Making Room for Process in Relationship-centered CareKathy McGrail MD, Rochester Regional Health SystemKrista Hirschmann PhD, Lehigh Valley Health Network

AACH Winter Course 2015

AgendaTime

• 10 min• 5 min• 5-7 min• 10 min• 5 min• 10 min• 25 min• 10 min

Topic

• Review of goals• Distribute roles • Why cycle time • 8 Wastes • Relational co-ordination mini-didactic • Debrief RCC survey results • Brainstorming and multi-voting• Debrief and Close

Our Objectives & Yours• Describe the impact of process on relationships

in primary care• Explain how standard roles and process are

essential to team based care• Apply cone in the box principles during an

interactive case scenario• List two ways you can promote attention to

process in your clinical setting as an avenue to relationship-centered care

Quadruple Aim

Improve Patient Experience

Decrease per capita cost

Improve Health of Populations

Improve Work Life of Healthcare Workers

Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider, Ann Fam Med. 12: 573-76, 2014

A Framework for the Quadruple Aim

Relational Coordination

Shared goalsShared knowledge

Mutual respectFrequent

TimelyAccurate

Problem-solving communication

Structural InterventionsShared accountability

Shared costs & rewardsSelection & trainingConflict resolution

Meetings & HuddlesBoundary spanners

Shared protocolsShared info systems

Spatial design

Performance

OutcomesQuality

EfficiencyPatient engagementWorker well being

Work Process Interventions

Goal and Role clarification Process mapping

Structured problem solving

Relational InterventionsCreate psychological safety

Relational diagnosisCoaching & Role Modeling

RELATIONAL COORDINATION

Jody Hoffer-Gittell , Edgar Schein, Amy Edmundson

http://rcrc.brandeis.edu/about-rc/model.html

Nature of the ChallengeTechnical Challenge• Problem is well defined• Solution is known and

can be found• Implementation is clear• You can always go to the

genius bar

Adaptive Challenge• Challenge is complex• To solve requires transforming

long-standing and deeply held assumptions and values

• Involves feelings of loss, sacrifice• Solution requires learning and a

new way of thinking, new relationships

• Those with problem must be those who develop solutions

R Heifetz, A Grashow, M Linsky. Adaptive Leadership, 2009

Why Cycle Time?

overall ex-plains

listens in-structs

knows re-spects

time rec-cmnd

access

Burki 87 98 96.3 96.1 88.9 98.1 92.6 88.9 76.6

Huselton

91.5 97.2 97.2 98.5 97.2 98.6 97.2 97.2 76.6

Mc-Grail

92.7 98.2 98.2 96.1 98.2 100 96.4 98.2 67.5

My-ers

90.7 96.1 96.1 93.2 97.4 94.7 96.1 93.3 71.6

Meyer

80 100 100 90.9 73.3 93.8 100 93.3 78.8

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Patient Satisfaction YTD Dec 2014

Patients perception of “knows my history” seems to drive overall score; it would be good to understand what that means to patients; national percentile rank: 50%tile = raw score of 92

Seen within 15 min of appt

Rec of-fice

Access Test re-sults

Office staff

quality

Clerks helpful

Clerks treat w respect

Nurses

Mar-14

100 95.7 75.2 100 95.7 NaN NaN NaN

Jun-14

54 98 72.7 94 96.1 94 98 NaN

Dec-14

51.6 94.2 70.3 92.9 94.9 93.8 96 92.6

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Overall Office Satisfaction Trends

Defects

Overproduction

• Lines, staff waiting for patients, patients waiting on phone or waiting for staff

Waiting

Non-used Talent

Transportation

Inventory

Motion

Extra/over processing Multiple people doing same tasks or parts of tasks

Doing more than is asked, needed, or really possible in a visit

Too much back and forth, walking to find/get reports, AVS etc

Pick up of lab specs, movement of paper through office

8

WASTES

Medications/ immunizations errors, missed screening opportunities/abnormal results

Stocking of rooms, supplies outdate before used

Top of license issues, moving secretarial tasks to support staff; forms processing

Lines, staff waiting for patients, patients waiting on phone or waiting for staff; MDs for POC testing

Current Process

• Total process time overall: 35 - 83 mins• Value added process time: 25 – 49 mins• Wait Time: 10 – 34 mins

Check inNurse visit

Provider visit

Check out

5-10 mins 7-14 mins

Waiting Room Exam Room Front Desk

13-25 mins 0 - ? mins3-12 mins 3-27 mins 0-? mins

Resource for process map & workflow diagram P Scholtes, B Joiner, B Streibel. The Team Handbook Chp 4

Exam roomMD Office

Secretaries

Waiting Room

Exam Room

Exam room

This is the activity pattern for 1 patient who needed spirometry during the visit PatientNurseMD

Rx Printer/scale

Nurses station

AVS printer

Workflow Diagram

Relational Coordination(How we would normally engage you)

1. What is Relational Coordination?• Communicating and relating for the purpose of task

integration2. What is the Relational Coordination Survey?

