20 Years of Sessions

Prescribing the wrong drug. Removing the wrong organ. Making the wrong diagnosis. This list of medical nightmares had been on Saul Weingart’s mind for some time while he was a resident at the Beth Israel Deaconess Medical Center in Boston, one of the premier teaching hospitals in the city. Was there a way to prevent these errors, he wondered? He had been to the Annenberg Conference, considered to be the birth of the modern medical error movement, and knew that others were also grappling with the same question.

Then one day, during his final year of residency, while
on vacation at home with his wife and new baby, Weingart
MPP 1984, PhD 1989 remembered the community policing executive session at the Kennedy School that he had sat in on as a student more than a decade earlier. He immediately picked up the phone.

“I called medical guru Lucian Leape, adjunct professor at Harvard’s School of Public Health, out of the blue and pitched him an idea. To his credit, and with characteristic vision, he agreed to meet,” says Weingart. “We talked about the idea of starting an executive session in medical errors as a way to understand why health care organizations had done so little about error, given the impressive research results.”

Once Leape was on board (As Weingart noted, “You don’t just go to people at Harvard and say, ‘Hey I have an idea!’ You need to get the Pope to the table first.”), Weingart approached his old friends and mentors, Frank Hartmann and Mark Moore MPP 1971, PhD 1973, who had together pioneered the use of executive sessions and had refined those efforts over two decades of experience.

“What was clear was that a lot of the solutions to medical errors were with organizations. It’s not simply that incompetent doctors are out there: the process we use to deliver care is poorly designed,” Weingart says. “I thought this kind of thinking was ripe for an executive session, which is about pushing the envelope. It seemed like a nice marriage.”

Hartmann and Moore agreed, and the Kennedy School’s Executive Session on Medical Error and Patient Safety was born, running from 1998 to 2000.

New Approach
Weingart’s idea is just one of more than a dozen ideas that have been developed into what the Kennedy School calls the “executive sessions.”

Conceived during the late 1970s, when the school was still in its infancy, the sessions bring academics and leading practitioners together as a working group for several years running to search for answers to important public problems — like medical errors.

“At the start, it was believed that academics would benefit from more direct contact with practitioners,” says Dick Darman, professor of public management and the man given credit for initially coming up with the session concept. “The school was very young and heavily rooted in academic analysis without much participation by or with practitioners, as is characteristic today.”

The need for such a collaboration seemed obvious, Darman says, and had the potential for a threefold benefit to the individuals involved: practitioners would benefit from exposure to more substantive information and historical context relating to issues (the academic side), as well as the chance to brainstorm ideas with other practitioners that they wouldn’t otherwise have contact with. Academics would benefit from a connection to people actually working on the front lines of an issue — police officers, caseworkers, city managers, doctors, CEOS, and legislators, for instance (the practitioner side).

There’s also a larger benefit to society, says Moore, professor of criminal justice and director of the Hauser Center for Nonprofit Organizations, who, along with Hartmann, organized the first session on juvenile justice that ran from 1983 to 1987. Both have been involved, in some capacity, in almost all of the subsequent sessions since then (14, as of December 2001).

“The executive sessions are a way of changing the world,” Moore says, admitting that although there’s a certain amount of grandiosity in that kind of statement, “Ideas matter. Our main effort is to get beyond the bounds of the academy and into the heart and brain of the real world.”

“Academics don’t own the executive sessions. It’s not our ideas being used,” says Hartmann, an adjunct lecturer in public policy and executive director of the Malcolm Wiener Center for Social Policy. “This isn’t Harvard teaching members of the sessions, which is always a disaster. An executive session is based on an inherent respect for practitioners and their expertise and wisdom.”

Case in point is the most known of the sessions, the one on policing, which started in 1985 and was so useful that the group renewed itself and continued until 1991 — two to three times longer than other sessions. This session did, in fact, get into the heart and brain of law enforcement, as Moore had hoped, and listened to what those most knowledgeable in law enforcement had to say. As a result, community policing, as we know it today, was strongly influenced by these sessions, helping to revolutionize the way that police departments across the country operate.

