Creating a Culture of

Innovation

Kedar Mate, MD Vice President, IHI

Assistant Professor of Medicine, Weill Cornell

Medical College

Objectives

• Identify the dimensions of organizational

culture that support innovation

• Assess the culture in teams and

organizations

• Describe actions that they can take to

enhance innovation in their organization

Introductions

Kedar Mate

• Big interest: Study/science of innovation

and improvement; Equity; Governments

• Background: Medical doctor (internist),

public health specialist, WHO, Partners

Healthcare (MGH & Brigham & Women‘s)

• Currently working on: A ―first hour of life

bundle‖; completeness and coverage of

safety interventions; innovations in

accreditation systems

One Definition of Innovation

• ―Innovation = the novel match between a

solution and a need that creates value‖

─Christian Terwiesch, ―Innovation

Tournaments‖

The innovation can be in the solution, the

need or the match

One of our oldest examples:

BUNDLES • In 1996, the average VAP rate is 25-30% in most

ICUs

• IHI worked with a couple of ICUs that were experiencing much lower rates of VAP

• We posed the question: Can VAPs be eliminated?

• Applied innovation techniques: Tested different evidence-based approaches in combination AND studied positive deviance

• Discovered the concept of a BUNDLE: A group of interventions when instituted together have synergistic effect on outcome

• Result: The Ventilator Associate Pneumonia bundle

The VAP Bundle

• Elevation of the Head of the Bed

• Daily "Sedation Vacations" and Assessment

of Readiness to Extubate

• Peptic Ulcer Disease Prophylaxis

• Deep Venous Thrombosis Prophylaxis

• Daily Oral Care with Chlorhexidine

―Innovation = the novel match between a

solution and a need that creates value‖

Discussion Point #1

• What is your definition of innovation?

• How is innovation similar or different from

improvement?

Improvement and Innovation

Improvement

The act of raising to a

more desirable or more

excellent quality or

condition

Innovation

Making changes in

something established,

especially by introducing

new methods, ideas, or

products (to make new)

Improvement and Innovation

• Improvement needs:

─ Will

─ Ideas

─ Delivery

• Innovation kicks in

when the existing

ideas are insufficient

and we need a new

view

• Innovation efforts

use the same tools

as improvement:

─ Planning

─ Measuring

─ Testing

─ Analyzing

Improvement and Innovation

Enrique Ruelas, IHI Senior Fellow

10

Improvement = Change

Doing the same

things better =

Incremental

Change

New in a specific

organization

(Contextual)

New everywhere

(Conceptual)

Doing new

things = Innovation

Discussion Point #2

• Why are you or your organization

interested in innovating?

• Do you have an existing system for

innovation? What is working and what is

not working?

Why IHI Innovates

12

• Other Industries: IHI was founded on the theory that health care could learn from other industries

• Unsolved Problems: Some problems cannot be solved by more of the same. We needed a new view.

• More Ambitious Aims: Pursuing Perfection-excellence everywhere. The old ideas were good but not enough.

Why IHI Innovates: History

• It came naturally, in collaboratives

• Idealized design projects

• Pursuing Perfection as a catalyst for innovation

• The demand for new models is endless

13

Campaigns;

Programs

From Pursuing

Perfection:

Mortality

Reliability

Practical RRT

Ideal AMI care

Bundles (VAP,

CLABSI)

From Idealized

Design:

Medication Safety

Office Practice

Critical Care

Our Initial Innovation Process

• Integrated into project

teams

• Created great ideas

─Bundles

─Reliability

─‗Move Your Dot‘

• Good, but not good

enough

What Was Missing

• Pace

• Staff with dedicated time

• Predictable results

• A forum for problems that needed innovation

• A reliable mechanism to transfer an idea into

program development

15

It Seems We Had to Learn to

Innovate

We asked ourselves:

How Do You Innovate?

• How do you identify

problems in your

organizations that

need solution?

• How do you develop

change ideas/

solutions?

• How do you test new

ideas?

An Innovation Process

Thinking differently to solve challenging

problems https://www.youtube.com/watch?v=2lXh2n0aPyw

A Test: Autumn 2006

Create a small team with dedicated resources

─ Based on Huston and Sakkab‘s Connect and Develop description of Proctor and Gamble‘s innovation method Work in 90-day increments

─ Implement ―waves‖ of at least five projects

(Huston L and Sakkab N. Connect and Develop. Harvard Business Review. March 2006. pp 58-66)

IHI Innovation Process

• A specific challenging question to be answered

• A charter than clearly states the problem &

deliverables

• A network of innovators, along with other

traditional methods (literature search, prototype

testing)

• A specific timeline, in this case 90 days

• A hard-stop decision-point at the end of each cycle

Components of a 90-Day

Project

Scanning

Goals:

• To get a broad view of the problem,

barriers and innovative solutions

• Understand all of the dimensions of the

topic through literature reviews and key

interviews.

