Presentation on theme: "Jack Silversin, DMD, DrPH"— Presentation transcript:
1 Jack Silversin, DMD, DrPH Engaging Healthcare Professionals to Transform Care10 April 2014Gary Kaplan, MDChairman and CEO, Virginia Mason Medical CenterJack Silversin, DMD, DrPHFounding Partner, Amicus, Inc
2 Virginia Mason Medical Center Integrated health care system501(c)3 not-for-profit336-bed hospitalNine locations500 doctors5,500 employeesGraduate Medical EducationResearch InstituteFoundationVirginia Mason Institute2
4 Seeing with our Eyes Japan 2002 Team Leader Kaplan reviewing the flow of the process withDrs. Jacobs and Glenn at Hitachi Air Conditioning plant4
5 Take-AwaysHow are air conditioners, cars, looms and airplanes like health care? Every manufacturing element is a production processesHealth 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 complexAll of these products involve the concepts of quality, safety, customer satisfaction, staff satisfaction and cost effectivenessThese products, if they fail, can cause fatality5
6 The VMMC Quality Equation Q = A × (O + S)WQ: QualityA: AppropriatenessO: OutcomesS: ServiceW: Waste
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 firstHighest qualityObsession with safetyHighest staff satisfactionA successful economic enterprise7
8 Value Stream Development RPIW (Rapid Process Improvement Workshop) VMPS Tools in ActionValue Stream DevelopmentRPIW (Rapid Process Improvement Workshop)5S (Sort, simplify, standardize, sweep, self-discipline)3-P (Production, Preparation, Process)Standard WorkDaily Work Life88
9 RN time available for patient care = 90%! “Nursing Cells” – Results > 90 daysRN time available for patient care = 90%!BeforeAfterRN # of steps = 5,818PCT # of steps = 2,664Time 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 = 20’8461256126’0%10%16%11’The RN and PCT are spending more time engaged in direct patient careA significant reduction in walking distance (85%) and time to complete the a.m. cycle of work (48%).An increase in patient satisfaction and a decrease in call light use because their care team is present and addressing their needs while they’re in the room.Again, supplies and equipment were brought to point of use, so they’re spending almost 50% less time searching for and gathering supplies.9
10 Lindeman Surgery Center Throughput Analysis Before Today % ChangeTime Available 600 min min 0%(10 hr day)Total Case Time 107 min min 39%(cut to close plus set-up)Case Turnover min 15 min 50%Time (pt out to pt in) (ability to be <10 min)Cases/day cases/OR cases/OR 60%Cases/4 ORs 20 cases 32 cases 60%
11 Primary Care – Flow Stations Creating MD Flow Reduces Patient Wait TimesVMPS Concepts of a Flow StationWaste of motion (walking)Continuous flowVisual control (Kanbans)External setupWater striderU-Shaped CellURGENTCERNER MESSAGEPAPER MAILDOCUMENT VISITRESULT REPORT$CHARGESLIP$
13 “Stopping the Line” Organization-wide Involvement Staff identify and report issues and concerns using the Patient Safety Alert SystemLeadership involvement with investigation and resolutionBoard Quality Committee review and approve closure of high-severity issues (Red PSA’s)Virginia Mason is unique in having a system in place where that occurs – and even more unique in the fact that it starts with the staff and goes all the way up to our Board.
14 Categorizing Patient Safety Risk Events 3 Basic Risk SourcesEvaluationTreatmentCritical interactions27 Specific Risk Categories3 of the top 5 risksDirect Patient CareMedicationLaboratory Order & CollectionThis past year VM developed a Risk Registry to enable us to use all the information we’ve been collecting over the years to more pro-actively identify areas of focus. Risk registers are tools to systematically identify risks and rank them based on both their impact and probability of occurrence to help organizations make more informed decisions about risk mitigation and intervention.We categorized our PSA into 27 risk categories; we then used VM claims experience to estimate the annual liability costs for each risk category. The last step was to conduct focus groups to obtain staff and manager input to elicit quantitative estimates of rate and relative harm for each risk category.We found that focus group risk perceptions agreed with PSA-based rankings for three of the top five risk areas.
