Transcript Quality A - Amazon Web Services
Slide 1
Engaging Healthcare
Professionals to Transform
Care
10 April 2014
Gary Kaplan, MD
Chairman and CEO, Virginia Mason Medical Center
Jack Silversin, DMD, DrPH
Founding Partner, Amicus, Inc
Slide 2
Virginia Mason Medical Center
•
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•
•
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Integrated health care system
501(c)3 not-for-profit
336-bed hospital
Nine locations
500 doctors
5,500 employees
Graduate Medical Education
Research Institute
Foundation
Virginia Mason Institute
Slide 3
Our Strategic Plan
Slide 4
Seeing with our Eyes
Japan 2002
Team Leader
Kaplan reviewing
the flow of the
process with
Drs. Jacobs and
Glenn at Hitachi Air
Conditioning plant
Slide 5
Take-Aways
How are air conditioners, cars, looms and airplanes like
health care?
• Every manufacturing element is a production processes
• Health care is a combination of complex production
processes: admitting a patient, having a clinic visit,
going to surgery or a procedure and sending out a bill
• These products involve thousands of processes—many
of them very complex
• All of these products involve the concepts of quality,
safety, customer satisfaction, staff satisfaction and cost
effectiveness
• These products, if they fail, can cause fatality
Slide 6
The VMMC Quality Equation
Q = A × (O + S)
W
Q: Quality
A: Appropriateness
O: Outcomes
S: Service
W: Waste
Slide 7
New Management Method: The Virginia
Mason Production System
We adopted the Toyota Production System philosophies
and practices and applied them to health care because
health care lacks an effective management approach that
would produce:
• Customer first
• Highest quality
• Obsession with safety
• Highest staff satisfaction
• A successful economic enterprise
Slide 8
VMPS Tools in Action
• Value Stream Development
• RPIW (Rapid Process Improvement Workshop)
• 5S (Sort, simplify, standardize, sweep, self-discipline)
• 3-P (Production, Preparation, Process)
• Standard Work
• Daily Work Life
Slide 9
“Nursing Cells” – Results > 90 days
RN time available for patient care = 90%!
Before
• RN # of steps = 5,818
• PCT # of steps = 2,664
• Time to the complete am cycle of work = 240’
• Patients dissatisfaction = 21%
• RN time spent in indirect care = 68%
• PCT time spent in indirect care = 30%
• Call light on from 7a-11a = 5.5%
• Time spent gathering supplies = 20’
After
846
1256
126’
0%
10%
16%
0%
11’
Slide 10
Lindeman Surgery Center
Throughput Analysis
•
Before
Time Available 600 min
Today
600 min
% Change
0%
(10 hr day)
•
Total Case Time 107 min
65.5 min
39%
15 min
50%
(cut to close plus set-up)
•
Case Turnover
Time (pt out to pt in)
•
Cases/day
•
Cases/4 ORs
30 min
(ability to be <10 min)
5 cases/OR
20 cases
8 cases/OR
60%
32 cases
60%
Slide 11
Primary Care – Flow Stations
Creating MD Flow Reduces Patient Wait Times
VMPS Concepts
of a Flow Station
URGENT
• Waste of motion
(walking)
• Continuous flow
PAPER
MAIL
CERNER
MESSAGE
• Visual control
(Kanbans)
• External setup
• Water strider
• U-Shaped Cell
RESULT
REPORT
DOCUMENT
VISIT
$
CHARGE
SLIP
$
Slide 12
Stopping The Line
Slide 13
“Stopping the Line”
Organization-wide Involvement
Number of PSAs Reported
per Month
700
600
500
400
300
200
100
0
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•
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
•
Staff identify and report
issues and concerns
using the Patient Safety
Alert System
Leadership involvement
with investigation and
resolution
Board Quality
Committee review and
approve closure of
high-severity issues
(Red PSA’s)
Slide 14
Categorizing Patient Safety Risk
Events
3 Basic Risk Sources
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Evaluation
Treatment
Critical interactions
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Imaging
Medical
Laboratory
Diagnostics
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Surgical/
Procedure
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Evaluation Treatment
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Provider
u
Critical
Interactions
n
Organizational
Behavior
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Care
Mgmt
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1
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Personal
Behavior
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Environment
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Occupational
Direct Patient Care
Medication
Laboratory Order &
Collection
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3 of the top 5 risks
2u
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27 Specific Risk
Categories
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n u
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l u n l u n
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Slide 15
Overall staff response rate
Virginia Mason Medical Center
100%
81% 82% 84%
90%
88%
75%
58%
50%
25%
47%
21%
16%
2013 AHRQ Mean = 51%
21%
0%
We look “different” since 2009. Why?
What might be the benefit and lesson if we go higher?
Slide 16
Slide 17
Reduction of Hospital
Professional/General Liability
Premiums
% change from previous
year, with 74% overall
reduction in premium since
2004-05
7%
12%
5%
26%
12%
12%
11%
12%
30%
'04-'05
'05-'06
'06-'07
'07-'08
'08-'09
'09-'10
'10-'11
'11-12
'12-'13
13-'14
Slide 18
Virginia Mason Medical Center
Hospital of Decade: Efficiency and Effectiveness
Slide 19
Tuesday Morning “Stand Up”
Slide 20
Our Quality & Safety Journey
1st IOM1
Report
2000
Falls
STPRA5
1st
Safety
Culture
Survey
Leapfrog
Declare One
Governance
Organizational
Mary L.
Award
Goal: Patient
McClinton
AHRQ4
IHI3 5
Fatal medical Safety
Safety
Million
Culture
Q4Q Site
PSA error CPOE
Lives
Survey: 81%
Visit
Case
Go Live
Participation
Studies
2002
2003
Virginia Mason
Production System
established
1st
Culture
of Safety
Work
Plan
2001
2004
Patient
2nd
Safety
Safety
Alert
Culture
(PSA) for
Survey
clinical
events
PSA for
2nd IOM1
Report
ADEPT2
Preprinted
Order Sets
CEO
Mandates
PSA System
VM Board:
Business
Case for
Strategic
Quality
Executive Quality
Plan
Walk
Rounds
1.