• Get as much as needed and no more

Scanning: 2-2-1

For each scanning cycle:

• 2 mainstream journals (look

for this topic)

• 2 mainstream organizations

(view their websites or call

them for interviews)

• 1 out of the box approach

(interview, news source,

other industry)

2-2-1

2-2-1

2-2-1

Components of a 90-Day

Project

Focus and Test

• Choose an angle

• Visit and test at the front line to refine

ideas about what actually works

• Create a driver diagram

• Develop a theory

25

Create a Driver Diagram: Theory

Reduce

Waste by 1-

3% in

Hospital

Settings

Improve

Safety

Engage

Patients

Improve

Efficiency

Leadership

Reduce medical errors and harm

Reduce ―never events‖

Chronic conditions self-management

Prevention and wellness (start with your staff)

Transparency for high-performing providers

Shared decision making

New models for medically complex patients

Palliative care improvement

Reduce artificial variation (LOS, use rates,

readmissions, etc.)

Eliminate ―flow faults‖

Set a goal of reducing waste by 1-3% of

operating expense budget for I year, year on year

Create a culture of getting value for money

Adopt a proactive approach to errors and harm to

reduce malpractice claims and costs

Engage the BoardApril, 2011

Focus and Test

Example: Cancer Care that Patients Value

• Initial theory: Cancer care that meets patients‘

needs focuses on coordination and

emotional/family support

• Interviews and visits show that patients value:

coordination, support, no waiting, high levels of

personalization and continuous communication.

But what they value most is knowing everything

is done to save them.

Technique: Learn by Analogy

Gather new ideas from other industries:

• What does the process or structure

resemble?

• What can we learn from performing that

process well?

─Example: Hand-offs and Coordination

Technique: Learn by Analogy

Problem:

Communication between Primary Care and Specialist is poor, leading to overuse, underuse, lack of follow up

• What other industries deal with distance communication?

• What are good examples of successful distance communication?

Solution from Analogy

• Skype! When traveling long-distance,

people use video skype to keep in touch

with friends and family

PC physician “joins”

patient on specialist

visit real time with an

iPad held by the patient

using “sharethevisit”

software.

Technique: Learn by Analogy

Health Care Other Industries

Handoffs in Health Care Unaccompanied Minors in Airports

Self-Management Support Do-It-Yourself Store

Primary Care Visit

Racing Pit Crew

Medication Systems

High Hazard-Aircraft Carriers

Flow Through Hospitals

Supply Systems in Industry

Components of a 90-Day

Project

Summarize and Handoff

Handoff includes spread and scale-up

• Spread: Taking a system or intervention that has been

successfully tested and replicating it in an independent

site

• Scale-up: Overcoming the system / infrastructure issues

that arise during implementation and spread of changes

at the system level

33

Three General Themes for

Projects Sound ideas for

improvement exist

outside of health care

Simplification of core

premises and

processes for the day-

to-day care patients

Removal of accepted

system faults

Improving handoffs Bundles Triple Aim definition

Business case Optimizing stroke care Integration of behavioral

health and primary care

Production system

design

Safe transitions for

elderly patients

Palliative care

Execution model Remote monitoring of

patients

Primary Care 3.0

Risk resilience Antibiotic stewardship

High reliability systems

What Happens To These

Projects? Sound ideas for

improvement exist

outside of health care

Simplification of core

premises and

processes for the day-

to-day care patients

Removal of accepted

system faults

Improving handoffs Bundles Triple Aim definition

Business case Optimizing stroke care Integration of behavioral

health and primary care

Production system

design

Safe transitions for

elderly patients

Palliative care

Execution model Remote monitoring of

patients

Primary Care 3.0

Risk resilience Antibiotic stewardship

High reliability systems

Red=Waiting Green=Became a Program Blue=In Use in Other Programs

Innovation Team Linkages

Initial Set-Up of Internal Team

• Resources were made available by

management

• Weekly innovation team meetings (1 hour)

• Shared workspace – post all documents

• Every project has a content lead, an innovation

thought partner and a research assistant

• Shared timeline within the 90-day cycle

• Discuss the progress of each project every 4-6

weeks in the IHI Innovation Meeting

Discussion Point #3

Innovation Team Linkages

Innovation

Team

Management

Team

Field

•Lab Sites

•Spread Sites

1. Push

2. Pull

3. Laboratory

Relationship

4. Delivery

•Publication

•Capacitation

38

Alignment!

