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High Velocity,High Reliability Transformation
IHI National Forum
Introduction
Marty B Scott MD, MBA
SVP, Chief Transformation Officer,
Hackensack Meridian Health
Mindfulness
The practice of focusing
our attention purposely
on the present moment
and accepting it without
judging.
Objectives
1. Identify tactics and tools used to engage hospital and medical staff
leaders in their role for a successful HRO Transformation
2. Identify how to leverage the nursing leadership to fast forward the
HRO transformation
3. Explore the importance of branding, simulation, safety culture,
and robust process improvement in supporting the HRO
transformation
Presenters have nothing to disclose
Agenda
1:00 – 1:30 Introduction
1:30 – 2:30 Breakout Sessions
2:30 – 3:00 Break
3:00 – 4:00 Breakout Sessions
4:00 – 4:30 Debrief
“What will you do different on Tuesday?”
7
Medical Group
Imaging Centers
Laboratory Sites
Occupational Health
Post Acute Living
Rehabilitation
Sleep Centers
Surgery Centers
Behavioral Health
Children’s Hospitals
Community Hospitals
Convenient Care
Dialysis Centers
Fitness and Wellness
Home Care
Academic Medical Centers
Alert Ambulance
Health Village
Innovation Lab
Integrative Medicine
The most comprehensive and integrated health network in New Jersey
Medical School
Consumer ReportsDec 2015
Asbury Park PressJan and Mar 2016
Sepsis #1 cause of death in New Jersey
The “Secret Sauce”: Our First Ingredient
Steering Committee with Multidisciplinary Leaders
• The usual suspects
• The natural allies of the usual suspects
• The unusual suspects
• Marketing/Internal Communications
• Risk management/Legal
• Organizational development
• Human resources
• Operational Leader(s)
Leadership Support
System Chief Executive Officer
Board of Trustees
Hospital Leadership
Two Key Dyads:
• Chief Transformation Officer / Chief Nursing Officer
• VP Clinical Effectiveness & VP Nursing
Our Strategy to Deliver Excellence Unsurpassed Resonates in All the Right Ways
Safety
Quality
Empathy
Respect
"Doing the right thing
in the right way
at the right time
in the right place
with the right person
for the right reason
with the right feeling
the first time.“
… and every time
High Velocity Timeline
HRO ActivitiesInitiated Fall 2015
Network-wide education of all Team Members Summer 2016
High Velocity Highlights
5 Hospitals launched simultaneously
18,000 Team Members educated in 8 months
34% Reduction in CLABSI
40% Reduction in CAUTI
54% decrease in sepsis mortality
4 hospitals improved their Leapfrog rating
2 hospitals achieved 4 Star CMS rating
The Five Principles of HRO at Work
High Reliability for Experience in a Nutshell
17
Exam
ple
s
Behavior modeling
1. Be Mindful of high-risk situations
2. Be mindful of best practices
3. Turn best practices into habits
Risk of infection
Loss of empathy
Poor outcomes
Disrespectful communication
Poor teamwork
Best practice bundles
Communication standards
Mindfulness
Checklists
Self-care
Standard work (e.g. huddles, rounding)
Peer coaching
Recognition & Celebration
Training
Safety | Quality | Empathy | Respect
The HRO Toolkit
Unique HRO training
curriculum and tools
Training curriculum includes:
• Trainers
• Team Members
• Leaders
• Peer Coaches
• Physicians
Breakouts
1. Brand
2. Leadership
3. Simulation
4. Patient Safety and Robust Process Improvement
“Sometimes you just have to take the leap and build your wings on the way down.” ~ Kobi Yamada
Why some of your best friends should be marketers. Tria Deibert
Vice President, Experience Marketing
Hackensack Meridian Health
How to Seduce Your Marketing Team
22
We Bring the Appeal
23
Everything Has a Brand Personality…
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Even you!
Your Brand Should be Intentional
25
What Should Your Brand Do For YOU?
