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10 April 2014 Gary Kaplan, MD Chairman and CEO, Virginia Mason Medical Center Jack Silversin, DMD, DrPH Founding Partner, Amicus, Inc Engaging Healthcare.

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Presentation on theme: "10 April 2014 Gary Kaplan, MD Chairman and CEO, Virginia Mason Medical Center Jack Silversin, DMD, DrPH Founding Partner, Amicus, Inc Engaging Healthcare."— Presentation transcript:

1 10 April 2014 Gary Kaplan, MD Chairman and CEO, Virginia Mason Medical Center Jack Silversin, DMD, DrPH Founding Partner, Amicus, Inc Engaging Healthcare Professionals to Transform Care

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

3 Our Strategic Plan

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

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 processesmany 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

6 The VMMC Quality Equation Q: Quality A: Appropriateness O: Outcomes S: Service W: Waste Q = A × (O + S) W

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

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

9 Nursing Cells – Results > 90 days Before After 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 = % 10% 16% 0% 11 RN time available for patient care = 90%!

10 Lindeman Surgery Center Throughput Analysis Before Today % Change Time Available 600 min 600 min0% (10 hr day) Total Case Time107 min 65.5 min39% (cut to close plus set-up) Case Turnover 30 min15 min50% Time (pt out to pt in)(ability to be <10 min) Cases/day 5 cases/OR 8 cases/OR60% Cases/4 ORs20 cases32 cases60%

11 Primary Care – Flow Stations VMPS Concepts of a Flow Station Waste of motion (walking) Continuous flow Visual control (Kanbans) External setup Water strider U-Shaped Cell Creating MD Flow Reduces Patient Wait Times CHARGE SLIP $ DOCUMENT VISIT $ CERNER MESSAGE URGENT PAPER MAIL RESULT REPORT

12 Stopping The Line

13 Stopping the Line Organization-wide Involvement 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 PSAs)

14 Categorizing Patient Safety Risk Events 3 Basic Risk Sources Evaluation Treatment Critical interactions 27 Specific Risk Categories 3 of the top 5 risks Direct Patient Care Medication Laboratory Order & Collection

15 Overall staff response rate Virginia Mason Medical Center 2013 AHRQ Mean = 51% We look different since Why? What might be the benefit and lesson if we go higher?

16

17 Reduction of Hospital Professional/General Liability Premiums % change from previous year, with 74% overall reduction in premium since % 12% 5% 26% 12% 11% 12% 30%

18 Virginia Mason Medical Center Hospital of Decade: Efficiency and Effectiveness

19 Tuesday Morning Stand Up

20 AHRQ 4 Safety Culture Survey: 82% Participation (all staff, all electronic) Our Quality & Safety Journey Toyota Production System Introduced to VMMC 2 nd IOM 1 Report ADEPT 2 Preprinted Order Sets Virginia Mason Production System established Patient Safety Alert (PSA) for clinical events Strategic Quality Plan 1 st Safety Culture Survey Executive Walk Rounds PSA for non-clinical events 2 nd Safety Culture Survey Mary L. McClinton Fatal medical error CPOE Go Live Move to yearly AHRQ 4 Safety Culture Survey Declare One Organizational Goal: Patient Safety MD Disclosure Training IHI 3 100,00 Lives IHI 3 5 Million Lives Leapfrog Governance Award Staff & Patient Leader Rounds Patient/ Family Engagement AHRQ 4 Safety Culture Survey: 81% Participation 2010 HealthGrades Patient Safety Award Time Out ST- PRA 5 Just Culture Falls ST- PRA 5 1 st IOM 1 Report VM Board: Business Case for Quality 1 st Culture of Safety Work Plan PSA Case Studies 1.Institute of Medicine 2.Adverse Drug Events Prevention Team 3.Institute for Healthcare Improvement Standard Quality Goal Reporting Process CEO Mandates PSA System MDM RPIW 6 4. Agency for Healthcare Research and Quality 5. Sociotechnical Probabilistic Risk Assessment 6. Must Do Measure Rapid Process Improvement Workshop Cross Pillar Culture of Safety Work Plan Leapfrog Top Hospital of the Decade Q4Q Site Visit AHRQ 4 Safety Culture Survey: 84% Participation PSA 3P Patient Safety Risk Registry Respect for People Training Quest for Quality Citation of Merit AHRQ 4 Safety Culture Survey: 90% Participation Employee Safety Risk Registry

