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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
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
© 2014 Virginia Mason Medical Center
• 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
© 2014 Virginia Mason Medical Center
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
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
© 2014 Virginia Mason Medical Center
© 2014 Virginia Mason Medical Center
The VMMC Quality Equation
Q: Quality
A: Appropriateness
O: Outcomes
S: Service
W: Waste
Q = A × (O + S)
W
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
Seeing with our Eyes
Japan 2002
Stopping the Line ™
Virginia Mason’s Patient
Safety Alert System ™
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
Tuesday “Stand Up” • KPO aligned with
operational executive leadership
• Executive sponsorship
with accountability for sustained results
• Education • Standardization of
tools, results reporting, and communication
© 2014 Virginia Mason Medical Center
Educate & Engage 5,000+
© 2014 Virginia Mason Medical Center
Effective Sponsorship
• Vision of success
• Set stretch goals
• Provide resources
• Remove barriers
• “Fail forward fast”
• Celebrate achievements
© 2014 Virginia Mason Medical Center
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.
© 2014 Virginia Mason Medical Center
• 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
© 2014 Virginia Mason Medical Center
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?
© 2014 Virginia Mason Medical Center
The Value of Emotion Words
© 2014 Virginia Mason Medical Center
EBD Helps Bust Assumptions
We observe and learn directly from
customers about their experiences and what
they need
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
Know Me
The Board’s Role
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
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
Listen 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 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
© 2014 Virginia Mason Medical Center
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.
30
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
Where We’re Heading
32
© 2014 Virginia Mason Medical Center
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?
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
Here are some feelings we are hearing
39
Confident Valued
Important Really
valued
© 2014 Virginia Mason Medical Center
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”
© 2014 Virginia Mason Medical Center
Geography is not a barrier to engagement!
Tacoma
Lacey
Kent
Federal Way
Bainbridge Island
Edmonds
Juneau, AK
Ontario, OR
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
Virginia Mason Co-Design
43
© 2014 Virginia Mason Medical Center
Virginia Mason’s Co-Design Path
Designing for our
patients.
Including patients on events.
Bringing patient and family engagement
into all we do.
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
Flu Vaccination “Fitness for Duty”
Do we put patient first?
Compelling science
Staff resistance
Staying the course
Organizational Pride
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Institute
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
© 2014 Virginia Mason Institute
“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