Promoting Safety: Creating the culture needed to achieve system improvementaws-cdn.internationalforum.bmj.com/pdfs/H9KaplanFur… · · 2015-04-080 200 400 600 800 Respect 1000

© 2015 Virginia Mason Institute

Promoting Safety: Creating the culture needed to achieve system improvement

International Forum on Quality and Safety in Healthcare

April 24th, 2015

Gary Kaplan, M.D. Cathie Furman, RN, MHA


Learning Objectives

• Identify fundamental leadership methods and

structure to promote a culture of safety

• Design strategies to promote and enhance the

culture in your organization

• Explain how a culture of respect connects to the

delivery of patient-centered, safe, high-quality

care 2


Virginia Mason

• Integrated health care system

• 501(c)3 not-for-profit

• 336-bed hospital

• Nine locations

• 500+ physicians

• 5,500+ employees

• Graduate Medical Education

• Research Institute

• Foundation

• Virginia Mason Institute

3

Virginia Mason Medical Center

• Integrated healthcare system

• 336 bed hospital

• 6,000 team members

• Education & Research

• Eight Regional Centers


The Healthcare Culture Problem

• Blame, denial, scapegoats

• Hierarchical structure

• Lack of trust, fear, victimization

• Frustration, anger

• Helplessness, hopelessness,

resignation

• Apathy

Copyright © 2012 Virginia Mason Medical Center. All Rights Reserved.

4

© 2015 Virginia Mason Medical Center


The VMMC Quality Equation

Q: Quality

A: Appropriateness

O: Outcomes

S: Service

W: Waste

Q = A × (O + S)

W


6


Critical mass feels urgency for

change

Visible and committed leadership

New compact aligns expectations

with vision

Improvement Method Applied to ALL Processes

Executives address technical AND

human dimensions of change

Requirements for Transformation

Broad and deep commitment to shared vision


7


Vision Is Context for Compact

• Societal needs

• Local market

• Competition

• Organization’s strengths

STRATEGIC

VISION

Physicians give:

• What the

organization

needs to achieve

the vision

Organization gives:

• What helps

physicians meet

commitment

• What is

meaningful to

physicians


8


Physician

Compact

Board

Compact

Leader

Compact

Align Expectations

9


The Road to Transformation

Source: Gareth Morgan

10


The Virginia Mason Production System

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

11


Stopping the Line

12


Patient Safety Alert Process

• Leadership from the top

• “Drop and Run” commitment

• 24/7 policy, procedure, staffing

• Legal and reporting safeguards

13


Patient Safety Alert

Goal: zero defects

Based on VMPS

Continuous Improvement

14


Culture must support reporting

Weick and Sutcliffe “Managing the Unexpected”

15


A Defining Moment

16

0

200

400

600

800

1000

1200

Ju

l-11

Se

p-1

1

No

v-1

1

Ja

n-1

2

Ma

r-12

Ma

y-1

2

Ju

l-12

Se

p-1

2

No

v-1

2

Ja

n-1

3

Ma

r-13

Ma

y-1

3

Ju

l-13

Se

p-1

3

Nov-1

3

Ja

n-1

4

Ma

r-14

Ma

y-1

4

Ju

l-14

Se

p-1

4

No

v-1

4

Ja

n-1

5

Count of PSAs Reported per Month All PSAs (Inpatient and Outpatient)

Mistaking

Proofing

Sharing

of

Immediat

e PSAs

Standard

of Care

Improve-

ment

Kaizen

Making

Safety

Local

Quick

Entry

Screen

Respect

for

People

PSA

3P

Share

Point

SOS

Process

#2

Safety

Briefings

Kaizen

Optimizing

Trending

Awareness

Kaizen

Good

Catch

Award

New

Leader

Orien-

tation

Lab

PSA

Entry

SOS

Process

#1


50,000th PSA Reported

September

2013

40,000th

1,000th

July

2005

10,000th

March

2008

20,000th

February

2011

30,000th

October

2012

September

2014

50,000th

18

End of February 2015: 54,921


Assist, Celebrate & Recognize People

19


Share the Lessons

20


Why Culture is Important

21

A surgeon recently had to use

Seattle Surgical for a procedure

and realized no other staff were

engaged in the time out

“I realized I can no longer

practice without the surgery

attestation we use at VM”

”

“ I can’t tell you how important it

was to stop the line - It was

amazing to see the resources

get pulled in to support us”

One of the involved team

members

“Mary provided the face to

all the statistics”

First McClinton Award winner

“How do I tell them? I don’t

even know what happened

yet, what if they blame me?”

A provider

“You began with “I am sorry,”

and after that, I could listen

because I knew you cared.”

A family member


“Stopping the line” Organization-wide Involvement

0

100

200

300

400

500

600

700

800

900

1000

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

20

15

Number of PSAs Reported per Month

22

1. Staff report issues

using the Patient Safety

Alert System

2. Leadership investigates

and resolves issues

3. Board Quality

Committee review/

approve closure of

high-severity issues


(Excludes claims closed without payment.)