21 2013 Organizational Goals Quality and Safety: Care Delivery Innovations Delivering Patient-Centered Coordinated Primary Care Optimizing Care Transitions Smoothing Patient Flow Eliminate Healthcare Associated Infections Glycemic Control Prevention of Hospital Associated Delirium Service: Patient Experience Integration of the Patient Experience Strong Economics Growth Integrated I.S.: Technology and Care Delivery Partnerships Realizing the Potential of Our Electronic Health Record Update the Enterprise Orders and Documentation Framework Ambulatory CPOE Measure and Improve our Results Quality, Safety, Service, People, Innovation Respect for People People: Team Engagement Transformational Leadership Organizational Training & Education We attract and develop the best team People We foster a culture of learning and innovation Innovation We create an extraordinary patient experience Service We relentlessly pursue the highest quality outcomes of care Quality Vision To be the Quality Leader and transform health care Mission To improve the health and well-being of the patients we serve Values Teamwork | Integrity | Excellence | Service Strategies Virginia Mason Team Medicine SM Foundational Elements Patient Strong Economics Responsible Governance EducationVirginia Mason Foundation Integrated Information Systems Research Virginia Mason Production System

22 How Have We Gotten Here With engaged and committed staff and doctors!

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

24 Authentic Engagement Is Difficult Managers or administrators Some like making decisions and controlling outcomes 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 Doctors Perceive that past input has gone into black hole which leads to cynicism 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 dont get what you want in a given situation

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

26 A Helpful Perspective on Change

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

28 An Easily Adopted Change Technical not because its 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 Theres always the Genius Bar – someone does know what to do.

29 An Adaptive Challenge

30 The most common cause of failure to make progress is treating an adaptive problem with a technical fix. Wisdom from Ronald Heifetz Technical fixes New payment scheme for doctors Incentives or bonuses Reorganization Issuing new vision statement Adaptive solutions Giving authority to solve problems to the implementers Discussion that allows respectful airing of difference Bringing conflict to the surface and constructively resolving it

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

32 Foundation for Engagement Share a vision Inspire action with clear picture of future Engaged Doctors Modernize compact Co-create new gives and gets Modernize compact Co-create new gives and gets Enhance leadership Develop doctor leaders who sponsor change Increase urgency Turn up the heat Single method for improvement

33 Foundation for Engagement Share a vision Inspire action with clear picture of future Engaged Doctors Clarify new compact Co-create new gives and gets Clarify new compact Co-create new gives and gets Enhance leadership Develop doctor leaders who sponsor change Increase urgency Turn up heat Single method for improvement

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

35 Urgency for Change at VMMC Gary Kaplan, VMMC Professional staff meeting, October 2000 We change or we die.

36 November 23, 2004 Hospital error caused death Investigators: Medical mistake kills Everett woman Mary L. McClinton

37 37

38 The Challenge of Ongoing Urgency In a time of constant and tumultuous change, avoid complacency

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

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

41 Productive range of distress Threshold of learning Limit of tolerance Time Disequilibrium Distress and Adaptive Work Adaptive challenge Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108

42 Urgency: Make the Invisible Visible HOW Self-discovery – experiential More than facts: John Kotters 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

43 Leaders Role in Signal Generation Leaders are signal generators who reduce uncertainty and ambiguity about what is important and how to act. OR Charles OReilly III

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?

45 Foundation for Engagement Share a vision Inspire action with clear picture of future Engaged Doctors Modernize compact Co-create new gives and gets Modernize compact Co-create new gives and gets Enhance leadership Develop doctor leaders who sponsor change Increase urgency Turn up heat Single method for improvement

46 Our Strategic Plan

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

48 Lack of Shared Vision Reflects Silo Orientation and Value on Autonomy

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 dont 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

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

51 Basis of Vision is Shared Interests Organisations Interests Doctors Interests SHARED INTERESTS Commitment to patients care and safety Positive reputation Recruit and retain talent

52 To what extent do doctors, staff, and management share the same vision of where our hospital is heading? LittleGreat Why did you choose the number you did? What impact does this have on doctor engagement? Back Home Discussion About Shared Vision

