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

10 April 2014Gary Kaplan, MD

Chairman and CEO, Virginia Mason Medical Center

Jack Silversin, DMD, DrPH

Founding Partner, Amicus, Inc

Engaging Healthcare Professionals to Transform

Care

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

Our Strategic Plan

Seeing with our EyesJapan 2002

Team Leader Kaplan reviewing the flow of the process with Drs. Jacobs and Glenn at Hitachi Air Conditioning plant

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

The VMMC Quality Equation

Q: QualityA: AppropriatenessO: OutcomesS: Service W: Waste

Q = A × (O + S) W

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

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

“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 = 20’

846

1256

126’

0%

10%

16%

0%

11’

RN time available for patient care = 90%!

Lindeman Surgery CenterThroughput Analysis

Before Today % Change• Time Available 600 min 600 min 0% (10 hr day)

• Total Case Time 107 min 65.5 min39%

(cut to close plus set-up)

• Case Turnover 30 min 15 min 50% Time (pt out to pt in) (ability to be <10 min)

• Cases/day 5 cases/OR 8 cases/OR60%

• Cases/4 ORs20 cases 32 cases 60%

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

CHARGESLIP

$

DOCUMENT VISIT

$

CERNER MESSAGE

URGENT

PAPER MAIL

RESULT

REPORT

Stopping The Line

“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 PSA’s)

2002

2004

2006

2008

2010

2012

0

100

200

300

400

500

600

700

Number of PSAs Reported per Month

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

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Evaluation Treatment

CriticalInteractions

Provider

LaboratoryDiagnostics

Imaging Medical

Surgical/Procedure

Care Mgmt

PersonalBehavior

Environment

Organizational Behavior

Occupational

1

2

3

20022004200520062007-08

200920102011201220130%

25%

50%

75%

100%

21%16%

58%

21%

47%

81% 82%84%90%88%

Overall staff response rateVirginia Mason Medical Center

2013 AHRQ Mean = 51%

We look “different” since 2009. Why? What might be the benefit and lesson if we go higher?

Reduction of Hospital Professional/General Liability

Premiums

'04-'05 '05-'06 '06-'07 '07-'08 '08-'09 '09-'10 '10-'11 '11-12 '12-'13 13-'14

% change from previous year, with 74% overall

reduction in premium since 2004-05

7%

12%

5%

26%

12%12%

11%

12%

30%

Virginia Mason Medical CenterHospital of Decade: Efficiency and Effectiveness

Tuesday Morning “Stand Up”

AHRQ4

Safety Culture Survey: 82% Participation (all staff, all electronic)

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Our Quality & Safety JourneyToyota Production SystemIntroduced to VMMC

2nd IOM1

Report

ADEPT2

Preprinted Order Sets

Virginia Mason Production Systemestablished

Patient Safety Alert (PSA) for clinical events

Strategic Quality Plan

1st Safety Culture Survey

Executive Walk Rounds

PSA for non-clinical events

2nd Safety Culture Survey

Mary L. McClintonFatal medical error

CPOE Go Live

Move to yearly AHRQ4 Safety Culture Survey

Declare One Organizational Goal: Patient Safety

MD Disclosure Training

IHI3 100,00 Lives

IHI3 5 Million Lives

Leapfrog Governance Award

Staff & PatientLeader Rounds

Patient/ FamilyEngagement

AHRQ4 Safety Culture Survey: 81% Participation

2010 HealthGrades Patient Safety Award

Time Out ST-PRA5

Just Culture

FallsST-PRA5

1st IOM1 Report

VM Board:Business Case for Quality

1st Culture of Safety Work Plan

PSA Case Studies

1. Institute of Medicine2. Adverse Drug Events Prevention Team3. Institute for Healthcare Improvement

Standard Quality Goal Reporting Process

CEO Mandates PSA System

MDMRPIW6

4. Agency for Healthcare Research and Quality5. Sociotechnical Probabilistic Risk Assessment6. Must Do Measure Rapid Process Improvement Workshop

Cross Pillar Culture of Safety Work Plan

Leapfrog Top Hospital of the Decade

Q4Q Site Visit


PSA 3P

Patient Safety Risk Registry

Respect for People Training

Quest for Quality Citation of Merit


Employee Safety Risk Registry

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 learningand innovation

Innovation

We create anextraordinary

patient experience

Service

We relentlessly pursue the

highest quality outcomes of care

Quality

VisionTo be the Quality Leader and transform health care

MissionTo improve the health and

well-being of the patients we serve

Values

Teamwork | Integrity | Excellence | Service

Strategies

Virginia Mason Team MedicineSM Foundational Elements

Patient

Strong Economics

ResponsibleGovernance

Education Virginia MasonFoundation

IntegratedInformation

Systems

Research

Virginia Mason Production System

How Have We Gotten Here

With engaged and committed staff and doctors!

