Dr. Robert Wachter, Editor, AHRQ WebM&M: What got you interested in quality improvement and safety in the first place?
Dr. Brent James: I arrived in Utah in 1986, after completing my surgical training and advanced training in cancer statistics. At that point, people who had studied variation had looked almost exclusively at hospitalization rates. I think we were one of the first groups to carefully document massive variations within a single facility for carefully matched patients by nursing units or by individual physicians across time. We started to follow up on the variations. We couldn't determine who was right or who was wrong, but we could sure show that they were different. And we raised that as a question to the experts and the physicians themselves. Why are you so different? What is the best care for patients? When we did, we provoked a firestorm, frankly, a discussion about best clinical practice within our medical staff. We demonstrated a fairly massive narrowing in the variation that seemed to arise from those professional discussions, and it was associated with big improvements in clinical outcomes and at the same time significant drops in cost of care delivery. Deming had a theory that described what we were seeing, and we started to apply it within clinical trials within our system. That first big trial for postoperative deep wound infections, the idea of timing a prophylactic antibiotic, was published as the lead article in the New England Journal of Medicine in January of 1992, and this served as the foundation of the NSQIP measures. What the Journal did not allow us to publish was the cost consequences of massively reducing our postoperative wound infection rates. Today of course it's a no-brainer. At the time it was amazingly counterintuitive. But we built from there and just started to expand out.
RW: You were looking at care delivery from a business, a process, and a statistical perspective. How did you feel about this work as a clinician, and how did other clinicians take this work when you first began to introduce it?
BJ: At one level it made perfect sense. The key point here is the idea that this should have started in the House of Medicine. It fits our values so well. I'm trained in surgery. Deming's key concept of having a defined process is nothing new to any surgeon. Let's put it this way: when I was in the middle of a standard case, I expected to be able to put my hand back and have the scrub nurse put the right instrument in my hand without a word being said. The reason is that we always did them basically the same way. I did it because it made me faster. That means I didn't forget things, and then the big one—if things went south—I knew where everything was. But this idea of process management at an intuitive level, we've been following for generations.
Our little branch of research led us into the concept that every physician was a standalone little law unto themselves. At our flagship LDS Hospital, where we first started to measure this, every surgeon had his or her own different process. And we started to ask why? Why are we different? What does it mean? How do we know what's right for a patient? How do we find best care? And of course what Deming was teaching us was that our clinician outcomes and costs were two sides of the same coin. And nearly always they went as a set. I'd found myself in a unique position. I was the third physician in Intermountain's management ring. The understanding that the clinical values that had driven me so heavily for so many years were just the flip side to the administrative problems that faced my colleagues now in this new job, you see, that was a key insight right there. That the way to get to administrative efficiency was by better care, not by rationing care.
RW: I found it interesting when you said that this was so consonant with our values as physicians that it was surprising that we needed outside help. Yet you and others have written about the culture of medicine being so individualistic. It sounds like we came into this with a culture that you would expect would create tremendous variation from doctor to doctor.
BJ: Looking back, that's absolutely true. Of course it came to be called the craft of medicine, a cottage industry, where it's based on purely personal expertise, personal perfection, if you will. Speaking as somebody out of a surgical background—that concept is so central to what it means to be good, I mean for your patients, the best you can be. You don't want to lose that personal dedication. But you start to extend it a step further.
