peer review

Boston Children’s Hospital – A Case Study

Dayna McCabe, Yathish Gangadhar, Nicole Wei

Transforming Organizations LDR 6150 80553 Courtland Booth June 21, 2017

Organization Overview:

Boston Children’s Hospital is one of the nation’s leading children’s hospitals and is ranked in the top three of all pediatric specialties and number one in many others. Staffing over 13,000 employees and 800 volunteers, The Boston Globe has ranked BCH as of the top places to work. Boston Children’s Hospital main campus is located in the Longwood Medical Area of Boston Massachusetts, BCH also has satellite locations across Massachusetts. Partnering with Dana Farber Cancer Institute and Harvard University, their impact isn’t restricted to the Longwood Medical Area. Boston Children’s Hospital treats over 2,000 international patients from approximately 165 countries each year. making this one of the largest pediatric medical centers in the world.

Background Information:

There is currently an ongoing transformation that the hospital has undertaken since the fall of 2015. Senior leadership decided that Boston Children’s Hospital would become a High Reliability Organization (HRO) as part of a patient safety program. A high reliability organization is defined as “an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity.” Through adoption of an error prevention curriculum that 100% of staff must participate in, staff of all disciplines are trained to commit to using low risk behaviors to ultimately prevent human error and mistakes that can cause harm to patients and staff.

Issue:

Through the implementation of this high reliability initiative, there have been many groups who are enthusiastic about these efforts, and there are many individuals averse to participating. The organization has realized there are many difficulties and barriers around implementing an institution wide initiative/culture change. Some of the pushback has caused delays for the project, and there have also been many modifications to accommodate the requests of many groups and individuals. This case study will look through various frames to analyze possible reasons for the difficulties of implementing an organization wide effort. We will then hypothesize some of the potential issues that could be creating barriers for this type of global effort.

Key decision makers:

Before we begin to analyze the organization through various organizational frames, we would like to identify significant roles within the organization and who are some of the decision makers around these types of efforts. The strategic leadership team involved in this initiative involves many teams and individuals as follows: the senior leaders including CEO and COO, all VPs and department directors, and mid-level managers. In addition to this internal staff, there was also an external consultant involved with recommendations for best practices around implementing an organization wide effort. When the initiative was first launched, department managers were instructed that they would be trained to teach the curriculum to the staff. Managers and leadership did not feel that it would be best carried out if they were instructing the staff nor did they have the time to do so. This was one of the first modifications that were made to the program. In place of management teaching this training, they were allowed to nominate one member of their staff to go through the training in their place then commit to teaching the required hours.

Today the hospital is a little over a year into the journey of becoming a high reliability organization, but there are still nuances that need to ironed out to make this a sustainable effort. For example, this is an organization that is constantly hiring new staff, associated personnel, remote employees and temporary staff. Another significant barrier that was identified quite early was the need for this curriculum in other languages. Boston Children’s Hospital has a diverse staff and it is not feasible to have a cookie cutter training that is relatable and appropriate for all. Though the early stages of project planning and initiating, many of these necessary modifications were changed to accommodate these types of suggestions.

Structural Frame Analysis:

Boston Children’s Hospital similarly to Harvard University functions as a professional bureaucracy with a divisionalized form. Control relies heavily on professional training and specialization of expertise. The work is done in various departments and individual programs; each individual division of medicine or specialty has its own unique approach to medicine and teaching. The way that work is differentiated within the organization naturally creates a space where conflict and barriers are made plausible, particularly when adopting new policies from an operations standpoint. There are many factors that compete for stakeholder’s attention. Specifically, at Children’s Hospital there are chiefs and top doctors who ultimately drive patient care, there are department administrators that are concerned with operations and interdepartmental initiatives, and there are multidisciplinary teams who approach patient care with a varied approach. “Professional bureaucracies regularly stumble when they try to exercise greater control over the operating core…hospital administrators learn this lesson quickly, and often painfully, in their dealings with physicians” (Bolman, 80). Ultimately, all parties want what is best for the patients and families they serve, but each individual department and program within a department have different needs. I think this is evident in the implementation of the safety training because the implementation for the Cardiac Surgery staff would look very different than the implementation for the Food Services Department, or the Research Innovation team. Aside from the obvious like work schedule and clinic structure, the way a training program is presented to the whole staff cannot be a one size fits all approach.

