Judson Howe Maureen, take me to a moment that changed how you see healthcare forever and what you felt that made you say, I need to do something about this.
Maureen Bisognano I would say a very powerful moment for me is when I was a young nurse and I was taking care of my brother. I'm the oldest of nine and my brother Johnny was the third of our nine kids. And my brother was diagnosed with Hodgkin's disease, a kind of cancer. And I remember being in the hospital with my brother. And I thought my job as a young nurse and a sister was to give him hope. So every time the doctor would come in and give him a diagnosis or a return from a lab result, I felt like my job was to give him hope and to let him know that we were there for him and to take care of him. I remember standing with my brother when he was in the hospital, and all of the doctors came in to make rounds, and they were all standing with their long white coats around his bed and talking over him about his diagnosis and his prognosis and all of the lab results and the radiology results. At the end, they turned around and walked out and didn't communicate with my brother at all. I was a little bit taken aback, and one of the doctors walked back in, and he walked up to my brother, and he put his hand on my brother's arm, and he said, Johnny, what do you want? And my brother said, I want to go home. So the doctor walked over to me, took my jacket off me, and put it on my brother, picked my brother up, and carried him out to my car with the nurses running down the hallway screaming, you can't discharge him, you're not his doctor, you can't do this. And when I got Johnny home, that doctor had changed my life. He said, Johnny, what do you want? And when I got Johnny home, I said, Johnny, what do you want? And he said, I want to be 21. And he turned 21 on November 25th. That was Thanksgiving Day that year. And he died on December 1st. But those last two weeks at home were something I'll always treasure because we knew he was dying and he knew. We all could talk about it, what he meant to us in our lives. Everything about that, that last couple of weeks changed my perspective from being a young nurse thinking I was taking care of people to really thinking about a whole person and a family and what something as significant as dying meant and how I could work in a totally new way with
Judson Howe him on that. If you were to close your eyes and just picture that moment you brought Johnny home, what were the sounds, the sights, and what was the feelings you had when you brought him into the
Maureen Bisognano house. It was incredible. I remember sitting him on a chair in the living room with a nice
big quilt that my mother had made on him and saying, what do you want to eat? And in the hospital, they wouldn't let him eat anything. And we gave him everything. All his friends came. His very close friends from school came and all gathered around him. And each one got to tell stories. We told stories for two weeks about how Johnny made us laugh, how, you know, the things that he did when he was little. Each one of his friends was able to share what he meant to them. It was the most incredible way to think about what living and what dying meant. And every member of the family had a role to play. My littlest sister, I think she was about 12 at the time, her job was to put cream on his feet a couple of times a day. And that was her job and she loved it. Everybody took care of him. It was a complete way to help him to live those last few weeks with joy and to help him die in peace.
Judson Howe We hear so often that the healthcare system is broken. But can you bring us into one specific story from your journey at IHI, Institute for Healthcare improvement in your journey where you saw glaring proof of that brokenness? Who was hurt the most
Maureen Bisognano and how did it affect you personally? Well, I think that what IHI, what my work at IHI, I started as the chief operating officer when Don Berwick and I began IHI back in 1991. And then when I became CEO, one of the big frustrations I had is that how difficult it was to actually spread best practices. I loved harvesting. I began to work globally when I began with IHI and traveled all around the world and saw incredible improvements in the way we could provide health and care in other countries, in other systems. And I loved it. I loved being in the Netherlands and seeing the way that they cared for the elderly population and how they redesigned home care. I loved being in Sweden and seeing how they recreated care for little kids and for immigrants in that country. And yet when we came back to the United States, I found it so difficult to make those kinds of changes here. One, because of the system, the way that we get paid here, the volume-based care, where you get paid for a hospitalization or a procedure, to looking at the fragmentation in our system. Right now, we're looking at health care and taking care of sick people, when the joy that I got to see was taking care of people to prevent them from getting sick. And so I was so frustrated by seeing how good the health care system can be, and yet not being able to do it States, Don and I were, Don Berwick and I were sharing our frustrations one day and saying, how can we make healthcare better? And we called our kids, both my son and Don's son were working in campaigns. And they said, you need to run a campaign if you want to spread change quickly across the entire country. And they said, well, what do you want to do? And we said, we want to make it better really quickly. And they said to us, some is not a number and soon is not a time. We can't make some improvements whenever we want. We have to figure out how much we want to improve by when and then launch a campaign. So our kids taught us how to design a campaign. We said, okay, we want to save 100,000 lives. And they said, by when? And we said, okay, 18 months. And then we gave hospitals across the country some tools, six changes that they
could make that were proven scientifically, that were fairly easy to implement, that weren't costly, would actually save money and would make lives for patient and staff better. We asked hospitals across the country, help us to implement these six things quickly. We've only got 18 months. and we hired some very young people who got a bus and started going across the country to assure rapid spread of these six ideas. And at the end of 18 months, those hospitals had saved 122,000 lives. And it really changed my perspective on how we could make a really substantial difference when we trust the young and we take their advice and we launch campaigns like that.