Where it ended up for us was a form of Lean. It actually happened in 1991, when a fellow named Alan Morris, a pulmonary intensivist at LDS, had a major National Heart Lung and Blood Institute National Institutes of Health grant to test a new Italian artificial lung for the treatment of acute respiratory distress syndrome. We were having trouble with our control arm—standard ventilator management. We documented massive variations from intensivist to intensivist in terms of how they set a ventilator. This was almost an ideal model for understanding the expert human mind in the craft of medicine, and how it worked by pure dumb luck. We discovered significant variations in a single attending physician, morning to night on the same patient. It was the core complexity problem. It turns out there were about 40 significant classes of information that the attending physician should consider. The Educational Psychology literature held the answer. It showed that the maximum number of factors an expert clinician could address was about nine. Well, 40 is more than nine. In fact, if you worked it backwards, if you just assumed that every time the physician saw the patient they were subconsciously and randomly selecting six, seven, or eight factors to optimize, you could completely explain those ventilator settings. We showed the same thing for choice of antibiotics for otitis media in a carefully controlled trial. So that was the setting. What came out of it was a form of what we call Lean theory. Jim Womack had published the book, The Machine That Changed the World, which laid out Lean the year before. And Dr. Morris came up with a really clever idea. He asked what would happen if we establish an evidence-based best practice protocol, fully understanding that you really can't write a protocol that perfectly fits any patient.
Now I would argue that this is the core of that culture. All clinicians who practice for any time at all quickly understand that every patient is different. And this idea of a cookbook, a straitjacket, it just doesn't fit reality. Well, we thought that was fundamentally true. You can actually make the case in a fairly convincing way that all patients are different. So we established an evidence-based best practice protocol fully realizing that you could not write a protocol that perfectly fit any patient in the vast majority of circumstances. There are a few narrow circumstances where you can. To our physicians I say, ladies and gentlemen, it's not just that we allow or even encourage that you adjust this to the needs of your individual patients, we demand it.
RW: Let's talk about your role as an educator. I'd venture to say if we asked people around the world to talk about your legacy, it would probably be as much around your education of thousands of clinicians and leaders in the science of quality and safety as about your work in quality improvement. What got you involved in doing that kind of work?
BJ: We got interested in that from a couple of different things. I'd come out of an academic background and it just seemed like a natural thing to do. We wanted to deploy it broadly within Intermountain, get more people involved in actual teams. The real impetus, though, was Dr. Deming. We got to talking about exactly the issue that you just raised, the culture. As Dr. Deming told me one day, if you want to change the culture of an organization, you don't have to get everybody, but you do have to get what he called the square root of N. Meaning that if there are N individuals in the organization, you need to really educate the square root of that total. He said, convince that many and it will start to take on a life of its own and drive itself ahead without you there to keep it going all the time. We put together that course and specifically targeted thought leaders. Our aim was to convert them, to make the scientific case that this was the right way to go.
We did other things that were really important. The first is that we built firmly on the foundation of medicine. By that point, we'd understood that there's a whole bunch of jargon with improvement, but you didn't have to use any of it; you could describe the whole thing in the language of medicine. So rather than asking the natives to learn quality improvement jargon, we spoke the language of the native. The second thing was that in order to graduate you had to complete a successful improvement project. Our aim was to get hands-on experience that was real. And boy did that ever turn out well. I mean, not every project turned to gold, but I'd guess about one in five of the projects hit a home run.
The third thing we did was to include cost outcomes in parallel with the clinical outcomes. This was Dr. Deming again giving us that theory. But it was also just the demands of our administrative team. We did rigorous evaluations to show accountability back to the people who had sent us out to do the work. We could show at least a six-to-one return on investment from those projects that turned to gold. The reason we could show it is that we were tracking cost outcomes. It became quickly apparent that this was almost an ideal way to put organizational resources behind effective change in the organization. At the same time, you were cranking out a group of people who fundamentally got it. They tend to become quality zealots. They understand it in the context of our shared professional values. We went after physician leadership and nursing leadership. In 1991, Scott Parker, our then chief executive officer (CEO), mandated that all senior executives come to the course. It created a shared vision that drove a massive amount of change within our organization. It turns out that course was almost ideal. I have never seen a better way for driving organizational change.
RW: It sounds like there was a leadership imperative. But this was in the era before public reporting and pay-for-performance. As you began diffusing the course to other organizations and other individuals where there might not have been a leader saying you must do this, how did you get people into the seats?
