Post on 03-May-2018
transcript
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Organisational set up of the hospital sector of Region of Southern Denmark:
15-04-2016
Catchment Area: 1.205.000
No. of employees: 25.000
Hospital units: 4 somatic
1 psychiatric
33
Our story in brief:
In 2013 The Health Region of South Denmark had:
• a sound economy and no waiting lists
But we had:
• problems with quality / safety
We could foresee challenges like:
• no more money
• increasing expenses to drugs, treatments
• more elderly, more multi-ill and more frail patients
• higher demands on patient involvement
• higher expectations to quality and safety
• more stress of staff & more work place dissatisfaction
15-04-2016
44
We had to do something…
We decided to try to learn from the best…
hoping for a smooth and lasting transformation
We chose:
Seattle, Washington, USA
15-04-2016
© 2016 Virginia Mason Institute
Transforming Healthcare and World Class Management
Aligning Strategy and Goals throughout the
Organization
© 2016 Virginia Mason Institute
Virginia Mason Health System
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• Integrated health care system
• 501(c)3 not-for-profit
• 336-bed hospital
• Nine locations
• 500+ physicians
• 5,000 employees
Virginia Mason
• Graduate Medical Education
• Research Institute
• Foundation
• Virginia Mason Institute
• Yakima Valley Memorial Hospital
© 2016 Virginia Mason Institute
Requirements for Transformation
Sense of Urgency
Visible & Committed Leadership
Aligned Expectations
OneManagement
System
Technical & Human
Dimensions of Change
Shared Vision
8
© 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
9
© 2016 Virginia Mason Institute
The Virginia Mason Quality Equation
Q:
A:
O:
S:
W:
Q = A × (O + S)WQuality
Appropriateness
Outcomes
Service
Waste
11
© 2016 Virginia Mason Institute
What’s good enough?
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Imagine 99.9% quality at Virginia Mason…
15 Defective surgeries/year
17 Defective transfusions/year
1,000 Defective medication administrations/year
182 Wrong meals served/year
17,000 Defective bills sent/year
125 Defective paychecks/year
© 2016 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
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© 2016 Virginia Mason Institute
Healthcare Transformation
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Virginia Mason Production System Success
© 2016 Virginia Mason Institute
Aligned Expectations
Leader Compact
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Physician Compact
Board Compact
© 2016 Virginia Mason Institute
Respect for People
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Top 10 Ways to Show Respect
Listen to understand
Keep your promises
Be encouraging
Connect with others
Express gratitude
Speak up
Walk in their shoes
Grow and develop
Be a team player
Share information
© 2016 Virginia Mason Institute
Visible & Committed Leadership
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Learning and Supporting New Ways
Dr. Kaplan reviewing the
flow of the process with Drs.
Jacobs and Glenn
Leaders on the hospital floor
© 2016 Virginia Mason Institute
“It can be argued that the only thing of real importance that leaders do is create and manage culture; that the
unique talent of leaders is their ability to understand and work with culture”
-Edgar Schein
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© 2016 Virginia Mason Institute
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 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
© 2016 Virginia Mason Institute
1. Set priorities that align with the vision
2. Use lean tools & methods
3. Lead change
4. Allocate resources to infrastructure
5. Require accountability
6. Implement standard work for leaders
Executives’ Role
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© 2016 Virginia Mason Institute
“Leaders have a disproportionately large effect on the
cultures of organizations. By their behaviors,
leaders create the conditions that either
hinder or aid innovation.”
- NHS Institute
Traditional Health Care Management System?