15 Overall staff response rate Virginia Mason Medical Center 2013 AHRQ Mean = 51%Is this just VM docs, or is it everyoneWe look “different” since Why?What might be the benefit and lesson if we go higher?
17 Reduction of Hospital Professional/General Liability Premiums % change from previous year, with 74% overall reduction in premium since7%12%5%26%12%12%11%12%30%
18 Virginia Mason Medical Center Hospital of Decade: Efficiency and Effectiveness 1. We are pleased that the Leapfrog Group, an association of large employers, has designated VM one of two US hospitals of the decade, based on both effectiveness and efficiency.2. This designation by employers indicates that we are approaching the delivery of health care in a different manner from other provider groups and this is certainly the case.3. It was not always so, however,. In 2000, we found ourselves facing a negative margin and part of a health care industry that was clearly moving rapidly in the wrong direction.
20 Our Quality & Safety Journey Patient/ FamilyEngagementLeapfrog Top Hospital of the DecadeToyota Production SystemIntroduced to VMMC1st IOM1 Report2000200120022003200420052006200720082009201020112012Respect for People TrainingFallsST-PRA5Leapfrog Governance AwardVirginia MasonProduction SystemestablishedDeclare One Organizational Goal: Patient SafetyMary L. McClintonFatal medical error1st Culture of Safety Work PlanAHRQ4 Safety Culture Survey: 81% ParticipationAHRQ4 Safety Culture Survey: 84% ParticipationIHI3 5 Million Lives1st Safety Culture SurveyEmployee Safety Risk RegistryPSA Case StudiesCPOEGo LiveQ4Q Site VisitPatient Safety Alert (PSA) for clinical events2nd Safety Culture SurveyMove to yearly AHRQ4 Safety Culture SurveyStaff & PatientLeader RoundsAHRQ4 Safety Culture Survey: 82% Participation (all staff, all electronic)AHRQ4 Safety Culture Survey: 90% Participation2nd IOM1 ReportMDMRPIW6Cross Pillar Culture of Safety Work PlanPSA 3PADEPT2Preprinted Order SetsTime Out ST-PRA5As you all know our safety culture journey started quite some time ago; the work I have shared today provide just a few examples of how our journey continues and our commitment to pursuing perfection in all elements of the quality equations grows .CEO Mandates PSA SystemPSA for non-clinical eventsPatient Safety Risk RegistryVM Board:Business Case for QualityMD Disclosure TrainingJust CultureStrategic Quality PlanStandard Quality Goal Reporting ProcessQuest for Quality Citation of Merit2010 HealthGrades Patient Safety AwardExecutive Walk RoundsIHI3 100,00 LivesInstitute of MedicineAdverse Drug Events Prevention TeamInstitute for Healthcare ImprovementAgency for Healthcare Research and QualitySociotechnical Probabilistic Risk AssessmentMust Do Measure Rapid Process Improvement Workshop
21 2013 Organizational GoalsQuality 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 DeliriumWe attract and develop the best teamPeopleWe foster a culture of learning and innovationInnovationWe create an extraordinary patient experienceServiceWe relentlessly pursue the highest quality outcomes of careQualityVisionTo be the Quality Leader and transform health careMissionTo improve the health and well-being of the patients we serveValuesTeamwork | Integrity | Excellence | ServiceStrategiesVirginia Mason Team MedicineSM Foundational ElementsPatientStrong EconomicsResponsible GovernanceEducationVirginia Mason FoundationIntegrated InformationSystemsResearchVirginia Mason Production SystemQuality, Safety, Service, People, Innovation• Respect for PeopleService: Patient Experience• Integration of the Patient ExperiencePeople: Team Engagement• Transformational Leadership• Organizational Training & EducationFirst, I’d like to brief you on our key goal areas for this year.As you know, we have a lot going on at Virginia Mason! To help focus our attention and resources on the areas that matter most, we developed these goals – with approval of the board – and have shared them with staff and providers so everyone in the organization knows what we are working toward in 2013.I thought it might be simplest to bring you up to speed by focusing on many of these same areas, so my slides are divided based on our goals and what we’ve accomplished in each area during the past several months.Strong Economics• GrowthIntegrated I.S.: Technology and CareDelivery Partnerships• Realizing the Potential of Our Electronic Health Record• Update the Enterprise Orders and DocumentationFramework• Ambulatory CPOE• Measure and Improve our Results
22 With engaged and committed staff and doctors! How Have We Gotten HereWith 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 inputDevelop more realistic expectations of what is possibleHave greater commitment to solutions; successful implementation more likelyBuilds trust and partnership between doctors and management when doctors experience they have influence on outcomesHelps doctors move through psychological transition associated with change