Judson Howe Maybe understanding how effective IHI has been in the work that you and Dr. Berwick have done, what are some of your biggest disappointments of things you haven't accomplished?
Maureen Bisognano I would say right now I'm frustrated by our need to move upstream. I want us to think not only about improving health care, but how do we as health care leaders improve health? And it means we need a totally different perspective. Our job isn't just safely taking care of somebody when they come to the emergency department or safely providing a surgical procedure or managing diabetes. It's really prevention. I loved working at Cincinnati Children's with them when I was at IHI. They made rounds to every patient bed every day and say, what could we have done to prevent this patient from ever needing to be in the hospital? And it totally changed perspectives on the healthcare leaders because they started thinking upstream. This child has mental illness. How could we have built into the schools and into the care systems a way to take care of the stresses of being a child in these days and produce a mentally health population in that age group? How can we work with kids who have diabetes who can't afford meds? How can we look at obesity across the city and prevent obesity? Whenever I go into a hospital, the first thing I'll do is I'll say, can we go get a cup of coffee? And then I'll take the leaders down into the cafeteria because there's two things that I see. And immediately I see the culture of that hospital by the cafeteria. In some, you walk in and the very first thing you see is a big bucket of fruit. and it will say fruit, 10 cents. And if you want a candy bar, you have to walk all the way to the back of the cafeteria, and they're twice as expensive. In other hospitals, you walk in, and there's big bins of macaroni and cheese and fried chicken. And I'll ask the senior leaders, how can you be working on health if this is what you're feeding your employees? And they say, well, it's comfort food. There are many better ways to lead without creating obesity in the workforce. But it's really thinking upstream about what's our role in health, not just taking care of people when they need health care.
Judson Howe You got me thinking as you're talking about diet and what we promote, do you think that the personal health or the health lifestyle and choices of an executive matter?
Maureen Bisognano
Absolutely. Absolutely. I was working with a group of health care leaders in Wisconsin, in Green Bay, Wisconsin. And they were saying, we want to create a healthier community. We're going to go out to the workforces and ask all the employers in our community how they can make their workforce healthier. And I said, well, how about your workforce? Should we start here? And they looked at their own workforce. They started looking at sick days because of preventable illness. They started looking at the health of their own workforce, their own cafeteria. Right. And then those healthcare leaders started walking visibly every day. They would go out and walk, and they changed everything about sleeping and resting rooms and stress management and food in the cafeteria. And when they became healthy, when that leadership team focused on their own workforce and created the healthiest people in their community, then all of a sudden everybody else in the community, schools and businesses said, yes, come in and really let's work together
Judson Howe to create health. We want to move on a bit to diving deeper. Yeah. IHI has always been really effective. And yet here we are talking about problems in healthcare and what's broken. Why do you think, is America moving in the right direction in healthcare or are we moving the
Maureen Bisognano wrong direction. I don't think we're moving at all. I think that our payment system is holding us back and it's really causing different conversations. It's more about volume. How do we increase the number of procedures that we're doing? And the focus of healthcare because of the way we pay hospitals is really, I think, stuck in this mode of fee- for-service. I think I would love to see us And we're seeing some small examples start to emerge across the country that give me hope. Some examples of where health insurers, as an example, are new models of care are emerging. When we're starting to think about how do we partner with people? How do we co-produce health in families? How do we think about going to the schools and having little kids be focused on health? I really feel hopeful when I see those examples. I saw a wonderful example where there was a school I visited, first and second grades. And I looked around and I said, these kids are so healthy. And they started to laugh and they said that a few years before, there was an earl who lived in a big castle up on the hill in this beautiful town in Stirling, Scotland. and he used to come down to the school, the first graders and second graders, a couple of times a month and he would read and teach them poetry and music. And one day he said to the teacher, these kids are fat. And she said, well, that's not my problem. And he said, it is your problem. And so she started using quality improvement methods that we had taught her, running little PDSA cycles, plan, do, study, act.
Judson Howe So she's using healthcare techniques in her educational environment.
Maureen Bisognano Yes. So she took the first graders and she said, we're going to run a cycle. We're going to
run around the school once. And as she predicted, she said the kids were really tired and exhausted. They couldn't run the length of themselves is the way they say in Scotland. But pretty soon, she kept running PDSA cycles. And pretty soon, all the kids were running a mile a day around the school. And then all the teachers started to join. And then the kids would go home and say to their parents, you know, you're eating the wrong foods. You've got to start to run with me. Now the whole village is healthy because these teachers used quality improvement methods to create health in the kids. And I'm starting to see schools in the United States, in Chile, in around the world, pick up on ideas like that. I think when we can start to see the producers of health as more than the doctors and nurses, but how do we work with school teachers? How do we work with employers? How do we work across the community to bring people together and rethink health? We have a chance at improving health more quickly than we have a chance at
Judson Howe changing the payment system here. Yeah. It makes me, you know, humbled in the sense that, you know, I've spent 10 years trying to figure out how to make my communities healthier, but I'm almost hearing you say that I'm not the solution. Like almost like it's outside of healthcare where healthcare can be improved. Is that, am I hearing that correctly?