2.
3.
Leapfrog
Top
Hospital
of the
Decade
Patient/
Family
Engagement
Toyota Production
System
Introduced to VMMC
non-clinical
events
2005
2006
Move to
yearly
AHRQ4
Safety
Culture
Survey
MD
Disclosure
Training
IHI3 100,00
Lives
Institute of Medicine
Adverse Drug Events Prevention Team
Institute for Healthcare Improvement
4.
5.
6.
2007
2008
2009
Staff &
MDM
Patient
RPIW 6
Cross
Leader
Pillar
Rounds Time
Culture
Out STof Safety
PRA5
Work
Plan
Standard
Quality Goal
Reporting
Process
Just
Culture
Respect for
People
Training
AHRQ4
Safety
Employee
Culture
Survey: 84% Safety Risk
Participation Registry
2010
2011
2012
AHRQ4
AHRQ4
Safety
Safety
PSA Culture
Culture
3P Survey: 90%
Survey:
82%
Participation
Participation Patient
(all staff, all
Safety Risk
electronic)
Registry
Quest for
2010
Quality
HealthGrades
Citation of
Patient Safety
Merit
Award
Agency for Healthcare Research and Quality
Sociotechnical Probabilistic Risk Assessment
Must Do Measure Rapid Process Improvement Workshop
Slide 21
2013 Organizational Goals
Delivering Patient-Centered Coordinated Primary Care
Optimizing Care Transitions
Smoothing Patient Flow
Eliminate Healthcare Associated Infections
Glycemic Control
Prevention of Hospital Associated Delirium
Patient
Vision
To be the Quality Leader
and transform health care
Mission
To improve the health and
well-being of the patients we serve
Respect for People
Values
Teamwork | Integrity | Excellence | Service
Strategies
Integration of the Patient Experience
People
We attract
and develop
the best team
Quality
Service
We relentlessly
pursue the
highest quality
outcomes of care
We create an
extraordinary
patient experience
Innovation
We foster a
culture of learning
and innovation
Virginia Mason Team Medicine Foundational Elements
SM
Strong
Economics
Growth
Realizing the Potential of Our Electronic Health Record
Update the Enterprise Orders and Documentation
Framework
Ambulatory CPOE
Measure and Improve our Results
Responsible
Governance
Integrated
Information
Systems
Education
Research
Virginia Mason Production System
Virginia Mason
Foundation
Slide 22
How Have We Gotten Here
With engaged and committed
staff and doctors!
Slide 23
Benefits of Doctor Engagement:
The Obvious and Not So Obvious
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Contribute knowledge and expertise; solutions will be
better for doctor input
Develop more realistic expectations of what is
possible
Have greater commitment to solutions; successful
implementation more likely
Builds trust and partnership between doctors and
management when doctors experience they have
influence on outcomes
Helps doctors move through psychological transition
associated with change
Slide 24
Authentic Engagement Is Difficult
Managers or administrators
Doctors
• Some like making decisions
and controlling outcomes
• Perceive that past input has gone
into “black hole” which leads to
cynicism
• Experience pressure for timely
decisions
• Have not been successful
managing efficient and helpful
process for engagement
• Are faced with doctors’
expectation that asking their
advice should translate into
actions that reflect it
• Experience sincere attempts
have been met with cynicism
or disinterest
• Paid for productivity, some will
not participate in non-clinical work
unless compensated
• Having the option to do what I
want to do anyway makes
investing time in improvement
activity irrational
• Requires on going commitment to
engage even when you don’t get
what you want in a given situation
Slide 25
Doctor Engagement in Your Organization:
Current and Future States
Current state:
• When people say
“doctor engagement”
what do they mean?
What picture do they
have in mind?
• Descriptors of current
state doctor
engagement
Preferred future state:
•
•
When people say
“doctor engagement”
what will it mean?
What picture will they
have in mind?
Descriptors of preferred
future state doctor
engagement
Slide 26
A Helpful Perspective on Change
Slide 27
Two Kinds of Challenges
Ronald Heifetz
Technical
• Problem is well defined
• Solution is known can be
found
• Implementation is clear
Adaptive
• Challenge is complex
• To solve requires
transforming long-standing
habits and deeply held
assumptions and values
• Involves feelings of loss,
sacrifice (sometimes
betrayal to values)
• Solution requires learning
and a new way of thinking,
new relationships
Slide 28
An Easily Adopted Change
Technical not because it’s
technological but because:
• Its use involves no angst or
challenge to personal identity
• Adoption is intuitive or similar to
other successful changes. Past
experience provides a “road map”
or sense for how it works
• There’s always the Genius Bar –
someone does know what to do.
Slide 29
An Adaptive Challenge
Slide 30
Wisdom from Ronald Heifetz
“The most common cause of failure to make
progress is treating an adaptive problem with a
technical fix.”
Technical fixes
Adaptive solutions
• New payment scheme for
doctors
• Giving authority to solve
problems to the implementers
• Incentives or bonuses
• Discussion that allows respectful
airing of difference
• Reorganization
• Issuing new vision statement
• Bringing conflict to the surface
and constructively resolving it
Slide 31
Adaptive Work
“Solutions are achieved when ‘the people
with the problem’ go through a process
together to become ‘the people with the
solution.’ The issues have to be internalized,
owned, and ultimately resolved by the
relevant parties to achieve enduring
progress.”
- Heifetz and Linsky, Leadership on the Line
Slide 32
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up the
heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 33
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up heat
Share a vision
Inspire action
with clear
picture of
future
Clarify new
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 34
Time for a Change – VMMC
2000
• Issues
Survival
Retention of the Best People
Loss of Vision
Build on a Strong Foundation
• Leadership Change
• A Defective Product
Slide 35
Urgency for Change at VMMC
We change or we die.