24 Authentic Engagement Is Difficult Managers or administratorsSome like making decisions and controlling outcomesExperience pressure for timely decisionsHave not been successful managing efficient and helpful process for engagementAre faced with doctors’ expectation that asking their advice should translate into actions that reflect itExperience sincere attempts have been met with cynicism or disinterestDoctorsPerceive that past input has gone into “black hole” which leads to cynicismPaid for productivity, some will not participate in non-clinical work unless compensatedHaving the option to do what I want to do anyway makes investing time in improvement activity irrationalRequires on going commitment to engage even when you don’t 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 engagementPreferred 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
27 Two Kinds of Challenges Ronald Heifetz TechnicalProblem is well definedSolution is known can be foundImplementation is clearAdaptiveChallenge is complexTo solve requires transforming long-standing habits and deeply held assumptions and valuesInvolves 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 it’s technological but because:Its use involves no angst or challenge to personal identityAdoption is intuitive or similar to other successful changes. Past experience provides a “road map” or sense for how it worksThere’s always the Genius Bar – someone does know what to do.
30 Wisdom from Ronald Heifetz “The most common cause of failure to make progress is treating an adaptive problem with a technical fix.”Technical fixesNew payment scheme for doctorsIncentives or bonusesReorganizationIssuing new vision statementAdaptive solutionsGiving authority to solve problems to the implementersDiscussion that allows respectful airing of differenceBringing conflict to the surface and constructively resolving it30
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 Single method for improvementEngagedDoctorsModernize compactCo-create new gives and getsIncrease urgencyTurn up the heatEnhance leadershipDevelop doctor leaders who sponsor changeShare a visionInspire action with clear picture of future
33 Foundation for Engagement Single method for improvementEngagedDoctorsClarify new compactCo-create new gives and getsIncrease urgencyTurn up heatEnhance leadershipDevelop doctor leaders who sponsor changeShare a visionInspire action with clear picture of future
34 Time for a Change – VMMC 2000 Issues Leadership Change SurvivalRetention of the Best PeopleLoss of VisionBuild on a Strong FoundationLeadership ChangeA Defective Product34
35 Urgency for Change at VMMC “”We change or we die.— Gary Kaplan, VMMC Professional staff meeting, October 2000
36 November 23, 2004 Hospital error caused death Investigators: Medical mistake kills Everett womanHospital error caused deathMary L. McClinton
37 I would like to talk to you about Mary McClinton I would like to talk to you about Mary McClinton. Mary was a patient of Virginia Masons – she had who died at Virginia Mason of an avoidable medical error.3737
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 strongThe case for change has to be compelling if it is to move others to take action
41 “Distress” and Adaptive Work Limit of toleranceAdaptive challengeDisequilibriumProductive range of distressThreshold of learningTimeHeifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108
42 Urgency: Make the Invisible Visible HOWSelf-discovery” – experientialMore than facts: John Kotter’s see/feel/change approachWHATCost of doing nothing exceeds cost of changeCold, hard facts on performance and lack of sustainabilityGap between aspiration and realityThe 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.”— Charles O’Reilly IIIOR43
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 Single method for improvementEngagedDoctorsModernize compactCo-create new gives and getsIncrease urgencyTurn up heatEnhance leadershipDevelop doctor leaders who sponsor changeShare a visionInspire action with clear picture of future
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 transactionsDoctors don’t readily acknowledge their interdependenceVision process is often superficial; an exercise with a narrow purpose (e.g., for PR)Little connection between vision on paper and daily lifeNo 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, safetyEncourages different points of view to be heardBuilds commitmentVision is:Strategic and granularPerceived as a stretch, but not a fantasy
51 Basis of Vision is Shared Interests Organisation’sInterestsDoctors’ InterestsSHARED INTERESTSCommitment to patients’ care and safetyPositive reputationRecruit and retain talent
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 GreatWhy did you choose the number you did?What impact does this have on doctor engagement?