However, the session didn’t start out with the specific goal of making community policing its main focus. Like all executive sessions, it started with a broad practical problem to be explored by the group, which consisted of the U.S. attorney general, the head of Scotland Yard, and police chiefs and mayors from cities across the country.

“It’s less a single question than it is one problem that we return to a hundred times during the course of the session,” says Moore, explaining that this allows the group to track progress and stay focused. “You need the initial framing issue — the issue that brought people to the group to start with — which is often at a very high level of abstraction.”

With the policing session, the broad framing issue was how to use an asset — a police department — to make the widest contribution to a community. But then a unique question was posed to them at the first meeting: Are you responsible for fear in your community? At first, says Hartmann, they didn’t know what to think.

“The question set them back on their heels. When we asked if they were responsible for crime, they all said yes. But fear? They said no. This eventually turned to maybe,” Hartmann says. “Fear is actually much more destructive to a community than crime is. It makes people retreat to their houses and afraid to wait for buses in the dark. As the group thought about this, they changed their answer to yes and started thinking about how interesting the question was — it’s a whole different way to use a police force. Responding to crime after it happens, which is what most forces were doing at the time, wasn’t working, they said. Thinking about prevention would be a whole different deployment.”

What evolved from the policing session was a realization that the same old methods of law enforcement weren’t working and that a change was needed. That change turned out to be community policing, a concept built on reconnecting police with neighborhoods and making them feel safer, with the involvement and support of the community. Today the number of police forces across the country that follow this model has dramatically increased.

Key Elements
Key to the success of that session was the willingness of those involved to look outside the box and rethink how and why they do their jobs. This willingness is aided by an air of safety created in the meetings: all sessions are off-limits to the press; even the transcripts are confidential to members only (major news outlets have called asking for copies and have been turned down). Keeping the sessions closed allows members to take risks and throw out ideas that may not be good or are unheard of in the profession.

Also key to the success of the executive session model is time: there’s lots of it. Unlike the more traditional forms of interaction — seminars and conferences that last a day or a week — all executive sessions are “non-conferences,” as Dean Joseph S. Nye, Jr., once referred to them, and meet several times a year for two or more years straight.

“The core sensibilites in executive sessions roll out as people take the ideas, mull them over, experiment with them, have other ideas between meetings, then come back and talk to each other over a fairly long period of time,’” says Hartmann.

“At a seminar or conference, I tell an audience about what I’m doing. It’s factual,” adds Weingart. “But an executive session is different. It’s a working group. It’s not a seminar with a wise speaker communicating information to an uninformed audience. It’s about creating new knowledge…. In many ways, it’s less an exercise in finding facts than it is in seeking wisdom.”

Being at the right place at the right time also makes executive sessions more valuable. While the medical errors session was meeting, the Institute of Medicine (which included four members of the school’s executive session) released a report on medical errors that, while not new news, made a big splash in the media. Suddenly, the topic of patient safety was hot.

“An executive session is aided if there’s trouble or confusion in the field,” Moore acknowledges. The Executive Session on Domestic Preparedness, which had already met five times before the September 11 attacks, certainly fits that bill.

As Juliette Kayyem, co-director of the session, told the Bulletin last fall, the “likeliness” debate over terrorism happening on American soil was still going strong until the day the Pentagon and twin towers were attacked, meaning few thought the nation needed to be so focused on the issue. “People said the [national] domestic preparedness program was overfunded, a way to justify bloated budgets. Now the debate is totally over. Unfortunately.”

Today the issue that Kayyem and her colleagues have been talking about since 1999 — being prepared for future terrorist attacks — has suddenly become a household conversation, making the work being done with fire and police chiefs, emergency management administrators, mayors, and city health officials in the executive session even more timely and critical.

“The rate at which that group makes progress will skyrocket,” says Moore. “The earthquake hit.”

