Strange | Strategy and Change Shirine Moerkerken HRO Mindful Organizing in an Intensive Care Unit...

Strange| Strategy and Change

Shirine Moerkerken www.shirine.nl

HROHRO

Mindful OrganizingMindful Organizingin an Intensive Care Unitin an Intensive Care Unit

Fourth International HRO Conference

April 20 & 21, 2011

Twitter: @StrangeShirine#HRObytheDutch#InterveningWithPassion



What can you expect in the next 3 What can you expect in the next 3 minutes?minutes?

1. Situation: An Intensive Care Unit

2. Intervention Strategy: negotiating and experimenting

3. Results: To what question is HRO an answer?

#HRObytheDutch #HRObytheDutch #InterveningWithPassion#InterveningWithPassion



SituationSituation• 24 available beds• 8 doctors• Teaching hospital: fellows and doctors in

training• 130 nurses (that are not all ‘die hards’

anymore)• The question is not anymore: ‘can we keep the

patient alive?’, but ‘when do we add limitations to the treatment of the patient?’

• ICU as an important ‘player’ in the hospital: a better ICU means the possibility to do more complex churgeries

• Introduction of telemedicine




SituationSituation

This ICU:

•is regarded as one of the best in the Netherlands•keeps innovating and experimenting with new techniques with the doctors and nurses that started this unit 30 years ago




Question to the change accompanistQuestion to the change accompanist

We are the best ICU in the Netherlands…

Our knowledge is more than up to date…

Our protocols are precise…

Our equipment is state of the art…

And still, we think we can do better…

It has something to do with how people interact and we do not know how to improve that…




SituationSituationIssues are:

•We have 24 available beds, but due to a shortage in nurses, we never are able to open more than 18•The results of the Employee Satisfaction Research were alarming: employees are not happy to work here at all•Recently two patients died, which could probably have been prevented. Because of this, docters and nurses are restless. Some of them feel that they are to blame




SituationSituationA few examples of the nightmare ICU:

1.The suddenly instable patient

2.The departing patient

3.The patient with or without limited treatment

4.De nurse dressed as a civilian

5.The new equipment

6.The silent fellow




Intervention StrategyIntervention StrategyStep 1. Closing the mental contract

•Intake with the board of directors

•Intake with the 8 doctors

•Intake with the middle management

Is everybody in? And with what expectations?

•Negotiating meeting with doctors and management

What result do we want to accomplish together by introducing HRO?




Intervention StrategyIntervention StrategyStep 2. Creating shared references and shared sense of urgency

•Starting meetings with doctors and nurses• Nightmare and Dream ICU• Practicing in dialogue instead of discussion• Practicing in seperating observation,

interpretation and judgement• Creating experiments

•Meetings with doctors and managers• Leading the ICU: who decides on what?




Intervention StrategyIntervention StrategyStep 3. Learning by doing experiments

•Experimenting = possibility to make mistakes and learn from them

•Doctors and nurses work together in experiments

•Self organizing without the help of management

•Manager as coach of the experiment group

•Practice to not simplify: reflecting and evaluating




The HRO experimentsThe HRO experimentsShared references1.Explaining protocols2.Knowledge quiz3.End of life4.Talking blamefree about a situation

Redundancy:5.Time-Out6.Vliegende keep7.Blamefree evaluation of the day

Respect for expertise:8.Walk a mile in my shoes9.Frisse blikken spuien10.Telling stories

Focus on operations:11. To what question is this an answer?12. Think of your hat, stay on your seat




Intervention StrategyIntervention StrategyStep 4. Collective Sense Making

•Reflection meetings and evaluation meetings• Practice not to simplify• Acting AND reflecting

•Meetings with doctors and managers• Coaching the experiments• Explaining, sensemaking and being resilient• ‘Think of your hat and stay on your chair’




Intervention StrategyIntervention StrategyStep 5. Anchoring HRO

•Three gangs that keep HRO alive:• Content• Patterns in interaction• Leading

•HRO starting meeting for new employees

•Three rounds of HRO experiments each year




ResultsResults• Informed culture:

• Dialogue instead of discussion• Observation, Interpretation, Judgement• Checking assumptions

• Focus on mistakes:• I am a human being and do not have to be

perfect• I am not alone• Sometimes I just don’t know

• Not simplify:• No jumping to conclusions and solutions• Acting AND reflecting• CreatING shared references on f.e. protocols

and on end of life decisions




ResultsResultsIn short:

Doctors and nurses together:-Determined what can be improved in this ICU concerning quality of care, patient safety and cooperating-Created experiments to constantly improve-Used their experiences in the experiments to introduce new ways of working that improve alertness of doctors and nurses and therefore improve patient safety




To what question is HRO an answer?To what question is HRO an answer?

•HRO is not an answer to creating an even more perfect ICU

•It is an answer to creating more alertness between doctors, nurses and docters and nurses in working together. So that they can deal with unexpected events

•Mistakes will still be made, but doctors and nurses will notice weak signals early and will give strong responses to that weak signals. And that creates better patient safety


Strange | Strategy and Change Shirine Moerkerken HRO Mindful Organizing in an Intensive Care Unit...

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