BJ: For our physicians, of course, they're mostly community based. We couldn't mandate it. We got them there by attracting them with better clinical outcomes. So you take a few early adopters who are willing to engage intellectually. My job is to make them successful in a very transparent way. Data. I'd come in behind them. I'd help them with the theory. I'd help them with, never money, but usually some resources. Somebody to go collect a little bit of data; I'd help them with the analysis. Then my main role, believe it or not, was to trumpet their success. I could brag about them a lot better than they could. So every place I went, if you saw me coming down the hall, you could count on me buttonholing you and telling you about the last couple of great projects and who did them. And then creating opportunities for the physicians and nurses who led those projects to speak about it broadly and report it broadly. It's the best way in the world to lock them in. This kind of an approach, you see, they just got a constant steady song, a symphony of success.
It was those successes—then what happens next of course is you get a certain amount of a Tom Sawyer whitewashing the fence. Other clinicians looking and saying, well, you really ought to do this part this way. And your response to those is, well, you think so? That's a good idea. What if we tried it in your practice? Can I put in some measurement for you? Let's give it a shot. Next thing you know, you've got somebody else on board and then you've got a few more on board, and the next thing you know, you're well past the tipping point. You're well into the early adopters. And then the late adopters. And of course, at the bottom, there's always a group of people who will fight you to the bitter end. Rogers called them laggards. And what I discovered is that they were never going to change because of me. They were never going to respond to Intermountain. It's when their colleagues within the profession started to lean on them. You know, Doctor, exactly what is it that you don't understand about elective induction? Coming from the other obstetricians, that is normative. That's what drives that last bit of behavior out. It changed the discussion. Instead of arguing about whether we should do it, we started to argue about how we did it. And the infrastructure we needed in the system to make it happen consistently.
RW: It sounds like you made a lot of decisions when you started that worked out very well. Were there any decisions that you made that you wish you had done differently?
BJ: The honest truth is that one of the very good things about Intermountain is it doesn't count as a failure until you give up. On almost any one of these, I could show you the first three or four failures. But we are very good philosophically as an organization at trying and adapting quickly, shifting and trying again. Try and adapt quickly, shift again until you find one that hits. Here's the funny thing. I tend not to keep the early failures. I sometimes wish I had, just to show the path. This is a very common pattern for us. And the second funny thing is that I have to work hard to even remember them. Because what sticks in your mind is the final success. Oh, the first few tries when we were sharing data about variation in our quality improvement studies back when we first started, some of those were pretty excruciating. And all that you did, you're scientifically honest, you're an open learner, you model behaviors you like others to show, and you rolled back and hit it again to find truth.
RW: One of the tensions I think in teaching quality is data versus stories. And you come at this from a data background and a statistical background. How do you balance the need to dive deeply into statistics and data and variations with the kind of compellingness of the N of one case?
BJ: The key factor in any teaching is telling good stories. I realize that human beings learn from stories. The real question is whether the story is representative of the underlying population distribution or the principle you're trying to teach. So over time you build up a library of good stories that are designed to illuminate, bring to life, and elucidate particular principles. An honest teacher very carefully makes sure that the stories they tell are representative. That's exactly what you do: you tell the story and then from the story you extract truth. Adult learners come to you with a lot of experience, and you're connecting into their own history and experience. Of course if you're teaching at a university where you basically have a tabula rasa, no background, you use a very different technique. But for adult learners this is just absolutely critical.
We've trained about 3500 senior health care executives through the advanced training program: 42% physician executives, 25% nursing executives, 17% support staff, 8% CEO/chief financial officer types. They come from around the entire world. What happens when you get in that class, though, take any issue…you're going to see it from six or eight different perspectives because we have different people from different communities from around the world. You get huge insights from the stories and from the discussion. Then of course your job as a course leader is to link it back to verifiable scientific truth to the best of your ability, or at least to be precise and say here's what we know. "This one's reliable, this one has a certain amount of degrees of freedom in it, right? We're not sure that this is quite right." So that you're fairly precise about what is reliable truth versus what areas give you more wiggle room.
