moving from physician driven to patient driven...© 2014 virginia mason medical center virginia...

Moving from Physician Driven to Patient DrivenBuilding a Culture of Value

Gary Kaplan, MDPatient Experience Conference 2017

March 20, 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

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“Ifyouaredreamingaboutit…youcandoit.”

SenseiChihiroNakao


Virginia Mason

• Integrated health care system• Became two hospital system

in January 2016, withYakima Memorial affiliation

• 501(c)3 not-for-profit• 336-bed hospital• Nine locations• Graduate Medical

Education• Research Institute• Foundation• Virginia Mason Institute

© 2016 Virginia Mason Institute

Medicine Overall was Changing• Patient expectations• Economics• Provider expectations

Virginia Mason• Change in leadership• Economic challenges• Concerns about quality and

safety of the care we provide

A Sense of Urgency, Year 2000

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The Challenge of Healthcare

• PoorQuality………………………..3%defectrate• Impactonindividuals………….100%defect• Costofpoorquality…………….Billionsofdollars• Costofhealthcaretothosewhopay……………………..Unaffordable

• Access………………………………….Millions• Moraleofworkers………………..Unreliablesystems


Urgency for Change at VMMC

“Wechangeorwedie.”

— GaryKaplan,VMMCProfessionalStaffMeeting,October2000

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• Autonomy

• Protection

• Entitlement

• Improvesafety/quality

• ImplementEHR

• Createserviceexperience

• Bepatient-focused

• Improveaccess

• Improveefficiency

• Recruit/retainqualitystaff

Traditional “Promise”Legacy Expectations Imperatives

Clash of “Promise” and Imperatives


Virginia Mason Medical Center Physician Compact

Organization’s ResponsibilitiesFoster 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 ResponsibilitiesFocus 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

Listen 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 practice

Change• Embrace innovation and continuous improvement• Participate in necessary organizational change


Aligned ExpectationsPhysician Compact

Leader Compact Board Compact

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The VMMC Quality Equation

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

Q = A × (O + S) W


Think Different

• ½ the human effort• ½ the space• ½ the equipment• ½ the inventory• ½ the investment• ½ the engineering hours• ½ the new product development time


The Virginia Mason Production System

We adopted the Toyota Production System key philosophies and applied them to healthcare

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1. The patient is always first2. Focus on the highest quality and

safety3. Engage all employees4. Strive for the highest satisfaction5. Maintain a successful economic

enterprise


Seeing with our EyesJapan 2002

Stopping the Line ™

Virginia Mason’s PatientSafety Alert System ™


Stopping the line


Patient Safety Alert Process ™

Created August 2002

• Leadership from the top• “Drop and run” commitment• 24/7 policy, procedure, staffing• Legal and reporting safeguards

© 2014 Virginia Mason 20

As of February 1, 2017: 73,048

Oct2016

Over 70,000 PSAs


Reduction of Hospital Professional/General Liability Premiums

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'04-'05 '05-'06 '06-'07 '07-'08 '08-'09 '09-'10 '10-'11 '11-12 '12-'13 13-'14 14-15 15-16

9%

% change from previous year, with 75% overall reduction in premium since 2004-05

7%

12%5%

26%

12%12%

11%12%

30% 2 yr. rate

Expecting at 10% Decrease in this next year


Repetitive daily activities and behaviors that leaders engage in to ensure customer demand is met and identify abnormal conditions

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Daily Management

Leaders Have Two Jobs:1. Run your business2. Improve your business


Tuesday “Stand Up”• KPOalignedwith

operationalexecutiveleadership

• Executivesponsorshipwithaccountabilityforsustainedresults

• Education

• Standardizationoftools,resultsreporting,andcommunication


Educate & Engage 5,000+


Productive range of distress

Threshold of learning

Limit of tolerance

Time

Dis

equi

libriu

m Adaptive challenge

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

“Distress” and Adaptive Work


Effective Sponsorship

• Vision of success• Set stretch goals• Provide resources• Remove barriers• “Fail forward fast”• Celebrate achievements


2013-2017 Strategic Service Plan

INTEGRATIONOFQUALITY&SERVICE

Patientexperienceintegratedintoorganizationalstrategies.

PARTNERSHIPWITHPATIENTS&FAMILIESActiveparticipationin

processimprovementtotransformcaredelivery.

ENGAGE,DEVELOP&ACTIVATEPEOPLE

Selectforservice,developskillsandenhance

accountabilitywithourpeople.

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 onan understanding of the experiences andemotions of those who are involved inreceiving and delivering healthcare services,striving to understand what people naturallydo and feel.

What really matters to our customers?


The Value of Emotion Words


EBD Helps Bust AssumptionsWe observe and learn directly from customers about their experiences and what they need


Basic EBD Methods

Observations Interviews Experience QuestionnairesFocus

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 ResponsibilityAlignment with Strategic PlanQuality and SafetyPatient Experience and ServiceStrong Economics and GrowthHealth Care EnvironmentPositioning Virginia Mason for the Future


Virginia Mason Board CompactOrganization’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 resourcesListen 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 meetingsEducate• 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 documentsLead• 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 ResponsibilitiesKnow 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 planListen and Communicate• 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 communityTake 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 forcesPromote 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 treateach 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

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Create full partnership withpatients and families to improveand 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 mid-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 mid-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 year?

April 26 was our Inaugural Patient Experience Day


Overarching themes we heardRegarding 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

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Here are some feelings we are hearing

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Confident Valued

ImportantReally valued


What does “feeling valued” look like?

• My opinion matters• You “listen” to me

• stated 8 times during last session• You include me

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“It was one of the best weeks of my life”


Geography is not a barrier to engagement!

TacomaLaceyKentFederal WayBainbridge IslandEdmondsJuneau, AKOntario, OR


Co-Design at Virginia Mason

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Understanding Our Patients' Experience

Planning with Our Patients

Partnering to Implement Change

Forging Lasting Relationships

Experience-Based DesignFocus Groups

VisioningGoal setting Sorting Priorities

Event participationMaterials review/ creationCommittee memberEtc.

Continuous Improvement to Better the Patient Experience


Virginia Mason Co-Design

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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

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Catchballparticipant

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 JourneyToyota Production SystemIntroduced to VMMC

2nd IOM1 Report

ADEPT2Preprinted Order Sets

Virginia Mason Production Systemestablished

Patient Safety Alert (PSA) for clinical events

Strategic Quality Plan

1stSafety Culture Survey

Executive Walk Rounds

PSA for non-clinical events

2ndSafety Culture Survey

Mary L. McClintonFatal medical error

CPOE Go Live

Move to yearly AHRQ4Safety 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

AHRQ4Safety 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

FallsST-PRA5

1st IOM1Report

VM Board:Business Case for Quality

1stCulture 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

AHRQ4Safety 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 scienceStaff resistanceStaying the courseOrganizational 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

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“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

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moving from physician driven to patient driven...© 2014 virginia mason medical center virginia...

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