Maureen Bisognano I think you could be a help, but yeah, I think that we need to partner with people outside of the traditional healthcare system. We need to see school teachers and even police departments and all of these people as our partners. How do we bring them together and start to think about healthcare beyond the walls of a hospital or a clinic and start to say, if we want to produce health, we need to see all of the assets in our community. I've been teaching how to create an asset map, looking at school teachers, looking at police departments, looking at anybody in the community who wants to help as our partners in health. People think about the deficits. Well, I'll help them make a deficit map so that they can see it. Obesity rates, alcoholism.
Judson Howe You're thinking assets.
Maureen Bisognano And I'm thinking, but they have to make the deficit map for us because that's where the world that they've lived in. And then we move to the asset maps and it's making a big difference, but I'm seeing some hope in really fun ways to think about preventing illness and thinking about co-production of health as opposed to only taking care of the sick people.
Judson Howe You've mentioned the American system is largely volume driven or some would say fee for service. And yet over here, you're talking about co-production potentially making people
healthier. Wouldn't that be at odds with the economic models in the United States?
Maureen Bisognano It's at odds if you look at it only through the old lens. But I'm seeing hope. As an example, I was in Sweden and I said, take me to the place you're proudest of. Whenever I'm visiting someplace, I always say, take me to the place you're proudest of, because I would never know to ask. Take me to the patient self-dialysis unit. But that's where they brought me. And I said, tell me about this place. and they said there was a young mechanic from Saab Avionics. And he came down with glomerulonephritis and was on dialysis.
Judson Howe Is that a nephrology kidney issue?
Maureen Bisognano Yeah, and so he was on dialysis. And he would go into the hospital three days a week and spend a big part of his day there. And one day a nurse asked him, because she had heard me say, what matters most? And he said, I'm a mechanic. I can do this myself. Now, I know patients do their own hemodialysis and peritoneal dialysis, but what was different about what he wanted was he wanted control over everything. So he started doing his own dialysis. And then a 73-year-old lady in the next bed said, I want to do that. And then pretty soon they found that about 90% of the patients in the dialysis unit wanted to do their own dialysis. So the CEO of the hospital built a wing where the patients would come in, they schedule their own dialysis, they come in and do it all themselves, they clean the equipment for the next people. But when I asked, why didn't you want to do it at home? He said, social isolation. You're stuck there by yourself. For hours. Hours, every week, three or four days a week. They found that the social connection and getting healthy together was critical. So they're doing dialysis while they're on exercise bikes. I've never seen such a healthy group of people with a chronic disease as I did there. But they're riding the bikes while they're doing dialysis, yeah. And we're talking to Christian. He's the young man that started this whole thing. When I went to visit him most recently, he said, I said to him, tell me about your life. What is it that you want most? And the first time I asked him the question, he said, I want to get married. And I did get invited to his wedding. And when I asked him the next time, he said, I want to have a baby. And he's got two little kids now. He said, if he was in the old way of going to the hospital three days a week, he feels sure his life wouldn't be like this. But now he's working with me to spread this idea of patient co-production around the world. I brought him to Waco, Texas, where this community was largely Hispanic speaking. And we went into a dialysis clinic and he walked over to a patient and he started to turn the dialysis machine around so the patient could see it. A young man who looked just like him. And the nurse came over and said, don't do that. Don't turn it around. And he said, why not? He might touch it. He said, that's the whole idea. But this idea of spreading co-production and thinking about health, as opposed to just come in for your dialysis treatment, is now spreading across the United States. What gives me hope is that if we can prevent patients from having to be
hospitalized, from having to, all the complications from what happens. He said, dialysis care is much safer in my hands. One is I always do it the same way every time. The variation in people doing it when they're not me is cause complications. And two, he said, I'm healthier. I'm taking care of myself. It's my, I'm in control. And when, and now I asked him about his work at Saab Avionics, and he said, no, I went to nursing school. So now he's a nurse leader in Sweden, introducing these kind of co-production models across the whole healthcare system. If we start to look at it through a payer lens, what we're doing is shifting cost from the complications and the technology and building buildings to patients taking care of themselves. Through a payer lens, if you can look through it through this innovative way, we can save money in the healthcare system and produce better health.
Judson Howe You might need to explain more about what co-production is, but I do want to ask this question. Is co-production at odds with our language or our mindset around delivery of healthcare?