© DC Comics
© 2016 Virginia Mason Institute
Management by Policy
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Aligning Vision from Board Room to Front Line
© 2016 Virginia Mason Institute
Management by Policy
• Establish Organizational Priorities
– Environmental Scanning
– A3 Proposals
– Catch Ball
– Final Selection
• Align Resources
• Ensures Accountability(Check and Review)
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© 2016 Virginia Mason Institute
Cross-Functional Management
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Periop Flow
Clinic Experience
Inpatient Care
Follow Up Care
Orthopedic Value Stream
© 2016 Virginia Mason Institute
Cross-Functional Management
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MD, Medical Director,
Perioperative Services
RN, Administrative Director,
Perioperative Services
Accountable Leadership
Administrative Director,
Neuroscience Institute
RN, Director, OR Director Anesthesiology
RN, Director PACUAdministrative Director OSC/ASC’s
Administrative Director, Cancer
Institute
Sr. Vice President and Hospital
Administrator
MD, Chief of Surgery
MD, Chief of Anesthesiology
MD, Chief Medical Officer
RN, Vice President, Surgical and
Procedural Services
Vice President,Clinic Operations
© 2016 Virginia Mason Institute
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
© 2016 Virginia Mason Institute
Example: Inpatient Orthopedics
Example: Health Information Services
Have daily huddles with your team
Daily Accountability
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© 2016 Virginia Mason Institute
Genba Rounds Checking Status ofStandard Work
Daily Accountability
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Inpatient Gemba Rounds AGENDA
Date: 23 march 2010 Item Legend
A=Approval / Action Item D=Discussion / Input
FYI=Information only -
No discussion at meeting R=Review
ST=Standing
U=Update
Materials Legend
* Attached
+ Distributed at
meeting
Time: 0930
Location: Unit L9 Ortho
Meeting Length: 30 minutes
Statement of Purpose: Guide Inpatient Gemba Rounds on the unit.
Item Agenda Item
Presenter
.
COMMENTS/SUGGESTIONS/ACTION ITEMS
C/T
1 D/U
Foundational Element for
Discussion:
DAILY LEADER ROUNDS
Inpatient Leader
5
2 D/U
Success to Highlight:
Staff& Patient Feedback
Inpatient Leader
5
3 D/U
Recent Kaizen Work/PDSA
RPIW Therapeutic Zones
Inpatient Leader
5
4 D
Dialogue
Gemba participants
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5 R Summary Remarks 2
FYI
* FYI Attachments Foundational Elements Progress Reports
NOTE: The Hospital AD will make notes in the Comments/Suggestions/Action Items box during the course of the Gemba Rounds. The noted agenda is to be returned to the Inpatient Nurse Leader.
GenbaRounds Agenda
UnitsGeographic
Assignments
RN/PCT
Integration
In Room
Handoff
Huddles Every
Shift
Documentation
near the Patient
Hourly Rounds
by Caregiver
Daily Leader
Rounds
People Link
Board (PLB)
Updated
Monthly Staff
Huddles by PLB
Criteria Visual Controls Audit Tool Observation Observation Observation Audit Tool Observation Observation Observation
CCU-7NA NA
Level 7
Level 8
Level 9
Level 10
Level 11NA
Level 12NA
Level 14
Level 15
Level 16
Level 17
RHU
ED
Not Implemented
Implemented Plan with Progress
Fully Implemented © 2010 Virginia Mason
Foundational Elements Progress ReportUnit:L9 Month: March 2010
JGoulding Streifel
:Rowena Ponischil
Foundational Elements
Progress Report
© 2016 Virginia Mason Institute
Standard work for leaders specifies the actions to be taken each day to focus on the processes in each leader’s area of responsibility.
Leaders Standard Work
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Clinic Supervisor Daily List Director Daily List
© 2016 Virginia Mason Institute
Daily Kaizen
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Accountability and Engagement
Tier 1 ReportingSenior Leadership reports updates on key metrics to the Board of Directors
Tier 2 ReportingVice Presidents report updates on key metrics to the Chief Executive Officer
Tier 3 ReportingManagers report to department
staff and Directors
© 2016 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
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© 2016 Virginia Mason Institute
Requirements for Transformation
Sense of Urgency
Visible & Committed Leadership
Aligned Expectations
OneManagement
System
Technical & Human
Dimensions of Change
Shared Vision
39
© 2016 Virginia Mason Institute
Elements of Effective Transformation
40
Years 1-3 Foundation For Journey
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Challenges we have met in the transformation process:
Sentimental expressions:
• It’s all about LEAN and hence the purpose is to save beds,
money, jobs etc.