— Gary Kaplan, VMMC Professional
staff meeting, October 2000
Slide 36
November 23, 2004
Investigators: Medical mistake
kills Everett woman
Hospital error caused death
Mary L. McClinton
Slide 37
37
Slide 38
The Challenge of Ongoing Urgency
• In a time of constant
and tumultuous
change, avoid
complacency
Slide 39
Principle 1. Change Has to Start
With Urgency
“When people have a true
sense of urgency, they think
that action on critical issues is
needed now, not eventually,
not when it fits easily into a
schedule.”
- John Kotter, A Sense of
Urgency
Slide 40
The Status Quo is Like Gravity
• The invisible hold of
•
the status quo is very
strong
The case for change
has to be compelling
if it is to move others
to take action
Slide 41
Disequilibrium
“Distress” and Adaptive Work
Adaptive challenge
Limit of tolerance
Productive range
of distress
Threshold of
learning
Time
Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108
Slide 42
Urgency: Make the Invisible Visible
•
•
HOW
Self-discovery” – experiential
More than facts: John Kotter’s
see/feel/change approach
WHAT
Cost of doing nothing exceeds cost
of change
Cold, hard facts on performance
and lack of sustainability
Gap between aspiration and reality
The personal impact of incidents
Slide 43
Leaders’ Role in Signal Generation
“Leaders are signal generators who reduce
uncertainty and ambiguity about what is
important and how to act.”
— Charles O’Reilly III
OR
Slide 44
Back Home Discussion About Urgency
• What signals do leaders in our
•
organisation send regarding urgency
for care improvement? Are leaders’
signals consistent?
What is the impact of the signals sent
on doctor engagement in
improvement?
Slide 45
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 46
Our Strategic Plan
Slide 47
Principle 2. Engagement is Facilitated
When A Destination is Shared
Everyone needs to share the same
destination to make optimal use of all
resources
Slide 48
Lack of Shared Vision Reflects Silo
Orientation and Value on Autonomy
Slide 49
•
•
•
•
•
Challenges to Having Vision that Is
Shared
Often relationships between administration
and doctors are wobbly or strained. Built on
and reinforced by individual transactions
Doctors don’t readily acknowledge their
interdependence
Vision process is often superficial; an
exercise with a narrow purpose (e.g., for
PR)
Little connection between vision on paper
and daily life
No clear method to achieve vision
Slide 50
Requirements for Developing Shared
Vision
•
•
•
Doctors develop deep appreciation of interdependence
(to provide best, safest patient care)
There is a process to develop vision – not a one-off
meeting:
Deepens understanding of the various imperatives the
organisation must respond to including quality, value, safety
Encourages different points of view to be heard
Builds commitment
Vision is:
Strategic and granular
Perceived as a stretch, but not a fantasy
Slide 51
Basis of Vision is Shared Interests
Organisation’s
Interests
Doctors’
Interests
SHARED INTERESTS
Commitment to patients’ care and safety
Positive reputation
Recruit and retain talent
Slide 52
Back Home Discussion About Shared
Vision
To what extent do doctors, staff, and
management share the same vision of
where our hospital is heading?
Little
Great
1 2
3
4
5
Why did you choose the number you did?
What impact does this have on doctor
engagement?
Slide 53
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 54
Typical Views Doctors Hold of Their
Leaders
• Advocate
• Protector
• Communicator – go to meetings to
represent our views and keep us informed
of important news
• First among equals, “not one millimeter
above”
Slide 55
Consider Two Mental Models
Range of
Leadership
Activities
Other
Leadership
activities
Advocate for
my peers
Advocate for
subordinates
Professional managers’ view
Doctor leaders’ view
Slide 56
Reinforcement of Traditional Doctor
Leadership
• Preference for leadership that doesn’t
•
•
•
•
threaten personal autonomy
There are times when advocacy or protection
is appropriate
Doctors make leaders pay a price for
stepping out of advocate/protector role
Election to leadership roles
Short tenure in role limits development of a
wide range of leadership skills
Slide 57
VMMC Doctor Leader is a Real Job
• Appointed, not elected
• Clear expectations/job descriptions
• Performance feedback
• Training and development
• Succession planning
• Dyad model pairs administrative leader
with doctor leader at every level
Slide 58
For Doctor Leaders to be Effective,
Administrative Leaders Need to Change
• It’s not just doctor leaders who shift mindset and
•
•
actions
Working collaboratively with doctors represents
an adaptive change for many administrative
leaders
Need to move away from language such as: “We
need to gain their buy-in” and “We’ll roll it out”
Slide 59
Principle 3. Investment in New Model of
Doctor Leadership is Critical
Current Dilemma
Hospital needs
doctor leaders
to sponsor
change
Doctors don’t
easily accept
legitimacy of
leaders’
authority
Slide 60
Redefine Role of Doctor Leader
“Leadership now is the ability to step outside the culture that created the
leader to start evolutionary change processes that are more adaptive.“
- Edgar Schein
•
•
•
Sponsor change and engage colleagues
Demonstrate personal commitment to quality and safety
improvement
Be a role model and among the first to adopt the new way
Provide encouragement and acknowledgment to those who get
on with change
Hold colleagues accountable to engage in the organisation’s
quality and safety initiatives
Make practice life more efficient for clinical colleagues
Able to make and keep commitments on behalf of doctors
Slide 61
Back Home Discussion About Doctor
Leadership
• What model of doctor leadership is most
common in our hospital:
Advocate and protector of status quo for
doctor-colleagues?
Facilitator of change and skilled at engaging
colleagues?
• What is the impact of this model of doctor
leadership on our hospital’s ability to
change?
