WCBF 10th AnnualLean Six Sigma and Process

Improvement in Healthcare Summit

Culture of LeanThe Journey at

Massachusetts General Hospital

Mary O. CramerProcess Improvement Program Director

May 11, 2011

2

Objectives

Describe the Masschusetts General Hospital & Physicians’ Organization Process Improvement Deployment JourneyWithin a Highly Traditional, Firmly Entrenched Culture

Discuss the Critical Success Factors

Describe the Vision - What’s Next?

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• Establish a Sense of Urgency

• Build the Guiding Team

• Create the Right Vision

• Communicate for Buy-in

• Empower Action Throughout – Encourage Risk-Taking

• Plan for and Create Short-term Wins

• Reinvigorate the Process with New Projects

• Sustain the Changes

Source: Kotter, John P., “Winning at Change” Leader to Leader 10 (Fall 1998)

Kotter’s Eight Critical Stages of Successful Change Management

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Why is Change so Hard?

• Lack of Shared Vision

• Misaligned Expectations

• Lack of Urgency

• Lack of Commitment

• Culture

• Culture

• Culture

Source: Conner, Darryl R., Managing at the Speed of Change, 1992, 2006

5

What is Culture?

What is Culture; Is it Real?

One Definition:

“Culture in a work organization is the sum of peoples’ deeply ingrained habits related to what they do andhow they do it. It’s the way we do things here.”

Question:

Should an organization’s culture be among the considerations in Process Improvement program design and execution?

Source: Mann, David, Creating a Lean Culture, 2005

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Culture Matters

You bet!

Massachusetts General Hospital Background

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MGH Overview

• Founded in 1811, third oldest general hospital in the US• Original and largest teaching hospital of Harvard Medical School• Largest hospital based research program in US – annual research

budget: $550 million• Consistently ranked among top five hospitals in the US News &

World Report• Founding Member: Partners HealthCare – Integrated Healthcare

System

Some Operating Statistics:• 900 Inpatient Beds• 47,000 Inpatient Admissions• 1.5 Million Outpatient Visits• 83,000 ED Visits• 22,000 Employees• 4,000 Physicians

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Humble Beginnings: Ernest Codman’s End Results Guarantee 1915

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MGH Quality and Safety Program Recent Evolution

2000: Established Board of Trustees Quality Committee. Launched combined MGH & MGPO Clinical Performance Management program

2003 – Hospital Strategic Planning exercise identifies Quality and Safety as one of 5 institutional priorities. Plan developed

2004-2006 – Execution of plan, focusing on culture

Electronic incident reportingSafety culture surveysBoard presentations focused on the 6 IOM Aims

2005-2006 – Leadership RetreatsNovember 2005 PO Board retreatOctober and December 2006 Harvard Business School retreats

2006 – Proposal to Accelerate Progress

Creation of new leadership position

2007 – Center for Quality and Safety Established

2008 – Process Improvement Program Established

Historically committed to quality improvement at MGH using traditional tools including quality assessment, incident reporting, etc..

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What Do We Mean By Quality? IOM 6 AimsSafety - no needless death, injury, pain or suffering for patients or staff

Timeliness - waste no one’s time

Effectiveness - care and service will be based on best evidence, informed by patient values and preferences

Efficiency - remove all unnecessary processes or steps in processes; streamline all activities

Equity - all care and service will be fair and equitable – the system will treat all patients equally

Patient Centeredness - all care and service will honor individual patients – their values, choices, culture, social context and specific needs Source: Institute of Medicine

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Analysis of problem

Conceptual Framework

Performance reporting

Operations design

Executive oversight

Organizational strategy

Performance Measurement

(Signal detection)

Short term implementation

Executive incentives

Practitioner influence and

incentives

Longer term implementation

Research enterprise

Regular Operations

Improvement Efforts

Process Improvement

Design

ImprovementCycle

Operations Cycle

MGH/MGPO Culture

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Analysis of problem

Vision - the Big Ask

Performance reporting

Operations design

Executive oversight

Organizational strategy

Performance Measurement

(Signal detection)

Short term implementation

Executive incentives

Practitioner influence and

incentives

Longer term implementation

Research enterprise

Regular Operations

Improvement Efforts

Process Improvement

Design

ImprovementCycle

Operations Cycle

MGH/MGPO Culture

Doing Your Job

Improving Your Job

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MGH Center for Quality and Safety Organization Chart ~2008

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The MGH Process Improvement Program Deployment Journey

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Massachusetts General Hospital will lead the nation in

health care quality and safety.

Process Improvement is one important component of the plan to accomplish this goal and will

become part of the way business is done at the MGH and MGPO.

Vision

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Fasten Your Seatbelt!