Deliver a Clear Message
Confirm Your Credibility
Connect Emotionally
Motivate the Buyer
Create Loyalty
5 Simple Steps
For Example… My Brand
DetermineYour Goals
What are you most excited about achieving in the next few years? Do you want to write a New York Times bestselling book or would you rather land your first speaking engagement? Do you want to be generating a certain amount of revenue at your company or would you prefer to start your own venture?
Pinpoint Your Value Proposition
That’s a fancy way of saying you need to figure out A) what benefit you offer people B) who those people are C) how you solve their problems and D) what makes you different from others like you.
Craft Your ProfessionalStory Arc
Determining your own story arc will be crucial to crafting a brand narrative that your audience will relate to and remember. Your brand narrative will come naturally if you ask yourself the right questions: What obstacles have I overcome? What desirable goals have I reached or am in the process of reaching? How have I changed for the better?
Establish Your Character Personality
As you ponder your own personality traits, remember that people typically describe themselves a bit differently than others would describe them. And since “others” will be the ones engaging with your personal brand online, theirs is the more important perception. Your audience is never wrong.
Distill it Down to a Brand Statement
Source: Entrepreneur 7/16
Santa Claus is the CEO of a non-profit organization that gives gifts to children globally. With decades of experience in supply chain management and manufacturing technology, Claus has helped turn Christmas into the modern celebration that it is today.OR?Santa Claus is the jolly, grandfatherly figure behind the single biggest gift-giving operation in the world. Known for his spectacular flying reindeer and wacky chimney delivery system, Claus has become a loved cultural icon who’s turned Christmas into the modern celebration that is today.
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The heart and sole of this brand was about consistency, people and outcomes.
Finding Our Brand Essence
Which one is not like the others?
ACA
VBP
SBAR
HRO
Kina’ole
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"Doing the right thing
in the right way
at the right time
in the right place
with the right person
for the right reason
with the right feeling
the first time."
Creativity Drives Engagement
Safety * Quality * Empathy * Respect
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It can also set the stage for some really cool connective tissue
Brand Drives Consistency
33
96 are familiar with Kina’ole
n=1,526 team members
Consistency Drives Recognition
Brand Can Align Strategies
34
Words Matter. Words Connect. Words Package Ideas.
Quality. Safety. Empathy. Respect.
Kina’ole Coach.
Heartwire.
35
Hackensack Meridian Health High Reliability Excellence UnsurpassedSafety I Quality I Empathy I Respect
Packaging an Idea
But it’s not Hardwired, it’s Heartwired.
Hardwired = ProcessHeartwired = Purpose
38
Momentum Drives Culture
5 Takeaways
1. Engage your marketing team (and others) early.
2. Be open to their (perceived) crazy ideas.
3. Everything has a brand.
4. Be intentional. Be creative. Be consistent.
5. Heartwire, don’t hardwire.
39
High Velocity, High Reliability TransformationLeadershipMarty B Scott MD, MBA
SVP, Chief Transformation Officer,
Hackensack Meridian Health
Maureen E. Sintich, DNP, MBA, RN, WHNP-BC, NEA-BC
EVP, Chief Nurse Executive
ENGAGING KEY STAKEHOLDERS TO ACCELERATE CHANGE
BOARD MEMBERSCreating Active Engagement
Visual Management Tool
“I look at the whiteboard as a snapshot about me. So anyone who looks at that whiteboard knows about my current health status.”
“Use of the whiteboards make me feel more confident about the care I am receiving and lowers stress levels, especially in the ER.”
Another Visual Management Tool
Visual Magnets
http://theoryofthemeparks.blogspot.com/2015/08/wayfinding-in-themed-design-weenie.html
Could We Double Dip?
Engaging with Team Members
Lean Disney?
PARTNERING WITH THE MEDICAL STAFF
The Attending Physician Controls the Micro Culture
Why Is Change Hard?
Not everyone believes the change is necessary.
A common refrain - “It’s fine the way it is.”
Not everyone agrees how to change it for the better.
A common refrain – “That will never work.”
Fear the unknown of what MIGHT BE.