Slide 62
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 63
Compact
• Expectations members of an organisation
have that are:
Unstated yet understood
Reciprocal
• The give
• The get
Mutually beneficially
Slide 64
Traditional Doctor Compact
GIVE
• Treat
patients
• Provide
quality care
(personally defined)
GET
• Autonomy
• Protection
• Entitlement
Slide 65
Clash Of “Promise” And Imperatives
Traditional “Promise”
Legacy Expectations
Imperatives
• Improve
safety/quality
• Autonomy
• Protection
• Entitlement
• Implement
electronic records
• Improve efficiency
and value
• Be patient-focused
• Improve access
Slide 66
Old Compact at VMMC Not Working
• Despite the fact things weren’t working, most
doctors clung to the fundamental “gets” they
felt due them
Protection
Autonomy
Entitlement
• Doctor-centered world view prevailed
Slide 67
VMMC Compact Process
Doctor Retreat
(Fall 2000)
• Broad based committee of providers:
primary care, sub-specialists
• Focus of retreat: doctors-changing
expectations, tools to manage change
• Jack Silversin served as our consultant
• Spent time at VMMC talking to
doctors
Slide 68
VMMC Compact Process
Doctor Retreat
(Fall 2000)
Compact committee
drafts compact
(Winter 2001)
•
•
•
Broad based group of providers
Administrative Involvement: CEO, JD, HR, Board
Member (also a patient)
Starting point:
“Gives” and “gets” from the Retreat
Evolving Strategic Plan: patient centered
Slide 69
VMMC Compact Process
Doctor Retreat
(Fall 2000)
Compact committee
drafts compact
(Winter 2001)
•
•
•
Committee met weekly
Reality Checks
Departmental
meetings for input
(Spring 2001)
Management Committee
Doctors
Multiple Drafts until we reached the “final draft”
Slide 70
Virginia Mason Medical Center
Doctor Compact
Organization’s Responsibilities
Doctor’s Responsibilities
Foster Excellence
• Recruit and retain superior doctors and staff
• Support career development and professional satisfaction
• Acknowledge contributions to patient care and the
organization
• Create opportunities to participate in or support research
Listen and Communicate
• Share information regarding strategic intent,
organizational priorities and business decisions
• Offer opportunities for constructive dialogue
• Provide regular, written evaluation and feedback
Educate
• Support and facilitate teaching, GME and CME
• Provide information and tools necessary to improve
practice
Reward
• Provide clear compensation with internal and market
consistency, aligned with organizational goals
• Create an environment that supports teams and
individuals
Lead
Manage and lead organization with integrity and
accountability
Focus on Patients
• Practice state of the art, quality medicine
• Encourage patient involvement in care and treatment decisions
• Achieve and maintain optimal patient access
• Insist on seamless service
Collaborate on Care Delivery
• Include staff, doctors, and management on team
• Treat all members with respect
• Demonstrate the highest levels of ethical and professional
conduct
• Behave in a manner consistent with group goals
• Participate in or support teaching
Listen and Communicate
• Communicate clinical information in clear, timely manner
• Request information, resources needed to provide care
consistent with VM goals
• Provide and accept feedback
Take Ownership
• Implement VM-accepted clinical standards of care
• Participate in and support group decisions
• Focus on the economic aspects of our practice
Change
• Embrace innovation and continuous improvement
• Participate in necessary organizational change
Slide 71
Hardwiring Compact
• Recruitment
• Orientation
• Job Descriptions
Chief
Section Heads
Doctors
• Feedback
Slide 72
Principle 4. A New Compact Is an
Adaptive Change
• Journey as important as
•
•
destination
Iterative process for
understanding and buy-in
Mutual accountability (2-way
street)
Slide 73
Vision Is Context for Compact
• Societal needs
Doctors give:
• Local market
Organisation
gives:
• What the
organisation
needs to
achieve the
vision
•What helps
doctors meet
commitment
• Organisation’s
strengths
• Competition
Slide 74
Compact Supports Alignment with Vision
• Compact discussions as foundational – basic to
•
•
moving us toward vision
Compact is revisited, made alive, reinforced
Periodic assessments/dialogue as to how both
“sides” are living up to compact commitments
Slide 75
Back Home Discussion About DoctorOrganization Compact
• In what ways does the unwritten compact
between our hospital and doctors:
Support change and improvement?
Serve as an impediment to change and
improvement?
• Should we undertake a process to work
with doctors to create a new one? Who do
we need to involve?
Slide 76
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up the
heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 77
“In times of change,
learners inherit the
earth, while the
learned find
themselves beautifully
equipped to deal with
a world that no longer
exists.”
- Eric Hoffer
Slide 78
Readings
1.
2.
3.
4.
5.
6.
7.
8.
Bohmer R. and Ferlins E. Virginia Mason Medical Center –
Harvard Business School Case 9-606-044, President and Fellows
of Harvard College, 2006
Bridges, W. Managing Transitions. Addison-Wesley, 1991
Edwards, N, Kornacki, MJ, and Silversin, J. Unhappy doctors:
what are the causes and what can be done? BMJ 2002; 324: 835838
Heifetz, R. and Linsky, M. Leadership on the Line. Harvard
Business School Press, 2002
Kenny, Charles. Transforming Health Care: Virginia Mason Medical
Center’s Pursuit of the Perfect Patient Experience. CRC Press, 2011
Kotter, J. Leading Change. Harvard Business School Press, 1996
Kotter, J. and Cohen, D. The Heart of Change. Harvard Business
School Press, 2002
Kornacki, M.J. and Silversin, J. Leading Physicians through
Change: How to Achieve and Sustain Results, 2nd edition,
American College of Physician Executives, 2012
Engaging Healthcare
Professionals to Transform
Care
10 April 2014
Gary Kaplan, MD
Chairman and CEO, Virginia Mason Medical Center
Jack Silversin, DMD, DrPH
Founding Partner, Amicus, Inc
Slide 2
Virginia Mason Medical Center
•
•
•
•
•
•
•
•
•
•
Integrated health care system
501(c)3 not-for-profit
336-bed hospital
Nine locations
500 doctors
5,500 employees
Graduate Medical Education
Research Institute
Foundation
Virginia Mason Institute
Slide 3
Our Strategic Plan
Slide 4
Seeing with our Eyes
Japan 2002
Team Leader
Kaplan reviewing
the flow of the
process with
Drs. Jacobs and
Glenn at Hitachi Air
Conditioning plant
Slide 5
Take-Aways
How are air conditioners, cars, looms and airplanes like
health care?
