international reputation. His decisions have been guided by very analytical thinking about how to help others. "I always do a Best-Worst-Analysis," Carson says. "Whats the best thing that happens if I do this? Whats the worst thing that happens if I do this? Whats the best thing that happens if I don't do this? Whats the worst thing that happens if I don't do this? If you are worried about your career and your track record, you may answer those questions differently than if you think about the well being of the patient. And this rule has general applicability."

In his talk, Carson focused on the value of teamwork and the importance of playing your part well. At the end of his first landmark conjoined twin separation, "when the last cut was made, there were 59 people in the operating room, all integral to the process," Carson says.

He also addressed issues of social and personal responsibility in politics and legislation. "There was a time in this country when physicians were much more involved in the day to day running of everything. Five physicians signed the Declaration of Independence; more signed the Constitution." Physicians used to be more involved in civic life and that involvement can affect the tone of discussion. There is a difference in outlook betweek doctors and lawyers. Doctors are trained to care for others; lawyers are trained to win. In Carson's view, when the plurality of congress is lawyers, agreement is difficult because everyone wants to win.

Carson offered his own ideas to help address health care costs. "We have a system in this country that is largely based on insurance companies that make more money by denying people coverage. You can dress it up any way you want but you have a fundamental conflict of interest. This has to be discussed." He also suggested simplifing electronic billing married to higher penalties for medical fraud to ensure honesty in a simpler system.

His suggestions looked at other big picture ideas, that come to life in the Carson Scholars Fund nonprofit he founded. "We are always going to be running into problems, but we've been given these big brains for a reason," he says. "We need to be thinking not about how we can't do something but about how we can do something."

"We are looking to change the fabric of our nation, particularly the people in leadership down the road," he says. The Carson Scholars Fund gives out $1,000 awards to children for academic achievement and for humanitartian excellence. "You have to have both. If you dont care about other people, it doesnt matter how smart you are."

Carson closed with a moving story of a conjoined twin separation in South Africa in 1997, where he was the lead surgeon on a kind of case that had never been successfully performed with both twins surviving, despite over a dozen attempts. The separtion was a success, but not just for the twins, but also for the hospital, the city and the nation. For Carson, the story helps illustrate his definition of success: "Success is using the talent that God has given you to elevate the people around you."

To learn more about Carson, his passions and the Carson Scholars Fund, visit www.carsonscholars.org.

What comments did Dr. Carson make that inspired or challenged you? What offended you? Are there any changes you will make in your hospital or your own life because of the thoughts he shared?

Welcome to 2011 Creating Connections Conference

Welcome to 2011 Creating Connections Conference! The conference opened with NACHRI Chairman and CEO Chris Dawes, president and CEO of Lucile Packard Children's Hospital at Stanford, welcoming attendees and sharing vision for the upcoming proposed merger of NACHRI, N.A.C.H. and CHCA.

Dawes was followed by Jim Schmerling, president and CEO of The Children's Hospital, Denver, CO, and chairman of the task force aligning NACHRI, N.A.C.H. and CHCA. Shmerling outlined for attendees some of the major challenges and opportunities of the forthcoming merger, and adressed some of the most frequently asked questions about the proposed corporate structure and board structure and informed members how this will affect bugets and dues for the upcoming year.

The formal meeting of the membership will be held tomorrow. Check back to read results of the vote. To learn more about the proposed merger and to stay abreast of organizational changes, visit the NACHRI, N.A.C.H., CHCA Merger page on the NACHRI website.

If you are interested in participating in this blog, e-mail Tim Haynes, thaynes@nachri.org, for help becomming a guest Connnected Thinking blogger.

Take the Connections Challenge

We are looking for a few good members to join the conversation about the 2011 Creating Connections Conference on Facebook, Twitter and the new NACHRI Community. Members who demonstrate a high level of participation will be entered into a prize drawing for a complimentary full conference registration to the 2012 Creating Connections Conference. That's right we are giving away three complimentary registrations, three opportunities to win!

How do you enter the drawing? 

• Follow NACHRI on Twitter and send 10 or more tweets about the conference using the hashtag #CC2011, or
• Indicate you are attending the 2011 Creating Connections Conference on Facebook and send 2 to 3 status updates while you are here in Baltimore, or
• Join the NACHRI Community and complete your profile while you are here at the 2011 Creating Connections Conference

Choose any one of these paths to qualify for an opportunity to win a  1 of 3 complimentary 2012 Creating Connections Conference registration. Winners will be announced April 2, 2011.