Data alone is NOT sufficient!
Direct the Rider• Find the Bright Spots
• Script the Critical Moves
• Point to the Destination
Motivate the Elephant• Find the Feeling• Shrink the Change• Grow your People
Shape the Path• Tweak the Environment• Build Habits • Rally the Herd
Readying Our Leaders to
Direct, Motivate, and Shape
Everett Rogers Diffusion of Innovation
The Typical Medical Staff
Leaders Resistors
Leaders – Official and Unofficial
Align their WHY with your PURPOSEReinforce the respect for the AUTONOMY of the physician
Provide some MASTERY of the change you are proposing
Resistors
Active
Passive
1. Connect Champion Peer to Peer with Active Resistor2. Rehearse the Response to the Outlier Prior to the Initiation
ENGAGING THE NURSING LEADERS
Nursing Hierarchy
Formal Leaders Informal Leaders
Formal Structure
Informal Structure
Nurse Educators
APRNs
Peers
Focus on the Team – Peer Coaches
Teamwork By Another Name
• Watch out for each other
• Peers check each other’s work
• Teammates are willing to be checked
• Effectively coach
• Provide feedback and help
• Reinforce good habits
• Help extinguish bad ones
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High Performing Teams
Teams that perform well:
• Hold shared mental models• Have clear roles and responsibilities• Have clear, valued, and shared vision• Optimize resources• Have strong team leadership• Engage in a regular discipline of feedback• Develop a strong sense of collective trust and
confidence • Create mechanisms to cooperate and coordinate• Manage and optimize performance outcomes
(Salas et al. 2004)
Encourage safe and productive behaviors
Correct unsafe and unproductive behaviors
Be willing to coach others…and be willing to have others coach you!
Point out the good things!
Provide feedback based on observations
Use the “lightest touch” possible
Key phrase: “What you permit, you promote.”
When we Coach Each Other
63
5:1 Feedback
5 positive bits of feedback for every
1 bit of corrective feedback
Why It Works:• Positive is a more powerful influencer in managing resistance and
building habits
• Builds a relationship of trust and respect between employees and supervisors and among co-workers
• Enables individuals to more effectively give and receive corrective reinforcement for a behavior that needs to be changed
Todd
Shared Accountability
Creating environments of equity
for responsibility for outcomes.
“It’s everyone’s job”
LeadersVertical
Accountability
PeersHorizontal
Accountability
IndividualIntrinsic
Accountability
Optimal SharedAccountability
Shared Accountability vs. Hold Accountable
Stakeholders
Senior LeadersTrusteesMedical Staff
Other LeadersNursing
Peers
HRO Nirvana
Sim Your Way to SuccessChristine Hader, DNP, Director
Center for Simulation
Hackensack Meridian Health
Kristine Monia, DNP, Manager
Center for Simulation
Hackensack Meridian Health
The Huddle & Rounding to Influence are powerful tools for leaders to transform behaviors into habits
HRO Huddles
• Huddles positively impact daily
actions & quality & safety
commitments.
• The HRO Huddle design
provides structure to lead an
effective Huddle.
HRO Huddles
•
HRO Huddle Structure
Rounding to Influence
• Rounding to Influence creates
opportunities for leaders to
connect with frontline staff.
• The structure for Rounding to
Influence provides a method
in which leaders can reinforce
performance expectations.
Rounding to Influence
• Method for reinforcing
vital behaviors or
performance expectations
linked to organizational
foundations
• Expectation for
performance excellence
• Not an event – it’s a
lifestyle
Connect to our
uncompromised imperative
Assess knowledge and reinforce the
specific behavior expectations
♥
Identify problems impacting ability
to follow the behavior expectations
Ask about commitment actions
Rounding to Influence Structure
MindfulnessHigh Reliability
Organization
Anticipation
• Preoccupation with Failure: Continuous attention to the possibility of unexpected events that can threaten desired performance and being proactive to avoid them. Regarding small details and inconsequential errors as a symptom of larger problems in a system.