• Every manufacturing element is a production processes
• Health care is a combination of complex production
processes: admitting a patient, having a clinic visit,
going to surgery or a procedure and sending out a bill
• These products involve thousands of processes—many
of them very complex
• All of these products involve the concepts of quality,
safety, customer satisfaction, staff satisfaction and cost
effectiveness
• These products, if they fail, can cause fatality
Slide 6
The VMMC Quality Equation
Q = A × (O + S)
W
Q: Quality
A: Appropriateness
O: Outcomes
S: Service
W: Waste
Slide 7
New Management Method: The Virginia
Mason Production System
We adopted the Toyota Production System philosophies
and practices and applied them to health care because
health care lacks an effective management approach that
would produce:
• Customer first
• Highest quality
• Obsession with safety
• Highest staff satisfaction
• A successful economic enterprise
Slide 8
VMPS Tools in Action
• Value Stream Development
• RPIW (Rapid Process Improvement Workshop)
• 5S (Sort, simplify, standardize, sweep, self-discipline)
• 3-P (Production, Preparation, Process)
• Standard Work
• Daily Work Life
Slide 9
“Nursing Cells” – Results > 90 days
RN time available for patient care = 90%!
Before
• RN # of steps = 5,818
• PCT # of steps = 2,664
• Time to the complete am cycle of work = 240’
• Patients dissatisfaction = 21%
• RN time spent in indirect care = 68%
• PCT time spent in indirect care = 30%
• Call light on from 7a-11a = 5.5%
• Time spent gathering supplies = 20’
After
846
1256
126’
0%
10%
16%
0%
11’
Slide 10
Lindeman Surgery Center
Throughput Analysis
•
Before
Time Available 600 min
Today
600 min
% Change
0%
(10 hr day)
•
Total Case Time 107 min
65.5 min
39%
15 min
50%
(cut to close plus set-up)
•
Case Turnover
Time (pt out to pt in)
•
Cases/day
•
Cases/4 ORs
30 min
(ability to be <10 min)
5 cases/OR
20 cases
8 cases/OR
60%
32 cases
60%
Slide 11
Primary Care – Flow Stations
Creating MD Flow Reduces Patient Wait Times
VMPS Concepts
of a Flow Station
URGENT
• Waste of motion
(walking)
• Continuous flow
PAPER
CERNER
MESSAGE
• Visual control
(Kanbans)
• External setup
• Water strider
• U-Shaped Cell
RESULT
REPORT
DOCUMENT
VISIT
$
CHARGE
SLIP
$
Slide 12
Stopping The Line
Slide 13
“Stopping the Line”
Organization-wide Involvement
Number of PSAs Reported
per Month
700
600
500
400
300
200
100
0
•
•
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
•
Staff identify and report
issues and concerns
using the Patient Safety
Alert System
Leadership involvement
with investigation and
resolution
Board Quality
Committee review and
approve closure of
high-severity issues
(Red PSA’s)
Slide 14
Categorizing Patient Safety Risk
Events
3 Basic Risk Sources
•
•
•
u
Evaluation
Treatment
Critical interactions
l
n
u
u
l
u
u
n
l
u
n
l
Imaging
Medical
Laboratory
Diagnostics
u
n
u
l
n
u
Surgical/
Procedure
l
Evaluation Treatment
n
l
Provider
u
Critical
Interactions
n
Organizational
Behavior
u
n
l
u
n
u
Care
Mgmt
l
1
n
u
Personal
Behavior
l
n
u
l
Environment
n
l
u
n
l
u
n
Occupational
Direct Patient Care
Medication
Laboratory Order &
Collection
n
n
l
•
•
•
l
l
l
3 of the top 5 risks
2u
n
3
27 Specific Risk
Categories
l
l n u l n u l
n u
n
n
l
u n
l
l u n l u n
u
u
n
l
u
n
l
Slide 15
Overall staff response rate
Virginia Mason Medical Center
100%
81% 82% 84%
90%
88%
75%
58%
50%
25%
47%
21%
16%
2013 AHRQ Mean = 51%
21%
0%
We look “different” since 2009. Why?
What might be the benefit and lesson if we go higher?
Slide 16
Slide 17
Reduction of Hospital
Professional/General Liability
Premiums
% change from previous
year, with 74% overall
reduction in premium since
2004-05
7%
12%
5%
26%
12%
12%
11%
12%
30%
'04-'05
'05-'06
'06-'07
'07-'08
'08-'09
'09-'10
'10-'11
'11-12
'12-'13
13-'14
Slide 18
Virginia Mason Medical Center
Hospital of Decade: Efficiency and Effectiveness
Slide 19
Tuesday Morning “Stand Up”
Slide 20
Our Quality & Safety Journey
1st IOM1
Report
2000
Falls
STPRA5
1st
Safety
Culture
Survey
Leapfrog
Declare One
Governance
Organizational
Mary L.
Award
Goal: Patient
McClinton
AHRQ4
IHI3 5
Fatal medical Safety
Safety
Million
Culture
Q4Q Site
PSA error CPOE
Lives
Survey: 81%
Visit
Case
Go Live
Participation
Studies
2002
2003
Virginia Mason
Production System
established
1st
Culture
of Safety
Work
Plan
2001
2004
Patient
2nd
Safety
Safety
Alert
Culture
(PSA) for
Survey
clinical
events
PSA for
2nd IOM1
Report
ADEPT2
Preprinted
Order Sets
CEO
Mandates
PSA System
VM Board:
Business
Case for
Strategic
Quality
Executive Quality
Plan
Walk
Rounds
1.
