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June 8, 2016

The wake-up call that transformed Cincinnati Children's culture

Daily Briefing

Staff at Cincinnati Children's Hospital Medical Center got a rude wake-up call when they discovered they rated much lower in nationwide rankings than they had thought—but the revelation gave them the kick they needed to overhaul their safety culture.

When Cincinnati Children's staff found they ranked in the middle to lower third of U.S. hospitals for cystic fibrosis care, it "really shook us," Uma Kotagal, SVP for safety, quality, and transformation at the hospital, tells NEJM Catalyst. "It was the first time we had looked at data that had been available for a long time, but looked at it very openly."

As they investigated the root causes, they were shocked by stories they heard from patients about their experiences at the hospital.

"We cried in the beginning," Kotagal recalls, because patients' experiences were "dissonant with our view of how great we were."

But that wake-up call gave them the motivation to overhaul their culture and focus on becoming "the best at getting better."

Culture overhaul

Cincinnati Children's focused on implementing changes that would truly be transformational, starting with patient-physician and physician-nurse relationships.

First, Kotagal says, hospital staff spoke with about 100 current and former patients and their family members, who explained "what was wrong with the system."

The hospital used the feedback to set improvement goals and metrics—covering outcomes, patient experience, and patient safety—to hold staff accountable. Staff agreed the entire hospital would focus on improving immediately, even if they weren't completely ready for the task.

"We said, 'Let's get started,'" Kotagal says. "We didn't know [what] that would look like 10 years later, but we thought it was a temporary structure ... to focus on the whole system transformation."

The hospital created several teams that included members from several departments, including ED, inpatient, and outpatient. Each team was led by a physician, who focused on improvement efforts, as well as a nurse, who served as the operational leader. Doctors and nurses on the team were on "equal footing," which was crucial for teamwork and buy-in, Kotagal says.

The teams worked with frontline clinicians to ensure they had the resources—including tools, data, and capacity—to align with system-level goals and had a plan to achieve success. They focused both on clinical system integration—to make "sure that we were taking the big dots down to the lowest level of the work"—and on communicating across the care continuum.

Trying to 'change your culture'? You're already doing it wrong

Another key was promoting transparency, Kotagal says. Stakeholders, including administrators and the hospital board, agreed that "we would fail sometimes, but that was OK," which gave staff the freedom to experiment to find the best solution.

At the same time, "pursuit of perfection was critical," Kotagal says, "especially in areas like safety ... even having one child harmed was not good enough."

But changing cultures requires ongoing experimentation, Kotagal says. "We always have to keep pruning ... Everybody has a better idea. You don't want to squash that, but at the same time you don't want a thousand flowers blooming that can't come together."

Without that pruning, an overabundance of ideas can drown out the best ones, she adds.

"I would say our culture is collaborative, it is optimistic, it is transparent, it is aspirational, it is patient centered, and it is scientific," she says.

Hospital culture, staff camaraderie linked to patient outcomes

The transformation is still "a work in progress," Kotagal says—but the hospital's efforts so far have given it a good foundation.

The efforts also improved care quality. According to the Institute for Healthcare Improvement, among Cincinnati Children's patients with cystic fibrosis—the condition that catalyzed the culture change—the hospital significantly:

  • Increased its percentage of patients who received a quarterly respiratory culture and who were vaccinated for the flu; and
  • Decreased its percentage of patients below the 10th percentile for weight (Minemyer, FierceHealthcare, 6/2; Kotagal/Compton-Phillips, NEJM Catalyst, 6/1; Institute for Healthcare Improvement website, accessed 6/8).

Find opportunities to improve your culture

The Medical Group Culture Intensive is a questionnaire designed to assess a group’s status on each of the dimensions discussed above to help executives and their teams find their most immediate opportunities for improving their group’s culture.


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