Building a Culture of Value - Singapore Healthcare …€¦ · Building a Culture of Value ......

Moving from Physician Driven to Patient Driven Building a Culture of Value

Gary Kaplan, MD

Singapore Healthcare Management Congress

August 15, 2017

© 2014 Virginia Mason Medical Center

Today’s Objectives

• Hear the story of one organization’s

journey that learned to see the patient’s

experience more deeply

• To hear how it feels to be a leader of a

healthcare organization that opens its

doors to listening to the patients voice

from the front lines to the board room

2


Virginia Mason

• Integrated health care system

• Became two hospital system

in January 2016, with

Yakima Memorial affiliation

• 501(c)3 not-for-profit

• 336-bed hospital

• Nine locations

• Graduate Medical

Education

• Research Institute

• Foundation

• Virginia Mason Institute


• Autonomy

• Protection

• Entitlement

• Improve

safety/quality

• Implement EHR

• Create service

experience

• Be patient-focused

• Improve access

• Improve efficiency

• Recruit/retain

quality staff

Traditional “Promise” Legacy Expectations

Imperatives

Clash of “Promise” and Imperatives


Virginia Mason Medical Center

Physician Compact

Organization’s Responsibilities

Foster Excellence

• Recruit and retain superior physicians 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

Physician’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, physicians, 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


• 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


The VMMC Quality Equation

Q: Quality

A: Appropriateness

O: Outcomes

S: Service

W: Waste

Q = A × (O + S)

W


The Virginia Mason Production System

We adopted the Toyota Production System key

philosophies and applied them to healthcare

9

1. The patient is always first

2. Focus on the highest quality and safety

3. Engage all employees

4. Strive for the highest satisfaction

5. Maintain a successful economic enterprise


Seeing with our Eyes

Japan 2002

Stopping the Line ™

Virginia Mason’s Patient

Safety Alert System ™


Stopping the line

© 2016 Virginia Mason Institute

Repetitive daily activities and behaviors that leaders engage in to

ensure customer demand is met and identify abnormal conditions

13

Daily Management

Leaders Have Two Jobs:

1. Run your business

2. Improve your business


Tuesday “Stand Up” • KPO aligned with

operational executive leadership

• Executive sponsorship

with accountability for sustained results

• Education • Standardization of

tools, results reporting, and communication


Educate & Engage 5,000+


Effective Sponsorship

• Vision of success

• Set stretch goals

• Provide resources

• Remove barriers

• “Fail forward fast”

• Celebrate achievements


2013-2017 Strategic Service Plan

INTEGRATION OF QUALITY &

SERVICE Patient experience

integrated into organizational

strategies.

PARTNERSHIP WITH PATIENTS &

FAMILIES Active participation in

process improvement to

transform care delivery.

ENGAGE, DEVELOP & ACTIVATE PEOPLE Select for service, develop

skills and enhance accountability with our

people.

We create an extraordinary patient experience.


• Become an organization that routinely listens to and

deeply understands customers’ experiences

• Co-design better services through an active partnership

with patients, family and staff

The Vision

(Professor Paul Bate, UCL 2007)

Don’t listen very much to our users and

we do the designing

Design and improve, then ask our users

what they think

Listen to our users, then go off and do the

designing

Listen to our users and go off with them

to do the designing

Move from this to this


Experience-Based Design Is…

A philosophy and set of methods focused on

an understanding of the experiences and

emotions of those who are involved in

receiving and delivering healthcare services,

striving to understand what people naturally

do and feel.

What really matters to our customers?


The Value of Emotion Words


EBD Helps Bust Assumptions

We observe and learn directly from

customers about their experiences and what

they need


Basic EBD Methods

Observations Interviews Experience

Questionnaires Focus

Groups

Fly on the

wall; subtle

presence

Big ears, big

eyes, small

mouth

Collect

stories, guide

through an

experience

Open-ended

questions

Visual

depiction of a

process

Customers

select

emotions at

each touch

point

Small group

Guide

through a

common

experience

Open-ended

questions


Know Me

The Board’s Role


Board’s Responsibility

Alignment with Strategic Plan

Quality and Safety

Patient Experience and Service

Strong Economics and Growth

Health Care Environment

Positioning Virginia Mason for the Future


Virginia Mason Board Compact Organization’s Responsibilities

Foster Excellence

• Facilitate the recruitment and retention of superior board members

• Provide a process for regular, written evaluation and feedback through annual board self-evaluation