What are Your Linkages?

Where Does Innovation Come

From?

Thinking differently about old problems http://www.youtube.com/watch?v=AmyBp8e76eY&feature=related

Where Does Innovation Come

From? • Innovations come from within research and

industry (e.g. diagnostics, therapeutics, technology)

• ―Bi-directional‖ innovations (e.g., community care givers, pt extenders, NPs) – Nigel Crisp

• Disruptive innovations (e.g., mobile communications technology) – Clayton Christensen

• Innovations come from the ―lead-users‖ (staff & patients) – Von Hippel

No Scarcity of High-Impact

Innovations in Health Care • Very low birth weight baby survival (surfactant,

NICU technology)

• Vaccine discovery and development

• Disease eradication: smallpox, guinea worm, river

blindness, polio

• Diagnostic tests (malaria spot, HIV saliva, TB

nucleic acid test)

41

―Bi-directional‖ Innovation…Learning

from Low Income Settings

• Plumpy‘nut ready-to-use nutritional supplements

(? Laced with antibiotics)

• Sunflower seed oil for newborns

• LifeSpring Hospitals; Narayana Hospitals – low-

cost, high quality maternity; low-cost high-quality

cardiovascular hospitals in India

• $300 house - Vijay Govindarajan

42

Disruptive Innovations

• From the outside: DVD rental by mail rather than in-store

• Targets an underserved market: Low-cost airlines

• Initially inferior to existing products: Original digital cameras, Swiffer mop

• Less expensive than traditional product/service: Dental whitening strips

• Enabled by evolving technology: Movie rental to streaming online

Christensen, C. Innovators Dilemma

―Learning Health System‖:C3N

• Membership network of providers that share data and innovations to improve care for children

Social: Development of patient communities in rare conditions

Technological: Use passive reporting, Facebook & Twitter to understand disease progression

Scientific: Data sharing across distributed network allows real-life efficacy studies

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

2007 2008 2009 2010 2011 2012

RemissionRate

Year

PercentofIBDPa entsinRemission

Figure1

Innovating at the Front Line

with Lead Users

Can process improvement, lean, or reliability

science produce true innovation? YES!

• Noticing, testing, adopting - Accidental Innovation

• Promoting and celebrating positive deviance - Intentional

Innovation

• Respecting those individuals with strange ideas and

rewarding disruptive innovation

Rogers‘ Diffusion Curve

Lead Users

Innovation by definition, precedes market acceptance. - Clayton Christiansen

Discussion Point #4

• Where might you turn for ideas that you

could test in your systems?

• Can you think of some lead users in your

system: patients, families, staff members?

They might be a good source for initial

testing

New Threats

• Rising rates of harm

• Resistant pathogens

• Overuse

• Spiraling health care costs

A thriving innovation engine…

• Innovation cannot be viewed as

technology alone

Three Dimensions of Value:

The Triple Aim

Health Outcomes

Patient Experience

Per Capita Cost

A thriving innovation engine…

• Innovation cannot be viewed as

technology alone

• Innovation needs community

IHI Innovators Network

185 organizations around the world

52

140 members and counting…

A thriving innovation engine…

• Innovation cannot be viewed as

technology alone

• Innovation needs community

• Innovation needs recognition

• Innovation requires failure

―I did not fail one thousand times;

I found one thousand ways how

not to make a light bulb.‖

Thomas Edison

A thriving innovation engine…

• Innovation cannot be viewed as

technology alone

• Innovation needs community

• Innovation needs recognition

• Innovation requires failure

• Innovation needs a technical method and

deep practice

Malcolm Gladwell and

10,000 Hours ―The emerging picture

from such studies is that

10,000 hours of practice

is required to achieve

the level of mastery

associated with being a

world-class expert–in

anything.‖

A thriving innovation engine…

• Innovation cannot be viewed as

technology alone

• Innovation needs community

• Innovation needs recognition

• Innovation requires failure

• Innovation needs a technical method

• Innovation needs funding and time

Perspective http://www.youtube.com/watch?feature=player_embedded&v=cDDWvj_q-o8

Thank You

kmate@ihi.org

Appendices

Degree of Belief that an Innovation

will result in Improvement

de

gre

e o

f b

elie

f

Prototype

Phase

Pilot Phase

Adapt &

Spread

High

Mod

Low 1 org

5 org

25 org

125 org

R&D

Full

Scale

625 org

All

Case Study: Topic Selection

61

• Request from Executive Quality Leader‘s Network:

―How do we create a culture of safety?‖

• Program in development: ―How does organizational

culture foster and sustain the highest levels of

performance?‖

• Portfolio request: Culture of Safety has become a

cornerstone of safety programs, with weak

evidence that it is associated with lower rates of

harm

Day-5 to 0

Components of a 90-day Project 62

Charter, Intent and Sponsor

• To answer the question—―How does one create

a culture of safety and excellence in health care

delivery systems?‖—with the aim of helping

leaders draw closer to excellent performance

across the organization

• Deliverables: We will define what such a culture

looks like, how culture can be changed, and if

and how it contributes to high levels of

performance

• Sponsor: Portfolio and program leads

63

1-7

Days

Background

• Culture of Safety has become a cornerstone of safety programs, with weak evidence that it is associated with lower rates of harm

• Evidence: • Cochrane Library: No evidence that organizational

culture change efforts have changed clinical outcomes -Cochrane Review 2011

• Annals of Int Med 3.15.11 – Better AMI outcomes in organizational cultures that support improvement

Lessons from Scanning and Interviews:

Cultures Change, but Slowly

• Leaders at All

Levels

• There is a reason – a motivating

factor – to want to change

• Set aims

• Select vital behaviors – work on

―things‖ not ―culture‖

• Set structures that foster

behaviors

• Persist

65

ChangeRole of Structure in Causing Change

1

4 3

2

Adapted from Improvement Guide 2nd Edition, Figure 13.4 p 316

Source: Improvement Guide 2nd Edition, Figure 13.4 p 316

Components of a 90-day Project 66

Focus: Changing a Culture

• Great cultures were fascinating but

it was time to focus on how cultures

change: • Boston after the Marathon

• Alcoa under Paul O‘Neill

• Virginia Mason under Gary Kaplan

• We had a theory: One does not

change culture, one changes

behavior and culture follows

• Time for testing and visiting

67

28-

66

Days

Examples of ―Culture‖ Change

Acute Care Examples:

• Bellin Health-

Execution

• Virginia Mason

Medical Center-

Lean

• Cincinnati

Children‘s-Safety

• Denver Health-Lean

and Equitable

68

Military

Alcoa

Creating a Culture of Excellence:

Theory

Aims

Structures and Methods

[governance, training,

incentives, rules, hiring]

ID Vital

Behaviors

Catalyst Environment,

Leader…

Attitude Change

Climate and Culture Change

Front Line

Mid

Managers

Leaders

Behavior

Change

Adapted from Improvement Guide 2nd Edition, Figure 13.4 p 316

What are Vital Behaviors?

• Those few behaviors that: • Drive toward the desired outcome

• Are teachable, coachable, and observable

• Often in evidence already: • To lose weight: exercise at home; eat breakfast;

weigh daily

• To help children read: more praise than punishment; constantly alternate teaching and questioning

• Patterson et al. Influencer: The Power to Change Anything (2007)

What are vital behaviors for us?

Components of a 90-day Project 71

Handover

• A Culture of Excellence is…

• A Minicourse

• Integrated into Other IHI programs

• Leadership, Middle Managers

• Executive Quality Leaders

• Safety

• The Concept of Vital Behaviors is Widely Used Within IHI in Coaching Organizations

• It is not yet its own program, perhaps never will be

72

What‘s Next?

• What are some tests you can try when you get home?

─ Think small

─ How will you evaluate?

• What are some other industries you could visit?

• Have you identified an area in which you would use this technique of observation and idea generation?

Exercise if needed

Core Concepts vs. Specific Ideas

Vague, strategic, Improve process to reduce anxiety

creative

Give patients and families access to information

Use beepers for family and friends waiting

Specific, actionable, Make beepers available to

Results families of all surgery patients 1 day next week

ConceptAn opportunity to create

a new connection

Thoughtprocess

Specificidea B

Specificidea A

What Change Can We Make

that Will Lead to Improvement?

Core Concept: A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement

ConceptAn opportunity to create

a new connection

Thoughtprocess

Specificidea B

Specificidea A

What Change Can We Make

that Will Lead to Improvement? Change Concept: A general notion or approach to change that has been found

to be useful in developing specific ideas for changes that lead to improvement

ConceptAn opportunity to create

a new connection

Thoughtprocess

Specificidea B

Specificidea A

Let‘s Get Some Ideas!

Core Concept: A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement

Creativity Techniques

Take your idea and… • Apply it to a different object – yourself, a unit, a process…

• Use a different verb

• Add constraints – if you only had $10, if you only had 1 minute or

1 day, if you had a team of 1, 10, 100…

• Substitute something – functions, relationships, theme,

message, environment…

• Combine it with something else – another process or

object…

• Eliminate something – smaller, streamlined, separate parts…

• Reverse or rearrange it – sequence, layout, schedule,

environment, priorities, people, goals, roles…