53 Foundation for Engagement Single method for improvementEngagedDoctorsIncrease urgencyTurn up heatModernize compactCo-create new gives and getsEnhance leadershipDevelop doctor leaders who sponsor changeShare a visionInspire action with clear picture of future
54 Typical Views Doctors Hold of Their Leaders AdvocateProtectorCommunicator – go to meetings to represent our views and keep us informed of important newsFirst among equals, “not one millimeter above”
55 Consider Two Mental Models Range of Leadership ActivitiesAdvocate for my peersOther Leadership activitiesAdvocate for subordinatesProfessional managers’ viewDoctor leaders’ view
56 Reinforcement of Traditional Doctor Leadership Preference for leadership that doesn’t threaten personal autonomyThere are times when advocacy or protection is appropriateDoctors make leaders pay a price for stepping out of advocate/protector roleElection to leadership rolesShort tenure in role limits development of a wide range of leadership skills
57 VMMC Doctor Leader is a Real Job Appointed, not electedClear expectations/job descriptionsPerformance feedbackTraining and developmentSuccession planningDyad model pairs administrative leader with doctor leader at every level
58 For Doctor Leaders to be Effective, Administrative Leaders Need to Change It’s not just doctor leaders who shift mindset and actionsWorking collaboratively with doctors represents an adaptive change for many administrative leadersNeed to move away from language such as: “We need to gain their buy-in” and “We’ll roll it out”
59 Principle 3. Investment in New Model of Doctor Leadership is Critical Current DilemmaDoctors don’t easily accept legitimacy of leaders’ authorityHospital needs doctor leaders to sponsor change
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 ScheinSponsor change and engage colleaguesDemonstrate personal commitment to quality and safety improvementBe a role model and among the first to adopt the new wayProvide encouragement and acknowledgment to those who get on with changeHold colleagues accountable to engage in the organisation’s quality and safety initiativesMake practice life more efficient for clinical colleaguesAble to make and keep commitments on behalf of doctorsBuild network of leaders for peer support and identity development
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?