• Provide a thorough orientation process for new board members

• Support governance excellence with adequate board resources Listen and Communicate • Share information regarding strategic intent, organizational

priorities and business decisions

• Offer opportunities for constructive dialogue • Report regularly on implementation of strategic plan and

achievement of specific board objectives • Disclose to and inform board on risks and opportunities facing the

organization

• Provide materials to members necessary for informed decision making sufficiently in advance of board meetings

Educate • Provide information and tools necessary to keep members

informed and educated on local and national health care issues

• Provide educational and training opportunities to maintain a high level of board member effectiveness and knowledge

• Educate board members about organization, its structures and its guiding documents

Lead

• Manage and lead organization with integrity and accountability • Create clear goals and strategies • Continuously measure and improve patient care, service and

efficiency

• Resolve conflict with openness and empathy • Ensure safe and healthy environment and systems for patients

and staff

Board Member’s Responsibilities

Know the Organization

• Know the organization’s mission, purpose, goals, policies, programs, services, strengths and needs

• Keep informed on developments in the Health System’s areas of expertise, and on health care policy and future trends and best governance practices

Focus on the Future

• Spend three fourths of every meeting focused on the future

• Consistently maintain a current and vital strategic plan


• Actively participate in board discussions

• Participate in educational opportunities and request information and resources needed to provide responsible oversight

• Provide and accept feedback

• Represent the board to the organization and be an advocate for the organization in the community

Take Ownership

• Attend meetings

• Ask timely and substantive questions at board and committee meetings consistent with your conscience and convictions

• Prepare for, participate in, and support group decisions

• Understand and participate in approving annual and longer range financial plans and Quality & Safety oversight

• Make an annual, personal financial contribution to the organization, according to personal means

• Serve on board committees or task forces

Promote Effective Change

• Foster innovation and continuous improvement

• Pursue necessary organizational change


Voice of the Patient

• Each board meeting begins with patient story

• Presented by a patient

• Stories are both good and bad

• Drives accountability

Respect for People

refers to how we treat

each other as we work

together to create the

perfect patient experience.

Respect for People “2.0”

is anchored in the 10

foundational behaviors of

respect and focuses on what

respect “feels” like when the

behaviors are demonstrated.

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Patients and Family Partners

─ Insightful about what we do well and areas where changes may be needed

─ Help us develop priorities and make improvements based on patient- and family-identified needs

─ Push us out of our mental valleys and come up with new ideas and solutions


Where We’re Heading

32


Create full

partnership with

patients and families

to improve

and transform our

delivery of care.

Understanding

customer

experiences

stimulates

creative

thinking and

breakthrough

innovation.

Customers

define value-

added.

Do we really know

what matters?


Gaining the “voice of the patient” through

surveys

and random interviewing

Virginia Mason team members represent

the

patient voice

EBD formally began with development, testing of the

emotion word list and implementation

RPIW created a patient

recruitment

strategy

Innovation Event created

model for

strategic involvement of

patients &

families

PFP recruitment

and development

First

Innovation Co-Design

Event

Kaizen Event created standards

for preparing teams

108 PFP and

growing stronger!

+/- 100 leaders

trained in

EBD

More co-design

projects in

place

PFP join committees and guiding

teams

2007/08 2009/10 2011 2012 2013 2014 2015 2016 2016

Electronic recruitment increased response rate by 10% now over 150 PFP Held Inaugural Patient Experience Day Launched “Listening Sessions”

Timeline of Patient-Family Engagement


Gaining the “voice of the patient” through

surveys

and random interviewing

Virginia Mason team members represent

the

patient voice

EBD formally began with development, testing of the

emotion word list and implementation

RPIW created a patient

recruitment

strategy

Innovation Event created

model for

strategic involvement of

patients &

families

PFP recruitment

and development

First

Innovation Co-Design

Event

Kaizen Event created standards

for preparing teams

108 PFP and

growing stronger!

+/- 100 leaders

trained in

EBD

More co-design

projects in

place

PFP join committees and guiding

teams

2007/08 2009/10 2011 2012 2013 2014 2015 2016 2016

Electronic recruitment increased response rate by 10% now over 150 PFP Held Inaugural Patient Experience Day Launched “Listening Sessions”

What has been our focus this past year?