• Sensitivity to Operations: Ongoing interaction and information-sharing to prevent accumulation of concerns and paying attention to what’s happening on the front-line.
• Reluctance to Simplify: Deliberately question assumptions and receive information to make a knowledgeable decision. Encourage diversity in experience, perspective, and opinion.
Containment
• Commitment to Resilience: Ability to function
during high demand events.
• Preserve function despite adversity
• Return to service from untoward events
• Learn & grow from episodes
• Deference to Expertise: Elicit information from
those who possess the most developed knowledge of
the task at hand, regardless of hierarchy.
Patient Safety & Robust Process Improvement
Robbie Brown, Vice President, Process Improvement
Hackensack Meridian Health
Deeba Siddiqui, Vice President, Patient Safety
Hackensack Meridian Health
Patient Safety in a Highly Reliable Culture
A strong patient safety culture is inherent to high-reliability
organizations
High Reliability Organizations (HROs) “operate under very trying conditions all of the time and yet manage to have fewer than their fair share of accidents.”
•(Weick & Sutcliffe, 2015)
Safety culture is the sum of what an organization is and does in the pursuit of safety.
• Key Strategies:
• Leadership Support
• Build Trust and Transparency
• Analyze, Learn and Action Plan
• Robust Process Improvement
• Share Accountability
• Form Habits
• Team Member Support
AHRQ Safety Culture2015 survey decreased in
all 12 composites
Leadership Support
Chief Executive Officer
Board of Trustees
Chief Transformation & Risk Officers
Patient Safety Officer
Robust Process Improvement
Network & Hospital Leadership
Two Key Dyads:
• Chief Transformation Officer / Chief Nursing Officer
• VP Clinical Effectiveness & VP Nursing
Strategic Alignment
Build Trust and Transparency
• Classification• Create A Shared Language
• Sacred Time every week
• Power of Group Think
• “Harm happens here”
• Reporting• Increase Adverse Event Reporting
• Develop a Performance Management Decision Tree
• Good Catch Program
• Loop Closure
Safety Event Classification (SEC)Building Trust & Transparency
Early Identification of
Potential Litigation
2nd Victim Support
RPI Referral
Patient
Safety
Event
SECRCA/Peer
Review
Disclosure, Apology, Resolution
DOH Report
Strong CAP to
prevent recurrence
Notice to
Insurer Reserves
HMH Safety
Council -
Transportability
Adverse Event Reporting: 5 Hospitals
15,122
17,831
0
5,000
10,000
15,000
20,000
25,000
2014 2015
Events Reported
Events Reported11,244 11,640
Benchmark
Only 47%, Nonpunitive
response to error
Analyze, Learn & Action Planning
• Standard Curriculum
• Standard Team Structure & Tools
• Robust Process Improvement
• Less Rules/ More Tools
• Mindful Moments
• Lessons Learned
• Dig deeper – 5 why’s
• Prevent re-occurrence
Event Analysis
Use of Root Cause Analysis
& Apparent Cause Analysis
Why did it make sense for people who are well intended, educated and trained to do what they
did in that moment?
GOAL ZERO HARM
“….(health care) providers are human. As such
we make mistakes, and some of these mistakes
lead to patient harm. Because of this very
humanness, we also have strong emotional
responses to the suffering and harm that occurs
because of the mistakes we make.”
Pratt, 2015
We are Human…
Adverse events do not
result from recklessness
on the part of the
caregiver but from basic
flaws in the way health
systems are organized.
Systems Thinking
Robust Process Improvement or RPI® is a systematic, data-driven methodology that incorporates Lean Six Sigma and formal change management. It is the Joint Commission's performance improvement methodology.
RPI®
What is Robust Process Improvement?