53 Foundation for Engagement Share a vision Inspire action with clear picture of future Engaged Doctors Modernize compact Co-create new gives and gets Modernize compact Co-create new gives and gets Enhance leadership Develop doctor leaders who sponsor change Increase urgency Turn up heat Single method for improvement

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

55 Consider Two Mental Models Range of Leadership Activities Advocate for subordinates Advocate for my peers Other Leadership activities Doctor leaders view Professional managers view

56 Reinforcement of Traditional Doctor Leadership Preference for leadership that doesnt 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

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

58 For Doctor Leaders to be Effective, Administrative Leaders Need to Change Its 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 Well roll it out

59 Hospital needs doctor leaders to sponsor change Doctors dont easily accept legitimacy of leaders authority Principle 3. Investment in New Model of Doctor Leadership is Critical Current Dilemma

60 Redefine Role of Doctor Leader 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 organisations quality and safety initiatives Make practice life more efficient for clinical colleagues Able to make and keep commitments on behalf of doctors 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

61 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 hospitals ability to change? Back Home Discussion About Doctor Leadership

62 Foundation for Engagement Share a vision Inspire action with clear picture of future Engaged Doctors Modernize compact Co-create new gives and gets Modernize compact Co-create new gives and gets Enhance leadership Develop doctor leaders who sponsor change Increase urgency Turn up heat Single method for improvement

63 Compact Expectations members of an organisation have that are: Unstated yet understood Reciprocal The give The get Mutually beneficially

64 G IVE G ET Autonomy Protection Entitlement Treat patients Provide quality care (personally defined) Traditional Doctor Compact

65 Autonomy Protection Entitlement Improve safety/quality Implement electronic records Improve efficiency and value Be patient-focused Improve access Traditional Promise Legacy Expectations Imperatives Clash Of Promise And Imperatives

66 Old Compact at VMMC Not Working Despite the fact things werent working, most doctors clung to the fundamental gets they felt due them Protection Autonomy Entitlement Doctor-centered world view prevailed

67 Doctor Retreat (Fall 2000) Doctor Retreat (Fall 2000) VMMC Compact Process 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

68 Compact committee drafts compact (Winter 2001) Compact committee drafts compact (Winter 2001) VMMC Compact Process 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 Doctor Retreat (Fall 2000) Doctor Retreat (Fall 2000)

69 Departmental meetings for input (Spring 2001) VMMC Compact Process Committee met weekly Reality Checks Management Committee Doctors Multiple Drafts until we reached the final draft Compact committee drafts compact (Winter 2001) Compact committee drafts compact (Winter 2001) Doctor Retreat (Fall 2000) Doctor Retreat (Fall 2000)

70 Virginia Mason Medical Center Doctor Compact Organization 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 Doctor s Responsibilities 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

71 Hardwiring Compact Recruitment Orientation Job Descriptions Chief Section Heads Doctors Feedback

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)

73 Vision Is Context for Compact Societal needs Local market Organisations strengths Competition Doctors give : What the organisation needs to achieve the vision Organisation gives: What helps doctors meet commitment

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

75 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? Back Home Discussion About Doctor- Organization Compact

76 Foundation for Engagement Share a vision Inspire action with clear picture of future Engaged Doctors Modernize compact Co-create new gives and gets Modernize compact Co-create new gives and gets Enhance leadership Develop doctor leaders who sponsor change Increase urgency Turn up the heat Single method for improvement

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

78 Readings 1. Bohmer R. and Ferlins E. Virginia Mason Medical Center – Harvard Business School Case , President and Fellows of Harvard College, Bridges, W. Managing Transitions. Addison-Wesley, Edwards, N, Kornacki, MJ, and Silversin, J. Unhappy doctors: what are the causes and what can be done? BMJ 2002; 324: Heifetz, R. and Linsky, M. Leadership on the Line. Harvard Business School Press, Kenny, Charles. Transforming Health Care: Virginia Mason Medical Centers Pursuit of the Perfect Patient Experience. CRC Press, Kotter, J. Leading Change. Harvard Business School Press, Kotter, J. and Cohen, D. The Heart of Change. Harvard Business School Press, Kornacki, M.J. and Silversin, J. Leading Physicians through Change: How to Achieve and Sustain Results, 2 nd edition, American College of Physician Executives, 2012


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