2697

3500

3079 2726

2954

4322

5386

6196

9277

10082

79

67 66

86

60

70

78

23

19 16

0

10

20

30

40

50

60

70

80

90

100

0

2000

4000

6000

8000

10000

12000

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

PSAs Reported Reported Claims

Effectiveness of Safety Program

23


Leaders Sustain the Rigor

Tuesday Stand

Up

Friday Report

Out

Standard Work

for Leaders

24


25

1. RUN their business

2. IMPROVE their business

Standard Work for Leaders

Virginia Mason Leaders Have Two Jobs


“People change what they do less because they are given analysis that shifts their thinking than because they are shown a truth that influences their feelings" John Kotter

Change is Hard

26


Leadership on Genba

27

“It’s just saline.”


Respect for People

2010 2011 2012 2013 2014

Respect for People Patient Safety Curriculum

Mandatory

RFP Training

Mandatory

Service

Training

Lucian

Leape

Visit

Transformational

Leadership

Integration of RFP

Change Management

TeamSTEPPS

LEADERSHIP ROLE

AND

ACCOUNTABILITY

28


Defined as:

How we treat one another as we work

together to create the perfect

patient experience

29


Top 10 Ways to Show Respect

Listen

to

understand

Speak Up

Share

Information

Walk in

their shoes

30


Annual Goals

Long Term Vision

VMPS Priorities

Department Priorities

Aligning Vision with Resources

31


It is a Journey

2002 2003

2004 2005

2006 2007

2008 2009

2010 2011

2012 2013 2014

− Adopted TPS

− Implemented PSA

system

− First culture of

safety survey

− Implemented First 5

year Strategic

Quality Plan

− Established CME

course – EBM

− Created Must Do

Measures criteria,

information flow and

accountability

− First Top in region

Leapfrog survey

− Mrs. McClinton

− Adoption IHI

100,000 lives

campaign

− One goal

− First clinician

disclosure training

− Adopted mandatory

flu vaccine policy

− CPOE adopted

across the inpatient

setting

− HealthGrades

Distinguished

hospital award

− 1st major

decrease in

central line

infections

− Published peer

review article on

PSA system

− CDC

Immunization

Excellence

award

− QOC began

reviewing all red

PSAs

− 2nd series of

Disclosure

workshops

− Revised PSA

database

− Just Culture

training

− Surgical time

out ST PRA

held

− SSI team

McClinton

Patient Safety

Award winner

− Top Hospital of

the Decade

− Falls ST PRA

− PSA 3P

− Completed first

Patient Safety

Risk Register

− First Worker

Safety Risk

Register

− First Good

Catch Award

− Respect for

People Training

− Standard of

Care Process

Kaizen

− Established

Synchronized

Ongoing Support

Process

− Achieved target

of 1000 PSAs

reported in one

month

− Began PSA

Pointers

− ACPOE

− 50,000th PSA

− 108 Patient

Family

Partners

32


Strive for the Highest Satisfaction Levels

70

75

80

85

90

95

100

2007 2008 2009 2010 2011 2012 2013

Medical Center Overall Satisfaction and Likelihood to

Recommend

Clinic Patient Satisfaction Likelihood to Recommend

70

75

80

85

90

95

100

2007 2008 2009 2010 2011 2012 2013

Hospital Patient Overall Satisfaction and Likelihood to

Recommend

Hospital Patient Satisfaction Likelihood to Recommend

22nd

Percentile

76th

Percentile

30th

Percentile

91st

Percentile

23rd

Percentile

67th

Percentile

15th

Percentile

89th

Percentile

22

© 2014 Virginia Mason Medical Center

Maintain a Successful Economic Enterprise

$0.7

$3.2

$12.0

$18.4

$29.4

$49.4

$40.9

$35.5

$25.6

$22.5

$38.0

$0.0

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

$35.0

$40.0

$45.0

$50.0

$55.0

$60.0

2000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

$ (

Millio

ns)

Shared Success Program


Safety Culture Question Staff Speak Up Freely*

*Question: Staff will speak up freely if they see something that may

negatively affect patient safety – using the AHRQ rating method

76%

74%

79% 79%

81%

79%

77%

80%

78%

70%

72%

74%

76%

78%

80%

82%

35


Lessons Learned

Large scale organizational change requires leadership, perseverance and alignment

Communication is not sufficient

Accountability

Reinforcement

Training

Focus on continuous improvement

36


Questions?

37

A lean journey is a learning journey.TM


Documents

Promoting Safety: Creating the culture needed to achieve system improvementaws-cdn.internationalforum.bmj.com/pdfs/H9KaplanFur… · · 2015-04-080 200 400 600 800 Respect 1000