It is possible that part of the reason the leadership struggled to get buy in across the organization is because they failed to converse with the appropriate stakeholders on what the needs were for this initiative to have the greatest success rate possible. For example, it could be considered unreasonable to require staff to attend a training that was 12pm-5pm when their regularly scheduled hours are 7am-7pm. Alternatively, it could be considered unreasonable to require they attend the training from 10am-3pm in the middle of their scheduled shift. What works for one group or team may not as easily work for another subset of people. In failing to speak directly with the people that would be impacted, leadership would fail to address the diverse needs of their staff and respective programs.

Human Resource Frame Analysis:

Looking at Boston Children’s through a human resource lens, the notable reputation of their clinical staff, leading research centers and world renowned notoriety; Boston Children’s Hospital clearly recruits and retains the top talent in pediatric healthcare. Even their external facing website broadcasts their success. For example, when you Google their name the first link to populate reads Boston Children’s Hospital | Ranked Best Children’s Hospital. This has significant symbolic meaning for the organization to advertize their rankings. We will talk about symbolism later in this case study. Once inference we can make regarding the initiative to take on a hospital wide safety training tells us a few different things about the company. First and foremost, requiring this for 100% of their staff tells us that they are serious about patient safety. In addition to the training being a safety initiative, we have to conclude that BCH is invested in its workforce. When discussing the undertaking with a current staff member, we are able to learn a bit more about what this implementation looked like from a logistical sense. Each and every staff member would need to attend a consecutive five-hour intensive training, and then be held responsible for learning the material, and showing evidence of it in their work through their direct supervisor. It is quite significant for the company to require this from their entire staff.

Stakeholder buy in is key when attempting to initiate efforts that affect an entire company, especially one as large as Boston Children’s Hospital. Sudden change or operational implementation cannot come as a surprise to managers and their teams. Usually, when presented with change and directions to restructure, team leaders can become defensive of their people’s time and resources. When the BCH leadership decided to make this initiative mandatory to all staff, it would be wise to involve some of the people affected by the decision. When restructuring it is crucial for a company to “develop a new structure that is tailored to the company's needs, taking advantage of the wisdom within the organization and engaging key stakeholders” (Forbes) As we know, the right structure and professional development can enhance a team and individual’s performance. This idea is also relative at an organizational level.

One recommendation that could help BCH implement an organization wide initiative would be for leadership to communicate their vision regularly and often with department directors whose programs will be impacted. The Harvard Business Review emphasizes to, “plan communications across all steps of the reorganization. Start with transparent information: what will happen, when, and whom it will affect. Try to excite people only after it’s clear what they will be doing. If you try earlier, they won’t listen, and you’ll come across as detached” (HBR). When an organization’s leadership can collaborate with throughout the ranks with transparency and trust; they increase their effectiveness for success.

Political Frame Analysis:

The Leader responsible for implementation of HRO training program (for patient safety and reliability) should present a proposal the management with the aim of:

· Allocation of budget for rolling out the training program

· The benefits reaped by conducting such a program

· The clear demonstration of Return on Investment (RoI)

Peter Drucker hypothesized that if an organization could increase employee productivity by 10 percent, the organization’s profits would double. If we can coach individuals to come up with their own solutions that they are committed to, this will ultimately be far more effective than a “better” solution we offer that they are less committed to. If we wanted to use a formula to demonstrate the difference suggested by this approach, we could measure the gain as Quality of solution x level of Commitment = Benefit level or [Q x C = B].

We understand that the objective of the leadership programs is to enable and train managers to handle more responsibilities and social problem solving. Skill based approach laid emphasis on skills that can be acquired and competencies that can be mastered to become effective leaders (Mumford, Zaccaro, Harding, Jacobs & Fleishman, 2000). It is important to know that if leadership skills are taught, it is easier to create effective culture of leadership in the organization. The three leadership competencies problem solving skills, social judgment and knowledge do result from experience over period of time and also depending on the complexity of the environment we all operate.