Maureen Bisognano Oh, yes. Co-production is a word that was developed by Paul Batalden a pediatrician who was one of the founders of IHI many years ago. And Paul began to think that we need to shift the balance of power. It's one of the things IHI has been working on for some time now is not that I have the power. You make an appointment to come and see me. You sit in the waiting room. When I have my nine minutes, I'll bring you in. I'll tell you what to do. And then you go home and do it. Paul came up with this idea that we could co-produce health and we could co-produce care. And I think that... Two different things. Yes, yes. Co-producing care is like sitting with Christian Farman and creating a totally new way to do dialysis treatment. When I asked the nurses who were working in Christian's unit, you used to take care of all patients. What do you do now? And they said, because they learned from Paul, we're co-producing health. I said, what does that mean? There's only one nurse now in this whole building. And she said, when I get a new patient, the first thing I do is I ask them to bring in their CV because a large number of them are not working. They're so controlled by their disease. And the first thing I do is I help them rewrite their CV and help them get a job. Now, that's a totally different thing. That's co-producing health while the patient is co-producing their own care. Talking to people in Ireland about mental health, because I, especially during COVID, had been interviewing patients all over the world about what were the key things that they were concerned about in not being able to access health care. And mental health came out loud and clear globally. When I was in Ireland, I said, tell me about this. In the United States at that time, I talked to people who were having severe mental health problems, including suicidality, severe depression. And I said, did you talk to your doctor about this? And they said, I called my doctor. It was in the midst of the health crisis. And the doctor said, you need to see somebody in psych. Call this number. If they could get through, they said, we can see you in six to eight months. That is just catastrophic.
Judson Howe
So they're having an acute mental health crisis.
Maureen Bisognano Absolutely.
Judson Howe And they're being deferred out six to eight months.
Maureen Bisognano Yes. So in Ireland, I said, how did you deal with this? And they said, we had the same problem. But what we did was we opened up recovery colleges. They said, instead of getting a diagnosis or a waiting list, you get a college catalog. And the college catalog has courses in it, like eating correctly, getting enough sleep, dealing with intimate partner violence, how to cope with depression in the workplace. When you get diagnosed or you know you're having a psychiatric problem, you get the catalog. You pick out courses and you sign up for the courses. And I went and sat in on the courses. All the courses are taught by people with lived experience in mental illness. And it was the most heartening thing I've seen to sit there and talk to people who said, I trust this person because I know they've been through the same thing I have. I know they know how to manage it. And I can look up to this person as my model. They sign up for the college courses and they're with people who are going through similar things. The recovery rate is incredible. The experience is timely and effective. It was just one of the most exciting things I've seen when we co-produce mental health with the community as opposed to put somebody on a waiting list for six to eight months.
Judson Howe I heard you one time talk about the connection between behavioral health, loneliness, and physical health. Just dive deeper a little bit for me on that connection.
Maureen Bisognano It is something that, again, I've learned in my most recent years, not something that I ever learned in my clinical experience and certainly not something I thought about when I was a hospital CEO or a nurse or a healthcare executive. It was something that I learned really working with Vivek Murthy, the Surgeon General of the United States at that time. And he and I started working with a group of people from across the country on looking at mental health and its correlation to physical health. And we got people from all different parts of the country together and started meeting and talking about this. And we started studying this idea of loneliness. I was just blown away by not only the physical impact of loneliness on depression, on physical illness, but on the whole life of someone who's feeling lonely. It just, it really feels like something that we should be teaching in nursing school, in medical school, and we should be rebuilding our healthcare systems about how to diagnose and treat loneliness as a health problem. It really bothered me to think that we're not effective at this. Now, I am seeing some wonderful examples from across the country and around the world in communities coming together to think about how to build a community. In California, there was a woman who was looking at obesity rates in young
children, and she decided to ride the bus with these kids to school every day. And she gave each kid $5 to buy a healthy lunch. Just to watch the impact of kids coming together and saying, you shouldn't be eating that, and don't spend your $5 on this. Creating a community of kids had a tremendous impact on their physical health, obesity, but also on their sense of community and belonging. I think that we've dramatically underestimated this kind of impact. Even when COVID hit, I pulled out my Christmas card list. And, you know, being from a big, giant Irish family, I have 250 people that I send Christmas cards to every year. And I made a list of all the people on my Christmas card list who live alone. And I named it my reach list. And every day since COVID started, I've called or texted or sent a card or did a video connection with at least one person on that reach list because they're alone. And what I found is tremendous gratitude that people feel like someone cares enough to reach out to them. But it also helps me. learned that as an example, empathy triggers a part of your brain that makes you feel bad because you see someone who's in pain. But when you do something about it, when you act, act with compassion or kindness and do something about it, not only does it help this other person, but it triggers a part of your brain that makes you feel better. So I found that my acting to try and decrease loneliness is helping them, but it's helping me as well.
Judson Howe There's a lot of assumptions in healthcare. A lot of them are biases. They're poorly informed. If you could snap your fingers and crush one of those assumptions, one that does the most harm to healthcare in America, what would it be?
Maureen Bisognano I only have one.
Judson Howe You can give as many as you want, Maureen.