62 Foundation for Engagement Single method for improvementEngagedDoctorsIncrease urgencyTurn up heatModernize compactCo-create new gives and getsEnhance leadershipDevelop doctor leaders who sponsor changeShare a visionInspire action with clear picture of future
63 Compact Expectations members of an organisation have that are: Unstated yet understoodReciprocalThe giveThe getMutually beneficially63
64 Traditional Doctor Compact GIVEGETTreat patientsProvide quality care(personally defined)AutonomyProtectionEntitlement64
65 Clash Of “Promise” And Imperatives Traditional “Promise”Legacy ExpectationsImperativesImprove safety/qualityImplement electronic recordsImprove efficiency and valueBe patient-focusedImprove accessAutonomyProtectionEntitlement65
66 Old Compact at VMMC Not Working Despite the fact things weren’t working, most doctors clung to the fundamental “gets” they felt due themProtectionAutonomyEntitlementDoctor-centered world view prevailed
67 VMMC Compact Process Doctor Retreat (Fall 2000) Broad based committee of providers: primary care, sub-specialistsFocus of retreat: doctors-changing expectations, tools to manage changeJack Silversin served as our consultantSpent time at VMMC talking to doctors
68 Compact committee drafts compact VMMC Compact ProcessDoctor Retreat(Fall 2000)Compact committee drafts compact(Winter 2001)Broad based group of providersAdministrative Involvement: CEO, JD, HR, Board Member (also a patient)Starting point:“Gives” and “gets” from the RetreatEvolving Strategic Plan: patient centered
69 Compact committee drafts compact VMMC Compact ProcessDoctor Retreat(Fall 2000)Compact committee drafts compact(Winter 2001)Departmentalmeetings for input(Spring 2001)Committee met weeklyReality ChecksManagement CommitteeDoctorsMultiple Drafts until we reached the “final draft”
70 Virginia Mason Medical Center Doctor Compact Organization’s ResponsibilitiesFoster ExcellenceRecruit and retain superior doctors and staffSupport career development and professional satisfactionAcknowledge contributions to patient care and the organizationCreate opportunities to participate in or support research Listen and CommunicateShare information regarding strategic intent, organizational priorities and business decisionsOffer opportunities for constructive dialogueProvide regular, written evaluation and feedbackEducateSupport and facilitate teaching, GME and CMEProvide information and tools necessary to improve practice RewardProvide clear compensation with internal and market consistency, aligned with organizational goalsCreate an environment that supports teams and individualsLeadManage and lead organization with integrity and accountability Doctor’s ResponsibilitiesFocus on PatientsPractice state of the art, quality medicineEncourage patient involvement in care and treatment decisionsAchieve and maintain optimal patient accessInsist on seamless serviceCollaborate on Care DeliveryInclude staff, doctors, and management on teamTreat all members with respectDemonstrate the highest levels of ethical and professional conductBehave in a manner consistent with group goalsParticipate in or support teachingListen and CommunicateCommunicate clinical information in clear, timely mannerRequest information, resources needed to provide care consistent with VM goalsProvide and accept feedback Take OwnershipImplement VM-accepted clinical standards of careParticipate in and support group decisionsFocus on the economic aspects of our practiceChangeEmbrace innovation and continuous improvementParticipate in necessary organizational change
72 Principle 4. A New Compact Is an Adaptive Change Journey as important as destinationIterative process for understanding and buy-inMutual accountability (2-way street)
73 Vision Is Context for Compact Doctors give:What the organisation needs to achieve the visionOrganisation gives:What helps doctors meet commitmentSocietal needsLocal marketOrganisation’s strengthsCompetitionSTRATEGIC VISION
74 Compact Supports Alignment with Vision Compact discussions as foundational – basic to moving us toward visionCompact is revisited, made alive, reinforcedPeriodic assessments/dialogue as to how both “sides” are living up to compact commitments
75 Back Home Discussion About Doctor-Organization 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?
76 Foundation for Engagement Single method for improvementEngagedDoctorsModernize compactCo-create new gives and getsIncrease urgencyTurn up the heatEnhance leadershipDevelop doctor leaders who sponsor changeShare a visionInspire action with clear picture of future
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 ReadingsBohmer R. and Ferlins E. Virginia Mason Medical Center – Harvard Business School Case , President and Fellows of Harvard College, 2006Bridges, W. Managing Transitions. Addison-Wesley, 1991Edwards, 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, 2002Kenny, Charles. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. CRC Press, 2011Kotter, J. Leading Change. Harvard Business School Press, 1996Kotter, J. and Cohen, D. The Heart of Change. Harvard Business School Press, 2002Kornacki, M.J. and Silversin, J. Leading Physicians through Change: How to Achieve and Sustain Results, 2nd edition, American College of Physician Executives, 2012