2.
3.
Leapfrog
Top
Hospital
of the
Decade
Patient/
Family
Engagement
Toyota Production
System
Introduced to VMMC
non-clinical
events
2005
2006
Move to
yearly
AHRQ4
Safety
Culture
Survey
MD
Disclosure
Training
IHI3 100,00
Lives
Institute of Medicine
Adverse Drug Events Prevention Team
Institute for Healthcare Improvement
4.
5.
6.
2007
2008
2009
Staff &
MDM
Patient
RPIW 6
Cross
Leader
Pillar
Rounds Time
Culture
Out STof Safety
PRA5
Work
Plan
Standard
Quality Goal
Reporting
Process
Just
Culture
Respect for
People
Training
AHRQ4
Safety
Employee
Culture
Survey: 84% Safety Risk
Participation Registry
2010
2011
2012
AHRQ4
AHRQ4
Safety
Safety
PSA Culture
Culture
3P Survey: 90%
Survey:
82%
Participation
Participation Patient
(all staff, all
Safety Risk
electronic)
Registry
Quest for
2010
Quality
HealthGrades
Citation of
Patient Safety
Merit
Award
Agency for Healthcare Research and Quality
Sociotechnical Probabilistic Risk Assessment
Must Do Measure Rapid Process Improvement Workshop
Slide 21
2013 Organizational Goals
Delivering Patient-Centered Coordinated Primary Care
Optimizing Care Transitions
Smoothing Patient Flow
Eliminate Healthcare Associated Infections
Glycemic Control
Prevention of Hospital Associated Delirium
Patient
Vision
To be the Quality Leader
and transform health care
Mission
To improve the health and
well-being of the patients we serve
Respect for People
Values
Teamwork | Integrity | Excellence | Service
Strategies
Integration of the Patient Experience
People
We attract
and develop
the best team
Quality
Service
We relentlessly
pursue the
highest quality
outcomes of care
We create an
extraordinary
patient experience
Innovation
We foster a
culture of learning
and innovation
Virginia Mason Team Medicine Foundational Elements
SM
Strong
Economics
Growth
Realizing the Potential of Our Electronic Health Record
Update the Enterprise Orders and Documentation
Framework
Ambulatory CPOE
Measure and Improve our Results
Responsible
Governance
Integrated
Information
Systems
Education
Research
Virginia Mason Production System
Virginia Mason
Foundation
Slide 22
How Have We Gotten Here
With engaged and committed
staff and doctors!
Slide 23
Benefits of Doctor Engagement:
The Obvious and Not So Obvious
•
•
•
•
•
Contribute knowledge and expertise; solutions will be
better for doctor input
Develop more realistic expectations of what is
possible
Have greater commitment to solutions; successful
implementation more likely
Builds trust and partnership between doctors and
management when doctors experience they have
influence on outcomes
Helps doctors move through psychological transition
associated with change
Slide 24
Authentic Engagement Is Difficult
Managers or administrators
Doctors
• Some like making decisions
and controlling outcomes
• Perceive that past input has gone
into “black hole” which leads to
cynicism
• Experience pressure for timely
decisions
• Have not been successful
managing efficient and helpful
process for engagement
• Are faced with doctors’
expectation that asking their
advice should translate into
actions that reflect it
• Experience sincere attempts
have been met with cynicism
or disinterest
• Paid for productivity, some will
not participate in non-clinical work
unless compensated
• Having the option to do what I
want to do anyway makes
investing time in improvement
activity irrational
• Requires on going commitment to
engage even when you don’t get
what you want in a given situation
Slide 25
Doctor Engagement in Your Organization:
Current and Future States
Current state:
• When people say
“doctor engagement”
what do they mean?
What picture do they
have in mind?
• Descriptors of current
state doctor
engagement
Preferred future state:
•
•
When people say
“doctor engagement”
what will it mean?
What picture will they
have in mind?
Descriptors of preferred
future state doctor
engagement
Slide 26
A Helpful Perspective on Change
Slide 27
Two Kinds of Challenges
Ronald Heifetz
Technical
• Problem is well defined
• Solution is known can be
found
• Implementation is clear
Adaptive
• Challenge is complex
• To solve requires
transforming long-standing
habits and deeply held
assumptions and values
• Involves feelings of loss,
sacrifice (sometimes
betrayal to values)
• Solution requires learning
and a new way of thinking,
new relationships
Slide 28
An Easily Adopted Change
Technical not because it’s
technological but because:
• Its use involves no angst or
challenge to personal identity
• Adoption is intuitive or similar to
other successful changes. Past
experience provides a “road map”
or sense for how it works
• There’s always the Genius Bar –
someone does know what to do.
Slide 29
An Adaptive Challenge
Slide 30
Wisdom from Ronald Heifetz
“The most common cause of failure to make
progress is treating an adaptive problem with a
technical fix.”
Technical fixes
Adaptive solutions
• New payment scheme for
doctors
• Giving authority to solve
problems to the implementers
• Incentives or bonuses
• Discussion that allows respectful
airing of difference
• Reorganization
• Issuing new vision statement
• Bringing conflict to the surface
and constructively resolving it
Slide 31
Adaptive Work
“Solutions are achieved when ‘the people
with the problem’ go through a process
together to become ‘the people with the
solution.’ The issues have to be internalized,
owned, and ultimately resolved by the
relevant parties to achieve enduring
progress.”
- Heifetz and Linsky, Leadership on the Line
Slide 32
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up the
heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 33
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up heat
Share a vision
Inspire action
with clear
picture of
future
Clarify new
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 34
Time for a Change – VMMC
2000
• Issues
Survival
Retention of the Best People
Loss of Vision
Build on a Strong Foundation
• Leadership Change
• A Defective Product
Slide 35
Urgency for Change at VMMC
We change or we die.