Maureen Bisognano If I only had one, it would be this. It would be that we begin every clinical interaction with a different question. Some years ago, I was flying to Paris to do a plenary talk. And on the plane, on the red eye, I was reviewing all my slides. And then I happened to pick up a New England Journal of Medicine edition that said there was an article in there by Susan Edgeman Levitan and Michael Barry from Mass General. And I read this one sentence in there. and it said, we can't only ask what's the matter. We have to ask what matters to you. And that totally changed my thinking about healthcare. When I got to Paris, there were 4,000 people in the audience and I ripped out my speech and rewrote it on the plane and said, when you go back to work, I only want you to do one thing. Don't only ask what's the matter, ask what matters to you. Within a week, I started getting stories from all over the world. a nurse from Scotland wrote to me that she was a pediatric nurse. And she said, when she got back, she walked into her first patient's room, a little girl named Kendra. And she said, what matters to you? And her father was standing next to her and said, Kendra's 11. She's autistic. She's never spoken in her life. So the
nurse gave her a piece of construction paper and said, draw me a picture of what matters to you. And Kendra wrote, I'm Kendra. I'm 11 years old. I say hi by pulling your hair. I don't like medicines by my mouth, so I'll make a run for it. It's a three-person job. And she drew all these pictures of how to communicate with Kendra. That night, Kendra's father, who's her only caregiver, had a cardiac event, was taken to the adult hospital on the other side of Glasgow. And Kendra was by herself. But the doctors and has said, because that picture was on the door, we knew how to take care of her. If we went in and she pulled our hair and she jumped out of the bed and ran, we would have sedated her and restrained her. But we knew Kendra from that poster. And that spread all over the pediatric hospital and then adult hospitals all over the country. That nurse recently was named Scotland's Woman of the Year for changing the culture of healthcare in the whole country.
Maureen Bisognano Really?
Maureen Bisognano And it spread. I heard stories in Portuguese from Brazil, from all over the world, and people said that question changes everything because it really allows the person to say what matters. It's not, oh, I'm looking at your blood test results. It's what matters today. It could be I don't have food, I'm afraid. There's so many things. And that really brief question is creating a whole different conversation and really creating a change in the health care systems that are using that now.
Judson Howe You've seen a lot clinically, administratively, both as a hospital president and, of course, being a change agent with IHI. But what's been your darkest moment on your journey in health care?
Maureen Bisognano I have probably a few, but I remember being a very young nurse working in the operating room, my first job. And there was a tremendous sense of fear and hierarchy. And the surgeon asked me for an instrument and I handed him the instrument. It was the wrong one. And he turned around, it was a scalpel and he threw it at me and it barely missed me. And I walked out that day and said, I'm leaving the operating room and I'm going to go work in a different place where I feel like I have a sense of respect and a sense to make a difference. And I went to work in an ICU. It was in a brand new building and 14 beds. And every day I would walk through the 14 bed pediatric to get to the ICU. The ICU was filled every day. Patients in the hallway, patients in the emergency room, families were crying. It was just, and yet every day I walked through a 14-bed pediatric unit that maybe had two patients in it. And I read one day about a different way to manage ICU patients, this is how old I am, that was progressive care step-down units. And so I went to the head nurse, And I said to her, why don't we take over the pediatric unit and put a progressive care unit in there? And that will allow us to manage the patient flow much more effectively. And she said no. And so that night I couldn't sleep. And when I came in the next day, I said, would
you mind if I talk to the supervisor about it? And she said, no, go ahead. So I did.
Judson Howe Kind of dismissively.
Maureen Bisognano Yeah. Go right ahead. Yeah.
Maureen Bisognano Go ahead.
Maureen Bisognano Staff nurse, go ahead. And so I did. And the supervisor said no. And so I went to the vice president of nursing and she said no. And I finally asked if I go talk to the CEO and he started laughing at me. And he said, you're asking me to take the pediatricians out of their brand new building and move them back to the old building. And I said, yes. And he said, I'll tell you what, you go to the pediatricians meeting. If you can get them to move, you can have the unit. So I went to the pediatricians meeting and predictably they threw me out. In the next five months, I went six months in a row, and I learned really how to build a case for change. I learned that they all looked at me in a different way. But the sixth month, I started with a story. I started, and I could tell that I was touching some people's hearts of a patient who was separated from his family and couldn't get admitted to the ICU and had to be transferred to another hospital, and then all of the family reactions to that. I could tell I was getting to some. And then after the story, I extrapolated and said, it wasn't just this patient. This is how many other people are in the same circumstance. And then I told the human cost over time what that meant. And then I showed the financial cost. So I created this arc of story, extrapolation, human cost, financial cost. And I could tell I was getting to different people with different parts of the story. And at the end, they said, okay, I could have the unit. So I got the unit. Of course, I had to set up all the equipment, but it really taught me that, one, you need to be effective in communicating because people learn in different ways and have different priorities. Two, that you have to be relentless and you can't give up because if I took my first defeat, I probably would have left the ICU like I left the operating room.
Judson Howe What makes you so relentless?
