The situation:
In 2012, the cardiac surgery program at the Sunnybrook Health Science Centre in Toronto was in distress. The program had reached a flashpoint after public reporting of surgical outcomes indicated poor performance. Although based at the Hospital for Sick Children, my role as the Division Chair of Cardiac Surgery for the University of Toronto made me responsible to help design an intervention to change the trajectory of the Sunnybrook program.
Upon initial review of the Sunnybrook program, it was clear that there was a lack of alignment between the surgical group, the cardiology group, the anesthetists, and critical care. There were chilling discussions of closing the program entirely. Morale was extremely low in a program that had traditionally carried great pride in delivering excellent care. Consequently, there was a well-recognized ‘burning platform’ and a clear need for a decisive intervention to restore quality and save the program.
First step - Boots on the Ground:
The first step was a comprehensive ‘boots on the ground’ diagnostic evaluation which demonstrated that a major driver for the lack of alignment between groups was related to several years of diminishing financial resources due to budgetary pressure. ICU bed availability was a key site where the limitation on financial resources was most apparent. As each group struggled to maintain clinical volume, there was intense competition for ICU beds. As volumes diminished, the rationale for obtaining additional financial resources was paradoxically undermined. Decisions to proceed with surgical or cath lab cases were increasingly predicated on the sudden appearance of an available ICU bed - leading to on-the-fly decision making to take advantage of an available bed. Keeping a patient in an ICU bed to maintain control of the bed led to diminished overall efficiency and consequently further erosion in clinical volumes - which, in turn, further undermined any rationale for increasing available financial resources. Highly charged, stressful, and non-productive conversations became commonplace. Decision-making to decide which patients might undergo intervention was non-transparent and made outside of multidisciplinary venues. Reporting of outcomes was also not transparent and untoward clinical events were held up as ‘proof’ that one group or the other was providing inadequate care. The program was in a death spiral.
Second step - Design an intervention as a team:
After the comprehensive diagnostic evaluation, we spent six months of intensive activity developing and implementing a plan to refocus the Heart Center. Weekly Town Halls were held to create shared consciousness and focus the team on realignment. At first, it was relatively easy to define our overall objective (excellence in patient care) and then we drove consensus that change was required within the Heart Center, within each group, and within each individual if the program was going to survive. Next, we focused on potential roles for individuals in the redesign of the Heart Center. A ‘menu’ of involvement was presented to the membership of the Heart Center including the following roles:
Architect – Anyone interested in designing the new structure and processes in the Heart Center was invited to participate. The price would be a lot of work.
Participant- Anyone could elect to be a participant and would be expected to join working groups and contribute to the process of redesign as developed by the architects.
Bystander- Anyone could elect to simply go along with the changes and provide passive support through cooperation.
Sniper – Anyone wishing to sit in the back row offering nothing but negativity was asked to leave the organization.
As the Town Halls progressed, we worked towards identifying and articulating the problems being faced and the structure/processes needed to address them. To prescribe solutions, our first focus was to clarify our priorities (what were our highest priorities?). This sounds like a simple issue and one might reflexively state that the highest priority was improvement in clinical outcomes. In fact, it quickly became apparent that the competition between cardiology and cardiac surgery for resources (e.g. ICU beds) was intense and evaluation of decision-making processes demonstrated that decisions were not necessarily always based upon the best outcomes for and individual patient and instead unconsciously focused on preservation of resources. Gaps in trust between groups made it difficult to have rational conversations about sharing the resources focused upon prioritization of individual patients.
Third step – Implement the plan:
To address gaps in trust, the conference structure for clinical decision-making was reconfigured to provide completely transparent multidisciplinary decisions. Perhaps most importantly, the conferences included a requirement that the entire team collaboratively assess ICU bed availability and decide upon prioritization of cases with ICU beds as a shared resource. Forcing the group to prioritize utilization of ICU beds was a key ingredient in the overall strategy to improve alignment.
Secondly, the institution of ‘Performance Rounds’ (as developed by Dr Ed Hickey) was an important step towards providing transparency in outcomes. ‘Performance Rounds’ are a vehicle to encapsulate each patient’s journey with the objective of identifying every positive and negative aspect of the patient’s experience in a transparent forum with evaluation and discussion from the entire team. During Performance Rounds, physicians, nurses, therapists, and administrators reviewed every patient’s journey regardless of whether or not there was a ‘complication’. Invariably, in every patient’s journey there were opportunities for improvement in clinical care, emotional support, logistics, team interaction, timing etc… The ensuing discussions were rich and provided each group with new and transparent assessment of patients undergoing care in the ‘other’ group. The clinical groups quickly learned that they shared problems in patient management and could focus on patterns of management to improve care. Importantly, the groups could also focus on issues related to patient satisfaction which were universal between specialties and critically related to diminishing clinical volumes. Transparency and visualization of patient trajectories actually highlighted the alignment between teams as improvement in patient experience was becoming the unifying theme for a program that had only recently felt that it was disintegrating while under siege. It was remarkable how transparent identification and review of deficits in care actually united the group.
Using the Clayton Christenson model of organizational identity (resources, processes, priorities), it was clear that there was opportunity to improve alignment between the clinical groups and the hospital administration. As noted, a major driving issue was severe restriction in resources (ICU bed availability). At first, the clinical groups were fixated upon the idea that the solution for all problems was in the hands of the Hospital Administration – all they needed to do was to simply open more ICU beds. In fact, this ‘simple’ solution was a financial impossibility in the short term and deflected attention from the inefficient management patterns that had developed as a consequence of mistrust and lack common purpose between clinical groups. After alignment of priorities between groups focused on a shared mission, ICU beds were prioritized through consensus-based clinical decision-making processes which resulted in increased efficiency of bed utilization because all groups were aligned to shorten ICU stay by making good clinical decisions, working collaboratively to prioritize the patient above group-centric priorities, avoiding complications, and developing better processes to move patients more efficiently through their clinical course. Greater efficiency diminished ICU demand and as the Hospital was able to add more resources, the Heart Center was able to continue intensifying focus on optimization of patient care.
Current status:
In summary, the Sunnybrook intervention resulted in recognition of need for change to a true Heart Center model with clarification of a shared mission, engagement of team members as leaders with specific roles in reconstruction of structure and processes, and development of transparency in decision making, real time performance assessment, and development of quality metrics and transparent reporting. The heart center stabilized with this new organizational structure and processes and, as a result, clinical volume increased and outcomes improved over the next several years.
Was the intervention successful? The intervention in 2012 was recently described by the Chief of Cardiac Surgery, Dr Gideon Cohen as a ‘watershed moment with rebirth of the program through adoption of true Heart Center model’. Since the intervention, Dr Cohen and the leadership of the Heart Center and the hospital administration carried the momentum forward with hard work and excellent leadership. Persistence is the final critical ingredient in an intervention. Change is never as fast as desired, but as long as the foundation of the change is solid, excellent leadership can maintain the upward trajectory.
Currently, the Sunnybrook cardiac surgery program is now ranked #2 in Canada and is ranked #60 in the world. (Newsweek 2023 rankings). It is interesting to note that only 25 cardiac surgical programs in the United States were ranked higher than the Sunnybrook program in world-wide competition. Excellent outcomes indeed.
https://www.newsweek.com/rankings/worlds-best-specialized-hospitals-2023/cardiac-surgery