• It’s all American; will not work here!
• How can we in health care learn from car production?
• Just another new management project?
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1
4343
Challenges we have met in the transformation process:
More well founded apprehensions:
• We are overloaded, and do not have time to more projects!
• How do we know this will work?
• We have already tried LEAN: it did not work very well
• We have tried other management systems; all in vain!
• The language!!: American material, American trainers
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4444
Challenges we have met in the transformation process:
Problems for real – from the director
The culture:
• the material, the teaching, the coaching reflect the American culture
of discipline and hierarchy
• The Danish culture is based on: lesser discipline and more
engagement, and more team-work.
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4545
Challenges we have met in the transformation process:
Problems for real – from the director
The language:
• it is a serious problem, especially in the beginning: it hampers
peoples understanding and their ability to express themselves,
resulting in reluctance and sometimes hostility
The staff:
• Finding the right staff and the right way of organizing
the improvement work and leadership-training
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3
4646
Challenges we’ve met in the transformation process:
Problems for real
The clinical leaders:
• They really felt no time for the training:
• Six teaching days preceded with 2 x 6 days for reading and testing
assignments
• They felt it degrading to be given administrative learning assignments,
and to be ‘coached’
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4747
How to overcome the barriers:
The director
First step was to be convinced:
• This is a new way of leading (be in front)
• This is a new way of using frontline staff (ideas)
• This is LEAN, yes, but used differently and much more appropriate
Citation: “It is THE model for constant improvement,
that can be sustained”.
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4848
How to overcome the barriers:
The director
Next step was to stand firm against all the criticisme from the staff:
• Yes, you have to set aside time
• Yes, you have to join the training, and do your homework
• It was necessary to have individual talks (of the serious type)
with some of the clinical leaders
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How to overcome the barriers:
Carrots
Make things meaningful and relevant to staff:
• In selection of value streams (value, waste, critical)
• See to that they are involved for real
• See to that you celebrate the successes and share with others
• Buy time for staff, when it is serious and critical
Make it a career option to be frontrunner
in the improvement work
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How to overcome the barriers:
Sticks:
• Let people know that it is urgent; we cannot wait!
• The clinical leaders can see, that their leaders stand firm and
do not give leeway to halfhearted participation
• Serious talks to staff, that resist the work and participation
• Let people go, who cannot see themselves in the processes
and the model
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5151
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4
How to overcome the barriers:
Supplementary
The cultural aspect:
• Translate the material into Danish
• Let the training material be based on Danish examples
• Use Danish trainers / teachers
• Use enthusiastic peers to speak to staff
Things take momentum when staff:
• See that ‘the improvement work’ works, and it works from day one
• See that it does give value to the patients and the organization
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Citation from a director:
”The reluctance seen in the first ‘Lean for Leaders’, has completely
evaporated with the next group.
Enthusiasm has grown greatly and we hear and see no more
unwillingness from the clinical leaders”.
Citation from clinical leader:
‘It was so convincing to see, what normally takes a year to accomplish,
was completed in 5 days.
Intensive work, and many days, yes, but also so much enthusiasm, so
many innovative ideas, so much commitment. And the solutions work.
When can we have the next workshop?”
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In essence:
• Much/most improvement is based on the frontline staff and their
knowledge, experience and innovative ideas
• Leadership’s role is to set targets, allocate resources, consolidate
(standardize) and align the organization
• The validated LEAN tools are used as a mean for facilitating the
processes
BUT: it is 80% leadership and 20% LEAN (citation /employee)
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Conclusion:
We feel convinced that
we have got a generic
model, that can be used
in all situations where
improvement is identified
and desired,
But……..
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Follow up:
• The conclusions above, are based on narrative statements, like:
observations, interviews, presentations, minutes etc.
• To evaluate the evidence of improvement in the transformation
process, we have established a scientifically based evaluation
• This evaluation will – over time – explain:
• Does it work in the long run ?
• What works, and what doesn’t ?
• What makes it work ?
15-04-2016