Maureen Bisognano us? I think it's sitting next to a patient who's in pain, seeing that whole person and the patient. It's going back to my brother, Johnny. It's understanding that it's not just a diagnosis. It's a family who's going through something like this. And it gave me courage. And I think that that helped me to go from that staff nurse to a supervisor and then ended up as the chief operating officer in that hospital. And then I was hired to be the CEO of another hospital when I was 34 and a woman and a nurse. And at that time, that was very, very different. I was unique. And another painful lesson I learned was my first CEO
meeting, I walked into this very fancy room with about 30 other CEOs. It was my first one.
Judson Howe And you're younger at the time. I was 34.
Maureen Bisognano And they were all, I don't think there were any less than 60.
Judson Howe Was this pretty hierarchical as well, like the OR?
Maureen Bisognano All old white guys sitting around the table and me. And I walked into the room and one of the guys turned around and he looked at me and he said, honey, get me coffee.
Judson Howe Really?
Maureen Bisognano And I thought, how do I deal with this?
Judson Howe What'd you do?
Maureen Bisognano I'd be happy to get you coffee. How do you take it? And this afternoon when I want my coffee, you get it from me. and I take it black. And everybody started laughing. And I realized that anger wouldn't have gotten me where I got and ignoring him wouldn't have gotten me where I got. That humor and giving them a sense of my power was what really allowed my voice to be heard that day.
Judson Howe And your resilience. And you conveyed your power. I've been really curious lately, as I've reflected on my 15-year executive career. I feel like we've made some big changes in healthcare, but I also feel like we're, there's this big system, this big machine, and we've talked about some of the assumptions. We've talked about bright spots where you've had a chance to travel to other parts of the world and bring some of that back so effectively through your storytelling. But in this system, I've been reading this book called Thinking in Systems by Danella Meadows just up the street here in MIT. She passed away 20, 25 years ago, but she talks about leverage points, which are pivot points in systems where if we can identify the right leverage points, that we can have an outsized impact when we push on them. Through IHI's global work, what single pivot, policy, practice, or mindset can trigger outsized improvements in healthcare?
Maureen Bisognano Well, it's an interesting question. At IHI, we developed this way of thinking about change, which is will, ideas, and execution. You have to stop and build the will for change.
Judson Howe Is that kind of what you just talked about a moment ago with that method?
Maureen Bisognano Yes.
Judson Howe Story, data, human, finance.
Maureen Bisognano Build the will for change. Then you have to give people concrete ideas that they can implement. And then you have to give them tools like quality improvement methods and innovation models to implement them.
Judson Howe I want to repeat that. Will.
Maureen Bisognano Ideas and execution.
Judson Howe Will, ideas, execution.
Maureen Bisognano Although I will say that one of my team members was in Saudi Arabia, and she said, IHI, we teach will, ideas, and execution. And there was this huge gasp in the room where she texted me. I said, say, will, ideas, and implementation.
Maureen Bisognano Language matters.
Maureen Bisognano Language matters. Culture matters. But I think the whole idea is that we, I used to think that change came from the top down, that I could rely on really helping people to see the need for policy change. I'm thinking now that change happens from the bottom up. We've seen some incredible changes where if we can prove to lawmakers, to insurance owners, to hospital executives, that change can be better for staff, for patients, and for the bottom line, that that's how we're going to make change happen. It really, I think, starts from us proving that changes can make a huge difference and being able to articulate them the impact that's going to make a difference. So I think demonstrating that change can happen at a local level and then spreading it is very powerful. That can make change at a federal level. I've seen policy changes in the way we pay things happen from patients' experience being brought to Washington. But I think at IHI, we're focused on innovation. The current model's not working. We really need to both harvest ideas from around the world and bring people together to innovate, to create new models of care. Then we need to spread those reliably and quickly so that everybody gets the benefit of that. And then we need to exnovate. And that's my favorite word, exnovation.
Judson Howe Exnovation.
Maureen Bisognano Exnovation. That's getting rid of all the stuff in our lives that add no value. We're terrible at it in healthcare. If you walk into a hospital unit and you open a closet, you'll find old forms in there just in case, tubing that doesn't fit into any needles anymore.
Judson Howe Isn't that the entire EMR world? They've inherited the entire generation of
Maureen Bisognano workflows of American healthcare. Exactly. And so we need to get in and totally exnovate. When COVID hit and people were saying, I don't have any time to innovate. I don't have any time to improve. I said, exnovate. And that will give you time and energy to innovate. It's getting rid of everything, meetings. It's getting rid of looking at procedures.
Judson Howe Is it just like create over time these things that we've always done it this way?