— Gary Kaplan, VMMC Professional
staff meeting, October 2000
Slide 36
November 23, 2004
Investigators: Medical mistake
kills Everett woman
Hospital error caused death
Mary L. McClinton
Slide 37
37
Slide 38
The Challenge of Ongoing Urgency
• In a time of constant
and tumultuous
change, avoid
complacency
Slide 39
Principle 1. Change Has to Start
With Urgency
“When people have a true
sense of urgency, they think
that action on critical issues is
needed now, not eventually,
not when it fits easily into a
schedule.”
- John Kotter, A Sense of
Urgency
Slide 40
The Status Quo is Like Gravity
• The invisible hold of
•
the status quo is very
strong
The case for change
has to be compelling
if it is to move others
to take action
Slide 41
Disequilibrium
“Distress” and Adaptive Work
Adaptive challenge
Limit of tolerance
Productive range
of distress
Threshold of
learning
Time
Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108
Slide 42
Urgency: Make the Invisible Visible
•
•
HOW
Self-discovery” – experiential
More than facts: John Kotter’s
see/feel/change approach
WHAT
Cost of doing nothing exceeds cost
of change
Cold, hard facts on performance
and lack of sustainability
Gap between aspiration and reality
The personal impact of incidents
Slide 43
Leaders’ Role in Signal Generation
“Leaders are signal generators who reduce
uncertainty and ambiguity about what is
important and how to act.”
— Charles O’Reilly III
OR
Slide 44
Back Home Discussion About Urgency
• What signals do leaders in our
•
organisation send regarding urgency
for care improvement? Are leaders’
signals consistent?
What is the impact of the signals sent
on doctor engagement in
improvement?
Slide 45
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 46
Our Strategic Plan
Slide 47
Principle 2. Engagement is Facilitated
When A Destination is Shared
Everyone needs to share the same
destination to make optimal use of all
resources
Slide 48
Lack of Shared Vision Reflects Silo
Orientation and Value on Autonomy
Slide 49
•
•
•
•
•
Challenges to Having Vision that Is
Shared
Often relationships between administration
and doctors are wobbly or strained. Built on
and reinforced by individual transactions
Doctors don’t readily acknowledge their
interdependence
Vision process is often superficial; an
exercise with a narrow purpose (e.g., for
PR)
Little connection between vision on paper
and daily life
No clear method to achieve vision
Slide 50
Requirements for Developing Shared
Vision
•
•
•
Doctors develop deep appreciation of interdependence
(to provide best, safest patient care)
There is a process to develop vision – not a one-off
meeting:
Deepens understanding of the various imperatives the
organisation must respond to including quality, value, safety
Encourages different points of view to be heard
Builds commitment
Vision is:
Strategic and granular
Perceived as a stretch, but not a fantasy
Slide 51
Basis of Vision is Shared Interests
Organisation’s
Interests
Doctors’
Interests
SHARED INTERESTS
Commitment to patients’ care and safety
Positive reputation
Recruit and retain talent
Slide 52
Back Home Discussion About Shared
Vision
To what extent do doctors, staff, and
management share the same vision of
where our hospital is heading?
Little
Great
1 2
3
4
5
Why did you choose the number you did?
What impact does this have on doctor
engagement?
Slide 53
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 54
Typical Views Doctors Hold of Their
Leaders
• Advocate
• Protector
• Communicator – go to meetings to
represent our views and keep us informed
of important news
• First among equals, “not one millimeter
above”
Slide 55
Consider Two Mental Models
Range of
Leadership
Activities
Other
Leadership
activities
Advocate for
my peers
Advocate for
subordinates
Professional managers’ view
Doctor leaders’ view
Slide 56
Reinforcement of Traditional Doctor
Leadership
• Preference for leadership that doesn’t
•
•
•
•
threaten personal autonomy
There are times when advocacy or protection
is appropriate
Doctors make leaders pay a price for
stepping out of advocate/protector role
Election to leadership roles
Short tenure in role limits development of a
wide range of leadership skills
Slide 57
VMMC Doctor Leader is a Real Job
• Appointed, not elected
• Clear expectations/job descriptions
• Performance feedback
• Training and development
• Succession planning
• Dyad model pairs administrative leader
with doctor leader at every level
Slide 58
For Doctor Leaders to be Effective,
Administrative Leaders Need to Change
• It’s not just doctor leaders who shift mindset and
•
•
actions
Working collaboratively with doctors represents
an adaptive change for many administrative
leaders
Need to move away from language such as: “We
need to gain their buy-in” and “We’ll roll it out”
Slide 59
Principle 3. Investment in New Model of
Doctor Leadership is Critical
Current Dilemma
Hospital needs
doctor leaders
to sponsor
change
Doctors don’t
easily accept
legitimacy of
leaders’
authority
Slide 60
Redefine Role of Doctor Leader
“Leadership now is the ability to step outside the culture that created the
leader to start evolutionary change processes that are more adaptive.“
- Edgar Schein
•
•
•
Sponsor change and engage colleagues
Demonstrate personal commitment to quality and safety
improvement
Be a role model and among the first to adopt the new way
Provide encouragement and acknowledgment to those who get
on with change
Hold colleagues accountable to engage in the organisation’s
quality and safety initiatives
Make practice life more efficient for clinical colleagues
Able to make and keep commitments on behalf of doctors
Slide 61
Back Home Discussion About Doctor
Leadership
• What model of doctor leadership is most
common in our hospital:
Advocate and protector of status quo for
doctor-colleagues?
Facilitator of change and skilled at engaging
colleagues?
• What is the impact of this model of doctor
leadership on our hospital’s ability to
change?