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

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 don’t get what you want in a given situation

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

A Helpful Perspective on Change

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

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.

An Adaptive Challenge

“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

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

Foundation for Engagement

Share a vision

Inspire action with clear picture of

future

EngagedDoctors

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


Share a vision


future

EngagedDoctors

Clarify new compact


Enhance leadership


sponsor change

Increase urgency

Turn up heat

Single method for

improvement

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

Urgency for Change at VMMC

— Gary Kaplan, VMMC Professional staff meeting, October 2000

“ ”We change or we

die.

November 23, 2004

Hospital error caused death

Investigators: Medical mistake kills Everett woman

Mary L. McClinton

37

The Challenge of Ongoing Urgency

• In a time of constant and tumultuous change, avoid complacency

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

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

Productive range of distress

Threshold of learning

Limit of tolerance

Time

D

iseq

uilib

riu

m“Distress” and Adaptive Work

Adaptive challenge

Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108

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

Leaders’ Role in Signal Generation

“Leaders are signal generators who reduce

uncertainty and ambiguity about what is

important and how to act.”

OR

— Charles O’Reilly III

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?


Share a vision


future

EngagedDoctors

Modernize compact


Enhance leadership


sponsor change

Increase urgency

Turn up heat

Single method for

improvement

Our Strategic Plan

Principle 2. Engagement is Facilitated When A Destination is Shared

Everyone needs to share the same destination to make optimal use of all

resources

Lack of Shared Vision Reflects Silo Orientation and Value on Autonomy

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

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

Basis of Vision is Shared Interests

Organisation’sInterests

Doctors’ Interests

SHARED INTERESTS

Commitment to patients’ care and safetyPositive reputation

Recruit and retain talent

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?

Back Home Discussion About Shared Vision


Share a vision


future

EngagedDoctors

Modernize compact


Enhance leadership


sponsor change

Increase urgency

Turn up heat

Single method for

improvement

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”

Consider Two Mental Models

Range of Leadership Activities

Advocate for subordinates

Advocate for my peersOther

Leadership activities

Doctor leaders’ viewProfessional managers’ view

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

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

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”

Hospital needs doctor leaders to sponsor change

Doctors don’t easily accept legitimacy of leaders’ authority

Principle 3. Investment in New Model of Doctor Leadership is Critical

Current Dilemma

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 organisation’s 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

• 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?

Back Home Discussion About Doctor Leadership


Share a vision


future

EngagedDoctors

Modernize compact


Enhance leadership


sponsor change

Increase urgency

Turn up heat

Single method for

improvement

Compact

• Expectations members of an organisation have that are: Unstated yet understood Reciprocal

• The give• The get

Mutually beneficially

GIVE GET

• Autonomy• Protection• Entitlement

• Treat patients

• Provide quality care

(personally defined)

Traditional Doctor Compact

• 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

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

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

Compact committee drafts compact

(Winter 2001)


(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



Departmentalmeetings for input

(Spring 2001)


• Committee met weekly• Reality Checks

Management Committee Doctors

• Multiple Drafts until we reached the “final draft”


(Winter 2001)


(Winter 2001)



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 feedbackEducate• 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

individualsLead· 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 serviceCollaborate 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 teachingListen 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 practiceChange• Embrace innovation and continuous improvement• Participate in necessary organizational change

Hardwiring Compact

• Recruitment• Orientation• Job Descriptions

Chief Section Heads Doctors

• Feedback

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)

Vision Is Context for Compact

• Societal needs• Local market• Organisation’s

strengths• Competition

STRATEGIC VISION

STRATEGIC VISION

Doctors give:

•What the organisation needs to achieve the vision

Organisation gives:

•What helps doctors meet commitment

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

• 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


Share a vision


future

EngagedDoctors

Modernize compact


Enhance leadership


sponsor change

Increase urgency

Turn up the heat

Single method for

improvement

“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

Readings1. Bohmer R. and Ferlins E. Virginia Mason Medical Center –

Harvard Business School Case 9-606-044, President and Fellows of Harvard College, 2006

2. Bridges, W. Managing Transitions. Addison-Wesley, 1991

3. Edwards, N, Kornacki, MJ, and Silversin, J. Unhappy doctors: what are the causes and what can be done? BMJ 2002; 324: 835-838

4. Heifetz, R. and Linsky, M. Leadership on the Line. Harvard Business School Press, 2002

5. Kenny, Charles. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. CRC Press, 2011

6. Kotter, J. Leading Change. Harvard Business School Press, 1996

7. Kotter, J. and Cohen, D. The Heart of Change. Harvard Business School Press, 2002

8. Kornacki, M.J. and Silversin, J. Leading Physicians through Change: How to Achieve and Sustain Results, 2nd edition, American College of Physician Executives, 2012

Documents

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