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Process Improvement Framework

ServiceService

Quality &Quality & SafetySafety

EfficiencyEfficiency

PROCESS IMPROVEMENTPROCESS IMPROVEMENT

Program Director:Program Director: Mary Cramer

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Time

Suc

cess

ToolsTools

- Training- Modeling

Systems & StructuresSystems & Structures

- Org. Structure- Business Strategy

Culture & BehaviorCulture & Behavior

- Engagement- Continuous Improvement

- Sustain

Key Program Elements

Where We Started

Source: GE Healthcare

2020

Mobilizing Commitment

Why bother?Need sufficient support and involvement from key stakeholdersMust win-over critical mass

Tactics:Identify and analyze sources of support and resistance• Early Adopters• Late Adopters • Resistors

Develop Strategies for:• Encouraging Support • Overcoming Resistance

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Initial Model

At the Outset:

Building upon rich project management experience throughout Massachusetts General Hospital, developed full time Process Improvement Project Facilitators with competency to lead Process Improvement projects through training and application.

Curriculum:

Lean Tools and Concepts Change Acceleration Process©

Work-Out©

Project Design, Project Execution and Follow-up

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• Process Improvement Champions Group comprised of Senior

Leadership served as a Steering Committee charged with general

program oversight including prioritizing projects, championing and

supporting project teams as needed, overseeing project outcomes

and assuring that adequate and appropriate resources are allocated.

• Process Improvement Working Group comprised of directors of

operational areas providing project management support charged with

assuring effective design and implementation of the MGH/MGPO

Process Improvement Program including: project selection criteria,

project design, project management oversight, training plans, results

warehousing, communication, and recognition activities

Program Governance

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Comprehensive Training Curriculum

• Change Managementshaping a vision, mobilizing commitment, designing, implementing and sustaining change

• Value Stream Mappingend to end process diagram including process steps, interdependencies, information flow etc.

• Lean Tools & Techniques

• Project Workshop Design and Executionone day & four day formats

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40+ individuals selected from across the MGH and MGPO

Admitting Administration

Cardiac Services Center for Quality & Safety

Emergency Department Finance

Human Resources Infusion Center

MGPO Patient Care Services

Perioperative Services Police and Security

Practice Improvement Professional Billing Office

Radiation Oncology Research

At the Outset: Identified the Best and the Brightest

GE Healthcare engaged as Process Improvement skills transfer partner.

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Other Leadership Training

MGH/MGPO Leadership:Process Improvement Champions, Process Improvement Work Group, Senior Leaders, GEC/Clinical Chiefs, Patient Care Assessment Chairs, Others

• Process Improvement for Leaders • Engagement Overview & Process Improvement

Program Roadmap

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Other Ongoing Training

• MGH Leadership AcademyProcess Improvement PrimerProcess Improvement Practicum

• Patient Care Services Leadership DevelopmentOptimizing Core Processes

• Physician Leadership Development Process Improvement Capstone Course

• Practice Improvement CourseProcess Improvement Practicum

• Clinical Process Improvement ProgramProcess Improvement Course

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Learning Objectives

• Process Improvement Overview

• Project Selection

• Project Scoping

• Create and Facilitate a Team

• Manage the Change Process

• Conduct Root Cause Analyses

• Pilot Improvements

• Measure Outcomes

• Fully Implement and Sustain Improvements

~250 Employees~ 35 Discrete Depts

~ > 50 Projects

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Initially

Proof of Concept Awareness

Point Projects … driving project specific results & awareness

Dept Process

Dept ProcessDept Process

Project WorkshopProject Workshop

Project Workshop

Project Workshop

Dept Process

Project Workshop

Project Workshop

Dept ProcessDept Process

Project

Workshop

Project

Workshop

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Process Improvement Projects - Results

EP INPATIENT READINESS

0

0.5

1

1.5

2

2.5

# Patient Delays

Tim

e (

Days p

er

week)

Before

After

CARDIAC CATH LAB Patient Readiness

0%

10%

20%

30%

40%

50%

% Patients Completely Ready

Before

After

CHELSEA HEALTH CENTERUse of Outside Interpreter

0

200

400

600

800

1000

# of minutes per month # of calls per month

Before

After

CANCER CENTERFront End Check-in Process

0%10%20%30%40%50%60%70%

RRC Express PhoneRate

Co-pay Collection Rate

Before

After

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LEAP OUTPATIENT PSYCH

0

1

2

3

4

5

6

7

Cycle Time to Renew Meds

Tim

e (h

ours

)

Before

After

MEDICAL WALK IN CLINIC Informed Wait Time

0%

20%

40%

60%

80%

100%

Pre and Post % of Patient Negative Comments

Before

After

PAYROLL PROCESS

02468

10121416

# Manual Checks Issued

Before

After

PALLIATIVE CARE

0

100

200

300

400

500

600

Minutes Spent Meeting per Day

Tim

e (m

inu

tes

per

day

)Before

After

Process Improvement Projects - Results

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PBO PAPER CHARGE PROCESS

0

1

2

3

4

5

6

# Days from Claim Receipt to ChargeEntry

Tim

e (D

ays)