RW: You've done this now so many times that I'm sure you have a fairly clear idea of what works, and yet you have learners who bring so much to the table that you've got to give them enough freedom to essentially remake the course in their own image. That seems like a tricky balance.
BJ: It's actually one of the great joys of the course. There's not one of these where I haven't learned something important. It comes from that hands-on experience. These are people with some real knowledge and ability, and so you're leading a discussion to find truth within the group. Most of the arguments that come up I've been through 20 or 30 times. I've had a chance to explore them from many different viewpoints and so you're moving toward a particular view. Frankly, what I do usually to help the class move is tell stories. You tell a story that illustrates a key principle and then let people see a clear path to a valid solution. So that's part of your job in doing this. The other thing is that we now have about 40 sister training programs up and running. Institutions across the country, around the world, eight of them are international, have started with the Intermountain ATP (advanced training program) structure and have always modified it of course to fit their local environment. But we have a real collaborative now running of people who teach these things broadly. It's really kind of taken on a life of its own. I can't tell you how gratified I feel to see my students going out and changing the world. I feel like I lit a spark. They had the fuel and most of them burn true, in some sense truer than I do. I'm honest with them. I say I plan to steal shamelessly and I do.
RW: One of the new phenomena here is that medical schools, nursing schools, and residencies are beginning to try to teach this content. So there's a different kind of learner. Not quite the college student tabula rasa, but probably closer to that than the senior physician executive. What advice do you have to them as they try to figure out how to teach this quality and safety?
BJ: The key is finding faculty with enough stories to tell, enough background to be effective. It's that faculty development cycle so far as I can tell. I think that we're starting to get enough people within the profession that there's a base against which you can draw. This is one of those tipping point phenomena, and it's going to pick up a lot more speed as it moves ahead. You have to have experienced faculty who understand the principles and can tell the stories and lead people through a successful project the first time. The same faculty members have to be of sufficient stature to deal with the naysayers. In any group there's a group of laggards, and you have to be able to answer them in a reasonable way. You won't convince them, but that's not your primary goal. Your primary goal is to not undermine the others who are trying to move ahead, if that makes sense. So you have to have people to play that role.
RW: I'm interested in whether you explicitly set out to teach culture and leadership, or you think those things flow from other kinds of content that people are getting during your courses.
BJ: Change theory is so central to the whole course that we don't have a specific breakout section on it. We try to build change theory into every piece of it. You see, any good data on problem solving comes down to two fundamental questions. The first is aim to find the system; to quote Dr. Deming, what's your aim? The second one is, what's your change theory? Most people leave off that second one. How do you expect to drive change? What's your theory for change or how you move things? Now having said that, I do very explicitly teach leadership.
My favorite way to frame it has to do with Taylorism, the top-down approach. The best description of it is, how do you move the leader's ideas into the worker's hands? Deming taught a very different approach based around something called fundamental knowledge. The idea is that the only person who actually knows how it works is the person who does it every day. That there's a difference between theory and practice. The director points out that there's a strong tie in this concept to education level. That if you have a very poorly educated work force, then probably top-down is the answer. But that as your education level comes up, fundamentally, senior management doesn't know what's going on. I say that as a senior manager, by the way. And those bottom-up structures just become absolutely critical. So I try to make a compelling case for bottom up in our personal behaviors.
Every physician has the potential to be a Taylorist, relative to how they treat nurses, for example, or treat junior physicians as far as that goes. Nurses exhibit the same behaviors. Administrators, let's not even go there, it's built into the structure, this top-down approach. Half of the culture shift is making people open enough and humble enough to realize that maybe we don't quite have the answers and then finding a mechanism by which we can get something closer to the truth. This ability to shift rapidly. I'd like to believe that that's one of the things the ATP does most effectively, is show people how to be an effective change agent and an effective leader along the way. But we try to build it into every aspect of the course, start to finish.