Maureen Bisognano meeting structures and processes. And when we diffuse a new guideline, nobody undiffuses the old guideline. They don't call pharmacy and say, we're not going to use that med anymore. So we just add to the new one, add the new one onto the old one. We don't call central sterile and say, don't buy this equipment anymore. We're not using that anymore. We just keep adding and adding and adding. And I think exnovation is a powerful tool for us to get in and both decrease cost, but clean up our lives, take away a lot of the work that adds no value to us anymore and is
Judson Howe causing burnout in the staff. Give me an example, like a before and after of when you've applied this will and then communication, the tools. Give me a specific. So one example was working with a
Maureen Bisognano group of healthcare leaders. And I said, I'm going to talk about leadership, but I want to talk by interviewing a patient first. So they had me interview two patients up on the stage. And one of them was an elderly woman with breast cancer. And she was telling me how she had to take the chemo bus. I said, what's that? And they said, well, chemotherapy is so far apart that it's so far away from my home that I have to get on a chemo bus three times a week. And when she described her life. You could just see the leaders in the audience saying, how can we do this to people? And then the second person I interviewed was a young man in a wheelchair. And I said, tell me about you, Gilbert, and tell me about your life. And he was saying that when he was 19, he was meeting with one of his friends in Los Angeles, and they were afraid of gangs, and they were playing with a gun and his friend accidentally shot him and the bullet was still in his spine. So he'd been paralyzed
for many years and sitting in his wheelchair, he taught me so much about the wheelchair and about how he has to catheterize himself in the men's room. And then he said, and then I go wash the catheter in the sink. I said, why do you have to wash a catheter? And he said, there's a rule about you can only have so many catheters a week. And so I said, is there an impact. And he said, when he walks, he says, when I walk, when I walk, at least in a wheelchair, when I walk into the pharmacy, there's a shelf called Gilbert Cipro because I get so many urinary tract infections. And so I said to him, one of the doctors in the audience jumped up and said, Gilbert, I'll sneak you some extra catheters. I said, no, we've got to fix the system. So through Gilbert's story, we were able to tell the human cost. We were able to tell the financial cost of hospitalizations, of Cipro, of him not being able to work, and eventually got the system to change and then went to Washington and had the Medicaid rules change so that you were allowed as many catheters as you need, which was dramatic improvement in cost for them because they weren't having the hospitalizations and all the medications. So it's just an example of how I think you can tell a story, but don't give up on the one patient. But I'm having like an aha moment here, which is
Judson Howe you're saying, yes, be creative and human centered in the moment, but then don't forget the system.
Maureen Bisognano Absolutely. Do both. Absolutely. People will jump up in the audience and say, I'll sneak you this or I'll do you that. I'll get you in. They try and fix it for that person without seeing that it's the system. And so I think if you can create that chain of effect from Gilbert, why don't you have enough catheters? Well, there's a rule in the system that says I can only have so many per week. How many do you need? Many more than that means I have to wash them. After he washed them, the people in the men's room were going crazy. One of the doctors said, there is another way you can microwave it. But then he really started getting bad looks in the employee cafeteria, microwaving his catheter. But you can't leave it there. You've got to then go to the system
Judson Howe and then keep going through the payment rules. But that can be so exhausting.
Maureen Bisognano It can be. Yeah. Although it can be energizing too. When you start to measure how many hospitalizations you've decreased, when you start to measure the impact on Gilbert's life and then extrapolate it to how many other people. I said to all the people in the audience, how many other people in your system live in wheelchairs or how many other people in your system have to catheterize themselves. Nobody knew. Gilbert knew. But when you extrapolate and then you look at where are the barriers in the system, it gives you energy to keep fighting all the way for change. Let's look forward.
Judson Howe
I want to talk about liberation. And I know it's funny. It's actually not funny, but the political climates using that word today happens to be April too. When did you realize that you had to break free from your own limitations? Maybe self-doubt, old beliefs, the assumptions we talked about, or fear perhaps. I think we all have some fear underlying, but to become the leader that you are
Maureen Bisognano today. Well, I do think my clinical background helped because spending time at patients' bedsides with their families and the patients gave me a sense of the wholeness of the person, that it wasn't just that I had to go remove a Foley catheter. I was dealing with a person who was in the midst of a health crisis. And so that gave me a different perspective. And then walking around with Cincinnati Children's saying, how could we have prevented this, gave me a sense of community. How could we have, how could we work with people outside the healthcare system. Working with those kind of looking down at my own patients, then looking out at the community, it gave me, I think, a sense of hope that we could make the kind of changes that we need to make. I think the biggest change we need to make is perspective of leaders. I was a 34-year-old woman nurse who had to get coffee, but I learned that getting out and getting perspective gave me voice and that working to build the will for change was critical. And so I think the whole idea that I had was we can't only be an effective leader in the walls of our organization. We need to look outside and think upstream and co-produce health out in the community.
Judson Howe If there were no budget constraints and you could redesign healthcare entirely, what's the first radical shift that you would make?