Other current and future sessions are dealing with hot button issues as well. One on faith-based and community approaches to urban revitalization starts in the spring, in collaboration with the Harvard Divinity School and Stephen Goldsmith, President Bush’s former advisor on faith-based initiatives. Another, still in the planning stages, addresses the “backlash” against the work being done by international nongovernmental organizations. More recently, a session on the future of public service is exploring ways to make a career in government appealing to more Americans. At their second meeting in February, the group focused on recruitment, including limitations of the current government hiring practice. Looking at this “human capital crisis,” the public service session includes members of Congress, federal employees, CEOs, and think tank executives.

“Getting the right people means a lot of different things. ‘Right’ means people who have weight in the outside world, as well as people who are able to use this opportunity to learn,” says Moore. “You need both.”

Hartmann explains that the number of academics is purposely kept small, usually around five. The rest are practitioners who are literally responsible in some way for the issue.

“These are people who are so much a part of the conversation that they are accepted in the conversation,” Hartmann says, which is why as many as six months are spent up front making phone calls, talking to people, and reading to find out who should be included. Candidates must have a “shelf life,” Hartmann says, meaning they aren’t going to retire or move to a new career while in the session or shortly thereafter. They must also be good listeners and well regarded in the field. Commitment is also important: after the first or second meeting, the core group is formed and sealed shut, more or less. New members are not allowed.

“After the first meeting, we might say, ‘X would really
add to the conversation.’ But after the second meeting, you have to be hard-nosed about not letting new people into the conversation,” Hartmann says. “In a subtle way, their coming together as a group is seriously affected in a negative way by that. If a new person comes in after the third or fourth meeting and says, ‘You’re doing what?’ the others get scared and pull back. It hurts the progress of the group being able to boldly move forward.”

The Impact
So what happens after the group does move forward and the sessions end? Do they, in fact, change the world, as Moore hoped?

He believes they do.

“The executive sessions start influencing the world from their first meeting. They are not like commissions, which exert little influence until they have produced their final report. They start to change the conversations around the country throughout their lives,” he says. “The influence comes from the fact that a wider community is interested in what is going on at Harvard, and that the members of the session are in constant contact with that wider community. It is a porous boundary between the session and the field, and it is a continuous dialogue that goes on rather than thought, followed by conclusions, followed by action. It is ongoing dialogue that produces the results, not just a powerful conclusion effectively disseminated.”

Invigorated members go back to their agencies and classrooms with new ideas and visions that infect and influence others. The medical errors session, for instance, helped to keep the dialogue about patient safety going because most of the session members were people who run major hospitals or health systems and sit on related commissions.

“It’s hard to say that we’re responsible for ‘X’ percent of the medical error movement, but we certainly created a consensus among major stakeholders that medical error and patient safety wasn’t just a doctor issue,” says Weingart. “This kind of organic process is hard to justify or measure…but several members credit the executive session with an awakening about patient safety, and when you look at major organizational innovators in the area across the country, executive session alum account for most of them.”

The policing members chose to organize a large meeting and invited many of their colleagues. They also wrote pieces in various journals and sponsored an ongoing series of papers called “Perspectives on Policing” that were mailed to about 30,000 people and have become community policing training materials used by police departments and academies. In addition, says Hartmann, the session “…won the war on rhetoric on what policing was all about.” When the sessions first started, he did a literature search for the term “community policing” and got about 10 hits. In time that grew to 30 hits, then 80, then a couple hundred. In addition, recruitment firms started to report that when they were interviewing chief of police recruits, the term not only came up in the conversations, but that’s all that came up. “We could see the term coming into common parlance,” Hartmann says. “People know now what it means.”

This spreading of ideas — whether it’s tangible with policy papers and quotes in newspapers, or more fluid through conversations with colleagues — is exactly what Hartmann and Moore hoped for when they ran with Darman’s idea nearly two decades ago.

“We hope that in the end, members change the way they and their organizations think, and raise the level of dialogue within their profession to a level that challenges conventional wisdom,” Hartmann says. “Some may even change conventional wisdom.”