Slide 62
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 63
Compact
• Expectations members of an organisation
have that are:
Unstated yet understood
Reciprocal
• The give
• The get
Mutually beneficially
Slide 64
Traditional Doctor Compact
GIVE
• Treat
patients
• Provide
quality care
(personally defined)
GET
• Autonomy
• Protection
• Entitlement
Slide 65
Clash Of “Promise” And Imperatives
Traditional “Promise”
Legacy Expectations
Imperatives
• Improve
safety/quality
• Autonomy
• Protection
• Entitlement
• Implement
electronic records
• Improve efficiency
and value
• Be patient-focused
• Improve access
Slide 66
Old Compact at VMMC Not Working
• Despite the fact things weren’t working, most
doctors clung to the fundamental “gets” they
felt due them
Protection
Autonomy
Entitlement
• Doctor-centered world view prevailed
Slide 67
VMMC Compact Process
Doctor Retreat
(Fall 2000)
• Broad based committee of providers:
primary care, sub-specialists
• Focus of retreat: doctors-changing
expectations, tools to manage change
• Jack Silversin served as our consultant
• Spent time at VMMC talking to
doctors
Slide 68
VMMC Compact Process
Doctor Retreat
(Fall 2000)
Compact committee
drafts compact
(Winter 2001)
•
•
•
Broad based group of providers
Administrative Involvement: CEO, JD, HR, Board
Member (also a patient)
Starting point:
“Gives” and “gets” from the Retreat
Evolving Strategic Plan: patient centered
Slide 69
VMMC Compact Process
Doctor Retreat
(Fall 2000)
Compact committee
drafts compact
(Winter 2001)
•
•
•
Committee met weekly
Reality Checks
Departmental
meetings for input
(Spring 2001)
Management Committee
Doctors
Multiple Drafts until we reached the “final draft”
Slide 70
Virginia Mason Medical Center
Doctor Compact
Organization’s Responsibilities
Doctor’s Responsibilities
Foster Excellence
• Recruit and retain superior doctors and staff
• Support career development and professional satisfaction
• Acknowledge contributions to patient care and the
organization
• Create opportunities to participate in or support research
Listen and Communicate
• Share information regarding strategic intent,
organizational priorities and business decisions
• Offer opportunities for constructive dialogue
• Provide regular, written evaluation and feedback
Educate
• Support and facilitate teaching, GME and CME
• Provide information and tools necessary to improve
practice
Reward
• Provide clear compensation with internal and market
consistency, aligned with organizational goals
• Create an environment that supports teams and
individuals
Lead
Manage and lead organization with integrity and
accountability
Focus on Patients
• Practice state of the art, quality medicine
• Encourage patient involvement in care and treatment decisions
• Achieve and maintain optimal patient access
• Insist on seamless service
Collaborate on Care Delivery
• Include staff, doctors, and management on team
• Treat all members with respect
• Demonstrate the highest levels of ethical and professional
conduct
• Behave in a manner consistent with group goals
• Participate in or support teaching
Listen and Communicate
• Communicate clinical information in clear, timely manner
• Request information, resources needed to provide care
consistent with VM goals
• Provide and accept feedback
Take Ownership
• Implement VM-accepted clinical standards of care
• Participate in and support group decisions
• Focus on the economic aspects of our practice
Change
• Embrace innovation and continuous improvement
• Participate in necessary organizational change
Slide 71
Hardwiring Compact
• Recruitment
• Orientation
• Job Descriptions
Chief
Section Heads
Doctors
• Feedback
Slide 72
Principle 4. A New Compact Is an
Adaptive Change
• Journey as important as
•
•
destination
Iterative process for
understanding and buy-in
Mutual accountability (2-way
street)
Slide 73
Vision Is Context for Compact
• Societal needs
Doctors give:
• Local market
Organisation
gives:
• What the
organisation
needs to
achieve the
vision
•What helps
doctors meet
commitment
• Organisation’s
strengths
• Competition
Slide 74
Compact Supports Alignment with Vision
• Compact discussions as foundational – basic to
•
•
moving us toward vision
Compact is revisited, made alive, reinforced
Periodic assessments/dialogue as to how both
“sides” are living up to compact commitments
Slide 75
Back Home Discussion About DoctorOrganization Compact
• In what ways does the unwritten compact
between our hospital and doctors:
Support change and improvement?
Serve as an impediment to change and
improvement?
• Should we undertake a process to work
with doctors to create a new one? Who do
we need to involve?
Slide 76
Foundation for Engagement
Single method
for
improvement
Engaged
Doctors
Increase
urgency
Turn up the
heat
Share a vision
Inspire action
with clear
picture of
future
Modernize
compact
Co-create new
gives and gets
Enhance
leadership
Develop doctor
leaders who
sponsor change
Slide 77
“In times of change,
learners inherit the
earth, while the
learned find
themselves beautifully
equipped to deal with
a world that no longer
exists.”
- Eric Hoffer
Slide 78
Readings
1.
2.
3.
4.
5.
6.
7.
8.
Bohmer R. and Ferlins E. Virginia Mason Medical Center –
Harvard Business School Case 9-606-044, President and Fellows
of Harvard College, 2006
Bridges, W. Managing Transitions. Addison-Wesley, 1991
Edwards, N, Kornacki, MJ, and Silversin, J. Unhappy doctors:
what are the causes and what can be done? BMJ 2002; 324: 835838
Heifetz, R. and Linsky, M. Leadership on the Line. Harvard
Business School Press, 2002
Kenny, Charles. Transforming Health Care: Virginia Mason Medical
Center’s Pursuit of the Perfect Patient Experience. CRC Press, 2011
Kotter, J. Leading Change. Harvard Business School Press, 1996
Kotter, J. and Cohen, D. The Heart of Change. Harvard Business
School Press, 2002
Kornacki, M.J. and Silversin, J. Leading Physicians through
Change: How to Achieve and Sustain Results, 2nd edition,
American College of Physician Executives, 2012