Framework for rolling out the training program (FUEL framework)

1. Framing the initial conversation:

Training Head handles overall skill development initiatives in the organization and should schedule regular one-on-one meetings with the department heads to identify the training needs that are useful in domain and functional applications at all levels (entry, mid management and senior management).

The leader should also explore if the internal existing expertise should be utilized to train the other associates in the organization, similar to “Train the trainer” concept.

2. Understanding the Current state:

This step will result in knowing the current competencies and identifying what can be accomplished with the current know-how.

3. Exploring the desired state:

The outcome of this state is the gap analysis that will enable the training manager to draw up answers for all the questions what senior management can pose during the review of the proposed plan. This phase would throw light on the goals to be carried out, the possible plan of action, what might work and what might not, the barriers to be abrogated and other key points can be addressed.

4. Layout of the plan:

The importance of Accountability to ensure the plan (Zenger, Stinnett, 2010) is achieved by:

· Develop and agree on an action plan and timelines

· Enlist support from others

· Set milestones for follow-up and accountability

A hypothetical proposal:

· Step 1: Net approximation of benefits: Identify 10 managers who have already undergone a similar training before in last 2 years and draw a feedback survey to calculate the benefits of the program, application in real world and performance benefits calculation by calculating the delta of parameters before and after the program – productivity, conflicts, motivation, reduction of number of incidents and others. Extrapolate the results equivalent to 1000 employees who intend to undergo this training program. Attached the monetized value of net benefits (B).

· Step 2: Sign in 10 previously trained experts to act as trainers who will train at least 50 newly identified candidates for the HRO. Calculate the Opportunity Cost of efforts these managers have to invest in training others (C).

· Step 3: Identify the topics and phases to roll out the program. Assume that 50% of the program can be trained in-house. Remaining 50% has to be outsourced. Calculate the budget for the in-house training program including the consultant fee to develop customized curriculum (D).

· Step 5: Calculate the revised budget for the outsourced training program (D)

· Step 6:

· The positive difference of (B) – (A) indicates the RoI for the existing program (E)

· The positive difference of (B) – [(C)+(D)] indicates the RoI for the revised plan (F)

· The positive difference of (F) – (E) indicates the net gain from the revised plan.

This is the budget for which the training manager has to negotiate with the management

Symbolic Frame Analysis:

Bolman (2013) What images or associations come to mind when you think about each of these?

“The symbolic frame focuses on how humans make sense of the chaotic, ambiguous world in which they live. Meaning, belief, and faith are its central concerns. Meaning is not given to us; we create it.” (Bolman, 2013) An organization’s culture is revealed and communicated through its symbols. BCH culture is presented in many forms: vision, story, heroes and heroines, logo, tagline, and etc.

· Logo: The logo’s primary colors are Boston Blue, Boston Sky, and White.

· Tagline: “Until every child is well” is a mission statement and a promise. It speaks to our tireless commitment to improving the lives of all our patients and their families through top-quality pediatric health care.

· The Boston Children’s Hospital logo is the primary visual identifier of their brand. It is composed of the nurse-and-child seal and the Boston Children’s logotype.

· Vision turns an organization’s core ideology, or sense of purpose, into an image of the future (Bolman, 2013).

· Stories: BCH stories are inspired by their patients

· Myth & legend: Boston Children's Hospital is known worldwide for its current and historical achievements. From surgical innovations performed by doctors to the discovery of new treatments by researchers, the hospital continues its excellence in providing the proper care and attention to all of its patients.

· Diversity: Boston Children's Hospital has made a major commitment to diversity on all fronts.

· Overall, Boston Children’s Hospital’s photography style is genuine, unexpected and sensitive.

BCH brand message — They want people to feel:

· Confident that they are getting the best care at the hands of experienced, accomplished and knowledgeable pediatric professionals.

· Respected as partners in the healing process.

· Valued in everything BCH do.

· Inspired by BCH passion and commitment to pediatric healthcare . . . Until every child is well

Suggestions:

According to HBR article, three steps to a high-performance culture, reliable formula leaders can use to create a distinctive performance culture in their organizations.

1. Establish a common understanding of culture and metrics for it.

2. Focus on the few changes that matter most.

3. Integrate culture change efforts with business improvement initiatives.

Works Cited (needs to be completed)