Maureen Bisognano I think I would go into little community hospitals, little rural hospitals, and big hospital settings too, and I would convert them to health centers. We're starting to see this now with hospitals closing across the country because they can't make the business case for enough surgeries. They shouldn't be. They should be opening up, and I've seen some great examples of this in Memphis, Tennessee and around the world where they're taking old buildings, old buildings that used to take care of sick people and creating health centers. One, there's a gym in there where elderly people come and exercise. Not only are they getting physically healthier, but they have connections and they're working on social isolation. They go to the cafeteria and there's healthy food there. When many people can't afford to access healthy food, there's daycare and elderly care. combined where the older people are reading books to the younger people and the little kids so that people can work without worrying about cost of daycare. There are so many things that we can do if we think upstream and we think about co-producing health. So I get very excited when I get to go visit some of these places and see us moving from solely looking at the number of surgical cases on the schedule for today and thinking about the number of diabetics in the community, the people who are living alone, and how do we work in the community by creating a co-produced health and with all of the assets in the community.
Okay. So you're talking to a 34 year old Marie
Judson Howe Bezignano today, 2025. What are you telling her? I'm saying do what you're doing. I remember
Maureen Bisognano that my very first day at work, and I always give this advice to people when they're taking on a new job, plan your first day, because what you say and what you do is going to be visible to everybody. And it's going to tell everybody what matters to you. And I, my very first day, I spent the entire day walking through the hospital, sitting at patient's bedside, sitting in on staff meetings, sitting in the physician's lounge. I spent the whole first day saying, tell me what matters. And that became my agenda. I put it up on a piece of flip- flop paper on my wall. This is what matters. And listening to people's voices is so critical today. So I would say, do that again. I would say, get out into the community and do that as well. Go visit the places where people live. You'll get a sense of why they're being hospitalized. get out and make rounds. When I go to other countries and get to spend time in recovery college or in the Netherlands, in Berzog, which means neighborhood care, all of these new models of care are saying to my 34-year-old self, you can't only run the hospital effectively. You need to think about the health. And I would say the health of the workforce could come first. How do I create the healthiest workforce so that they create healthy families so that that's a lever to creating a healthy community?
Judson Howe If you and I were having this conversation again in five years, what data or proof would you give me to say that we've moved the needle in the right direction?
Maureen Bisognano I would say you could take a look at the workforce, the health of the workforce. You can look at mental health. Are you dealing with the kind of stress that people are working in, particularly post-COVID? And just the fact that we've gotten so much turnover in healthcare and we're having trouble recruiting new people. Is there a way that we can focus on the health of the workforce? In mental health, physical health, I would say walk around. Look at the number of times that your own workforce is hospitalized in a given year. What kind of medications are they on for chronic illness? Could we have prevented that? And then look at the health of their families. I can demonstrate how much I care by looking at the health of the workforce and the health of their families. And I think that gives us a lever to thinking about what our real mission is. Our mission is not only to take really good care of people when they're sick. And that means innovating new models of care and spreading them reliably, exnovating, but really thinking upstream about co- producing health as well as care.
Judson Howe If I've asked you a lot of questions, but what question have I not asked you that I should have asked you?
Maureen Bisognano um I guess um what I care most about is with my two little grandchildren now my grandson Jack's two and my granddaughter's two weeks Annabelle I would want for them to grow up in a different world. I would want for them to grow up in a world where from even their preschool, they're out learning about how to take care of themselves in a healthy way. The food that they get in school is healthy. The relationships that they build are healthy. And if there's a stress in the growing up period, that that gets dealt with so that they grow up in a vibrant, physical, and psychologically, mentally healthy way. And I would say, me, as I'm getting older, being a grandma, how do we take really good care of our older population? How do we think about what it means to be isolated, what it means to be disconnected and fragmented? You know, when you think about it, I was talking to someone recently who had some clinical symptoms. And he called his doctor and the doctor said, go in, run all these blood tests, have a CT scan, have a chest x-ray. And when the results came back, they were all negative. And the primary care doctor said, go to see this specialist, an endocrinologist and an epidemiologist. And this person spent about seven months, hundreds of thousands of dollars getting tested when it was a very simple vitamin deficiency. And I think we're often looking for clinical answers when the answer is much more holistic. I would say with medical schools, nursing schools, technical schools, rehab, anything, we need to start in the very early days to teach them about what whole health means, that it's not just your job to take out a diseased lung, but it's your job to really think about what matters to this person because what matters most might not be the clinical solution that pops into your head right away.
Judson Howe Thank you, Maureen, for your time today. I really appreciate all the work that you're doing to influence healthcare internationally, but also me personally. And I hope that this time, and I know that it will, will impact the next generation. Thank you so much for your time today.
Maureen Bisognano I'm so excited about the next generation. Trust the young. Ask what matters to them. And I think really spreading the whole movement, kindness in healthcare, is critical. The What Matters to You movement is now in over 50 countries. We started a movement called Kindness in Healthcare that is starting to influence nursing schools and medical schools. It's changing the whole culture of healthcare for young people. and that movement now is spread to over 25 countries. We need to make sure that every young student learns very early on that healthcare is not only curing but caring and we need to make sure that we take care of ourselves as well.
Maureen Bisognano Thank you.