Lean + Six Sigma
+ Change Mgmt
=
Robust Process Improvement
LeanDecrease
Waste
Six SigmaDecrease Variation
Change Management
Accept, Implement and Sustain
Components
Hackensack Meridian Health Methodology
PROCESS IMPROVEMENT
IDENTIFY CORE PROCESSES
IDENTIFY KEY
CUSTOMERS
CUSTOMER
REQUIREMENTS
CURRENT
PERFORMANCE
INTEGRATE
EXPAND
RPI Methodology
High Reliability and RPI
• Increases process improvement knowledge/skills across the network o Quality improvement vs process improvemento Chart abstractions vs process improvement
• Helps standardize RCA processo Example: Corrective actions before Root Cause
• Different perspectiveo The question – “Why”
• Involvement of front-line team members in process redesigno The real experts…
• Establish an improvement culture
The Science of Safety
System Design
Human-Based Performance
SEC Output: Common Cause Analysis: Patient Safety Event Types
Jan - June 2017 Event Statistics Total
Total # Events Reported
To Safety Event
Classification (SEC) 220Acute Care 188Post-Acute Care 32
SEC Classification:
Serious Safety Events 49
Precursor Safety Events 85
Near Miss Events 5
Non Safety Events 81
DOH/TJC Reportables 56
# of RCA's completed 91
# of ACA's completed 86
Referrals to Insurer 63
Disclosures 114
* Does not include events reported through other event reporting systems
SEC Output: Common Cause Analysis: Weekday, Shift & Department
JUST CULTURE
“An environment in which frontline staff feel comfortable disclosing errors including their own while maintaining professional accountability.”
• AHRQ, 2012
Performance ManagementDecision Tree
At the Heart of Safety… A Good Catch
Shared Accountability
Habit Formation
• HRO Coaches
• Rounding
• Huddles
• Days Since Last SSE, Fall, Infection…
• Visual Management Systems
Team Member Support
Caring for self in order to care for others
• Second Victim Support Program “We Care”
• Storytelling & Celebrating
• Systems vs. People Centric Thinking
• Mindfulness - exploration
• Empathy - exploration
The End Goal: Safe Patient Care
Safety Culture
Accountable Culture
Learning Culture
Reporting Culture
Culture Establishes Safety as the Priority
Thank you...
Did High Reliability Make a Difference?
Summation and Q&A
HRO Training OverviewTools For Individuals Tools for Teams Tools for Leaders
# complete # overdue Total # TMs eligible
% Comp-lete
# complete # overdue Total # TMs eligible
% Complete # complete # overdue Total # TMs eligible
% Complete
BMC 994 109 1103 90% 998 107 1105 90% 61 19 80 76%
Corp 1394 301 1695 82% 1371 323 1694 81% 251 52 303 83%
HUMC 1412 NA 8056 18% 1412 NA 8056 18% NA NA NA NA
JSUMC 3560 332 3892 91% 3560 332 3892 91% 250 18 268 93%
MH P Co 3018 696 3714 81% 2953 745 3698 80% 290 73 363 80%
OMC 1831 257 2088 88% 1765 321 2086 85% 90 14 104 87%
PMC 1401 19 1420 98% 1401 19 1420 98% 101 1 102 99%
PVMC 594 NA 694 86% 594 NA 694 86% 29 NA 49 59%
RBMC Not Available
RMC 1571 147 1718 91% 1556 196 1752 89% 104 23 127 82%
SOMC 1034 75 1109 93% 1034 75 1109 93% 62 10 72 86%
*As of 09/30, HUMC as of 10/20/17; Legacy MH as of 10/18/17** Meridian Health Partner Companies includes: Foundation, Medical Practice Institute, Meridian at Home, Meridian Health Resources, Meridian Nursing and Rehab, Quality Care Management and Shore Care
YTD Oct 2017 89% trained
across 9 sites
Event Reporting
15,122
17,83119,297
21,225
0
5,000
10,000
15,000
20,000
25,000
2014 2015 2016 2017a
Events Reported
Events Reported
2014-2016=28% increase
2014-2017 on track for
40% increase
Monitoring an Emerging HRO –Southern Ocean Medical Center
17301537
37664000
0
500
1000
1500
2000
2500
3000
3500
4000
4500
2014 2015 2016 2017a
Events Reported
Events Reported Linear (Events Reported)
Hospital Acquired Conditions
2013 2014 2015 2016 2017*
CLABSI 7 3 4 0 0
CAUTI 20 15 3 0 2
Sepsis Mortality
9.2% 10.5% 10.6% 7.43%
INPT HCAHPS Aggregate
2015 2016 2017**
64% 67% 63%
655 Days Since Last CLABSI
18 months without CAUTI
*YTD Sep 2017**YTD Oct 2017
Meridian Health –Stamp Out Sepsis Campaign
BCH JSUMC OMC RMC SOMCMeridian
Health
2014 37.68 24.47 19.02 23.27 15.71 24.03
2016 23.4 13.1 13.3 16.3 10.5 15.32
2017* 11.54 12.46 12.45 12.12 7.43 11.2
0
5
10
15
20
25
30
35
40
Sep
sis
Mo
rtal
ity
Rat
e
2014 v 2016 Comparison
329 lives lost in 2014
2014 to 2016 = 182 lives lost but,
147 lives saved!