Before

After

SDSU PREOP PROCESS

0%10%20%30%40%50%60%70%80%

% First Cases Ready for Transport by 6:45am

Before

After

USA WORKFLOW

0

10

20

30

40

50

60

70

# Mins to Obtain Cleaning Supplies

Tim

e (

min

ute

s)

Before

After

Process Improvement Projects - Results

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Process Improvement Projects - Results

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Observations:

• We all have a lot of information to share, we just don’t share it

• We’ve been hearing about these problems for years; we’ve needed a common way of problem solving

• When we’re all together, we can build on each other’s ideas

• Previously we’ve attacked this by working in our silos; now we’ve put our heads together to solve the problems

• We’re all part of the solution

• Regardless of role and level, everyone’s voice counts

Process Improvement Projects - Results

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Now What?

Let’s Ride the Wave

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Moving Forward

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Using Strategic Planning as the Context

Overall Direction and Goals of an Organization Developed as Informed by Effective Strategic Planning

One Common approach:

• Establish Mission/Vision/Values • Conduct Environmental Scan• Complete Internal Assessment – Perhaps SWOT

Analysis• Establish Goals• Develop Strategies, Objectives, Responsibilities &

Timelines

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What’s Next for the Process Improvement Program?The Process Improvement program is now at the next level

Key Attributes:

Program Focus; Alignment with Strategic Priorities

Robust Senior Level Oversight Body

Active Senior Level Sponsorship

Key: Alignment with Organization’s Strategic Priorities

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One Compelling Priority: The Patient Protection and Affordable Care Act

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And Most Importantly, the IOM 6 Aims:Safety - no needless death, injury, pain or suffering for patients or staff

Timeliness - waste no one’s time

Effectiveness - care and service will be based on best evidence, informed by patient values and preferences

Efficiency - remove all unnecessary processes or steps in processes; streamline all activities

Equity - all care and service will be fair and equitable – the system will treat all patients equally

Patient Centeredness - all care and service will honor individual patients – their values, choices, culture, social context and specific needs Source: Institute of Medicine

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Current Process Improvement Focus Areas

Strategic Initiatives End–to-End Focus

#1 # 2 #3 #4 #5 #6 #7 #8

Patient Affordability

#1 # 2 #3 #4 #5 #6 #7 #8

Care Redesign

End-to-End Process Emphasis

Driving Improvements Deeply Within Select Areas of Focus

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Process Improvement Program Timeline – The Work Continues

2008 2009 2010 2011

PlanningPlanning

Wave I Wave I Recruitment & TrainingRecruitment & Training

Coached Coached ProjectsProjects

Wave II Wave II TrainingTraining

Coached Coached ProjectsProjects

Centralized

Staff Deployment

Program Development, Training & Ad Hoc Project SupportProgram Development, Training & Ad Hoc Project Support

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Suc

cess

ToolsTools

- Training- Modeling

Systems & StructuresSystems & Structures

- Org. Structure- Business Strategy

Culture & BehaviorCulture & Behavior

- Full Engagement- Sustained Outcomes

- Continuous Improvement

Process Improvement Program Trajectory

Where We’re Where We’re HeadedHeaded

Where We Started

2008 2009 2010 2011+

Where We Are

Source: GE Healthcare

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Critical Success Factors

Within the Context of Strategic Planning Activities and

Consistent with the Culture of the Enterprise:

• Actively Engaged Executive Sponsorship

• Compelling, Well Understood Organizational Priorities – Aligned with Organization’s Strategic Vision

• Highly trained, Capable Process Improvement Practitioners

• Fully Engaged Workforce

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Lessons Learned

First, Critically Assess the Organizational Culture.

Next, Leveraging the Infrastructure Already in Place:

Build a Program Which Will Resonate Within that Culture and

Which is Designed to Enable the Organization to Advance Strategic Priorities

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“It must be considered that there is

nothing more difficult to carry out, nor

more dangerous to conduct, nor more

doubtful in its success, than an attempt

to introduce innovations. 

For the leader in the introduction of

changes will have for his enemies all

those who are well off under the

existing order of things, and only

lukewarm supporters in those who

might be better off under the new.”

“It must be considered that there is

nothing more difficult to carry out, nor

more dangerous to conduct, nor more

doubtful in its success, than an attempt

to introduce innovations. 

For the leader in the introduction of

changes will have for his enemies all

those who are well off under the

existing order of things, and only

lukewarm supporters in those who

might be better off under the new.” Niccolo Machiavelli

1469 – 1527“The Prince and The Discourses”

1513, Ch. 6

Niccolo Machiavelli1469 – 1527

“The Prince and The Discourses” 1513, Ch. 6

It’s not Surprising -

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Thank You

Questions?