• Seven question instrument based on

• Survey participants re a particular work process • Communication and relationships with other

participants in that work process

Frequent Communication Shared Goals

Timely Communication Shared Knowledge

Accurate Communication Mutual Respect

Problem-Solving Communication

Role Groups

Survey Questions1. How frequently do people in each of these groups communicate with you

about addressing patient wait time in the office?

2. Do they communicate with you in a timely way about addressing patient wait time in the office?

3. Do they communicate with you accurately about addressing patient wait time in the office?

4. When there is a problem with patient wait time, do people in each of these groups blame others or work with you to solve the problem?

5. Do people in each of these groups share your goals for addressing patient wait time?

6. Do people in each of these groups know about the work you do with addressing patient wait time?

7. Do people in each of these groups respect the work you do with addressing patient wait time?

Your Aggregate RC Results

Debrief• What’s the story or example you could tell

about these numbers?

• Does anything surprise you?

• What do you think would be the most important dimension for the team to work on?

• Is that something that you’d be willing to do?

Start where you are. Use what you have. Do what you can Teddy Roosevelt

Brainstorming

• Used to help brainstorm and focus on the reasons why a problem is occurring• Problem: Long cycle time for patients• Let’s brainstorm root causes:• Process/Policy• Equipment/Supplies• Environment• 8 Wastes Think about what you see in your day to day

work that, if done differently, could improvepatient cycle time. Write down all the ideas on post-its (6 mins)

Resource for brainstorming, multi-voting & nominal group technique:P Scholtes, B Joiner, B Streibel. The Team Handbook Chp 3-13 through 23

Prioritizing: Multi-voting

• Cluster Post it notes in shared categories• Review, name categories• Vote• Identify priorties

Next Steps

• What can we start right away?• Next meeting: Future State Process Map

If you want to go fast, go alone. If you want to go far, go together. African proverb

Debrief Workshop• How did we set up the team meeting that could

produce a change in the team dynamics and behavior? • How do you do these things within the

constraints of real time limits?• How is similar or different than your home

practice? • What got you excited or curious?

Enhancing Facilitation with Relational Coordination Data

outtakes• Assumption: This is an office with some ground of health; that assessment is

based on either site visit and conversation, observation and/or review of self assessed function/teamwork

• If ground of health is not present at a foundational level, don’t start with something this complex; start with something simple and an easier win; you may not even be able to start with work; you may need to start with relationship repair or basic relationship building

• Without collecting new data, some data is routinely collected by healthcare organizations that can be used to form some initial impressions about the team’s ground of health: existing patient satisfaction scores, existing hedis measures (not as helpful for safety net settings), Culture of safety scores (or equivalent)

• Existing scores provide information about how well the teams are doing under current circumstances, but do not necessarily give an accurate picture of their capacity to be creative, to learn, and to adapt to changing circumstances

• A goal central to improvement work is to do the work , improve it while doing, and to create self sustaining, reflective, learning communities

Continuous Quality Improvement

Multi-method Assessment Process and Reflective Adaptive Proces

Vision Improved components, improved measurement, improved patient outcomes

Reflective, adaptive practices, increased capacity for learning, improved systems, richer connections & relationships, improved pt outcomes

Leadership Goals

Create better run organization, increased efficiency, effectiveness, predictability and control

Optimize potential to co-evolve in ways that increase organizational fitness

Perspect-ive

Emphasizes what agents know todayAttempts to minimize effects of diversityStrives to reduce variationFrames future by planning/ forecastingTries to get everyone to conform to the formal organizationDoes not focus on social relationships

Emphasizes developing learning capacityLeverages diversityPromotes some types of diversityFrames the future by social interactionRecognizes/uses interdependence of the formal & informal organizationUses social interaction for sense-makingUses multiple methods/perspectives to enhance learning capacity and identify priorities

Continuous Quality Improvement

MAP & RAP

Teams Views teams as the way to implement organizational change and solve problemsPatients typically not members of teamFacilitator sometimes viewed as external to the team

Views teams as connected to the entire organization and a small complex adaptive system that may change the culture of the entire organizationPatient is a full team memberFacilitator acknowledged as part of team, not external to it

Orientation Improvement cycles to enhance one process at a time

Enhance relationships and information sharing around a set of interrelated processes

Stroebel C, McDaniel R, Crabtree B, et al. How complexity science can inform a reflective process for improvement in primary care practice. J on Quality and Patient Safety 31(8): 438-446, 2005