54% decrease in Sepsis Mortality Network-wide
*YTD Sep 2017
HAC Penalty Trend
Hospital FY2015 FY2016 FY2017 FY2018
Bayshore Medical Center N N Y Y
Jersey Shore Univ Medical Center N N Y N
Ocean Medical Center Y Y N N
Riverview Medical Center N Y Y N
Southern Ocean Medical Center Y Y N N
Total Hospitals Receiving Penalty 2 3 3 1
Savoring Our Success
RTI: Turned this Behavior into Habit
116
286 269204 221 201
518564
671
960
1185
1388
928
758
0
200
400
600
800
1000
1200
1400
1600
Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17
118
HRO,Heartwired
What Matters Most…
119
Author Karlene Roberts
High Reliability Organizations:
• Seek perfection but never expect to achieve it
• Demand complete safety but never expect it
• Dread surprise but always anticipate it
• Deliver reliability but never take it for granted
• Live by the book but are unwilling to die by it
New Challenges to Understanding Organizations, 1993
Where are we today?
12 acute care sites by Jan 2018
Developing:
• Highly Reliable Healthcare Experience• Emotional Harm RCA, SEC
• We Care (Second Victim) Program
• HRO University
• Leadership Development
• Coaches Program
Dec 2015 Jan 2016 Jul 2016 Jan 2018
5 7 11 12
For Ongoing Discussion
Robbie Brown – [email protected]
Tria Deibert – [email protected]
Chris Hader – [email protected]
Kris Monia – [email protected]
Marty Scott – [email protected]
Deeba Siddiqui – [email protected]
Maureen Sintich – [email protected]
ReferencesGlymph, D., Olenick, M., Barbera, S., Brown, E.L., Prestianni, L., & Miller, C. (2015). Healthcare
utilizing deliberate discussion linking events (HUDDLE): A systematic review. AANA Journal, 83(3), 183-188. Retrieved from: https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=109799869&site=eds-live&scope=site.
Institute of Medicine (IOM). (2004). Keeping patient safe: transforming the work environment of nurses. Washington, DC: The National Academies Press. Retrieved from http://www.iom.edu/Reports/2003/Keeping-Patients-Safe-Transforming-theWork-Environment-of-Nurses.aspx.
James, J.T. (2013). A new evidence based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122-128.
Jones, K.J., Skinner, A., Xu, L., Sun, J. & Mueller, K. (2008). The AHRQ hospital survey on patient safety culture: A tool to plan and evaluate patient safety programs. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK43699/
Kolovos, N., Levy, F., & Bratton, S. (2008). A novel error-reporting tool in pediatric intensive care. Journal for Healthcare Quality, 30, 43-50.
Vogus, T. & Sutcliffe, K. (2007). The safety organizing scale: Development and validation of a behavioral measure of safety culture in hospital nursing units. Medical Care, 45(1), 46-54.
Weick, K. & Sutcliffe, K. (2015). Managing the unexpected: Sustained performance in a complex world. (3rd edition). Hoboken, NJ: Wiley & Sons.