We have now had two Patient

Experience Days


Overarching themes we heard

Regarding improvement

work together:

• We build false walls;

patients & families help

us see our blind spots

• Patients and families

want to give back to

other patients and

families

• Co-design needs to

become the way we

operate

Regarding the patient-

family experience:

• Patient loneliness and

need for advocates is a

major concern

• Communications and

listening to understand are

vital

• Remember that every

patient is our

responsibility, whether in

our personal direct care at

the moment or not


Expanded to “Listening Sessions”

• Held 4 listening sessions so far

• Total of 86 individual touchpoints • “We want feedback about our contributions – we want

to know outcomes and results”

• And geography is not a barrier

38


Here are some feelings we are hearing

39

Confident Valued

Important Really

valued


What does “feeling valued” look like?

• My opinion matters

• You “listen” to me

• stated 8 times during last session

• You include me

40

“It was one of the

best weeks of my life”


Geography is not a barrier to engagement!

Tacoma

Lacey

Kent

Federal Way

Bainbridge Island

Edmonds

Juneau, AK

Ontario, OR


Co-Design at Virginia Mason

42

Understanding

Our Patients'

Experience

Planning with

Our Patients

Partnering to

Implement Change

Forging

Lasting

Relationships

Experience-

Based Design

Focus Groups

Visioning

Goal setting

Sorting

Priorities

Event participation

Materials review/

creation

Committee member

Etc.

Continuous

Improvement

to Better the

Patient

Experience


Virginia Mason Co-Design

43


Virginia Mason’s Co-Design Path

Designing for our

patients.

Including patients on events.

Bringing patient and family engagement

into all we do.


Support Groups

Patient Engagement & Involvement

45

Catchball participant

Everyday Lean Ideas

Event Participant

Waste Walks

Participate in Stand Up or Report

Out

Peer Partners

Co-Design Project

Kaizen Planning

Committee Participant

Goal Setting

Board Member

Patient Panel

Review Materials

Rounding Partner

Data Collection

EBD Questionnaires

Journaling

People Link Attendance


Genchi Genbutsu

• “It’s all lies”

• Go where the action is

• Know your people and let them know you

• Vulnerability is ok

• Connect the dots


Holding the Gains

• It takes hearts and minds

• Great people and great systems

• The gift of time is a treasure

• Accountability and audit

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

Our Journey

Toyota Production

System

Introduced to VMMC

2nd IOM1

Report

ADEPT2

Preprinted

Order Sets

Virginia Mason

Production System

established

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.

McClinton

Fatal 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 &

Patient

Leader

Rounds

Patient/

Family

Engagement

AHRQ4

Safety

Culture

Survey: 81%

Participation

AHRQ4

Safety

Culture

Survey:

82%

Participation (all staff, all

electronic)

2010

HealthGrades

Patient Safety

Award

Time

Out ST-

PRA5

Just

Culture

Falls

ST-

PRA5

1st IOM1

Report

VM Board:

Business

Case for

Quality

1st

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

RPIW6

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

AHRQ4

Safety

Culture

Survey: 84%

Participation

PSA

3P

Patient

Safety Risk

Registry

Respect for

People

Training

Quest for

Quality

Citation of

Merit


Flu Vaccination “Fitness for Duty”

Do we put patient first?

Compelling science

Staff resistance

Staying the course

Organizational Pride


VMMC Influenza Vaccination Rates

38.0%

54.0%

29.5%

97.6%

98.5%

98.7%

98.9%

98.9%

99.8%

99.7% 99.7%

99.8%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013


Ongoing Challenges - Culture

• Patient First

• Belief in Zero Defects

• Professional Autonomy

• “Buy In”

• “People are Not Cars”

• Pace of Change

• Victimization

• Leadership Constancy

• Rigor, Alignment, Execution

• Drive for Results


From

• Provider First

• Waiting is Good

• Errors are to be Expected

• Diffuse Accountability

• Add Resources

• Reduce Cost

• Retrospective Quality Assurance

• Management Oversight

• We Have Time

To

• Patient First

• Waiting is Bad

• Defect-free Medicine

• Rigorous Accountability

• No New Resources

• Reduce Waste

• Real-time Quality Assurance

• Management On Site

• We Have No Time

Transforming Healthcare

52


“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

53

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