Jack Silversin, DMD, DrPH Engaging Healthcare Professionals to Transform Care 10 April 2014 Gary Kaplan, MD Chairman and CEO, Virginia Mason Medical Center Jack Silversin, DMD, DrPH Founding Partner, Amicus, Inc

Virginia Mason Medical Center Integrated health care system 501(c)3 not-for-profit 336-bed hospital Nine locations 500 doctors 5,500 employees Graduate Medical Education Research Institute Foundation Virginia Mason Institute 2

Our Strategic Plan

Seeing with our Eyes Japan 2002 Team Leader Kaplan reviewing the flow of the process with Drs. Jacobs and Glenn at Hitachi Air Conditioning plant 4

Take-Aways How are air conditioners, cars, looms and airplanes like health care?  Every manufacturing element is a production processes Health care is a combination of complex production processes: admitting a patient, having a clinic visit, going to surgery or a procedure and sending out a bill  These products involve thousands of processes—many of them very complex All of these products involve the concepts of quality, safety, customer satisfaction, staff satisfaction and cost effectiveness These products, if they fail, can cause fatality 5

The VMMC Quality Equation Q = A × (O + S) W Q: Quality A: Appropriateness O: Outcomes S: Service W: Waste

New Management Method: The Virginia Mason Production System We adopted the Toyota Production System philosophies and practices and applied them to health care because health care lacks an effective management approach that would produce: Customer first Highest quality Obsession with safety Highest staff satisfaction A successful economic enterprise 7

Value Stream Development RPIW (Rapid Process Improvement Workshop) VMPS Tools in Action Value Stream Development RPIW (Rapid Process Improvement Workshop) 5S (Sort, simplify, standardize, sweep, self-discipline) 3-P (Production, Preparation, Process) Standard Work Daily Work Life 8 8

RN time available for patient care = 90%! “Nursing Cells” – Results > 90 days RN time available for patient care = 90%! Before After RN # of steps = 5,818 PCT # of steps = 2,664 Time to the complete am cycle of work = 240’ Patients dissatisfaction = 21% RN time spent in indirect care = 68% PCT time spent in indirect care = 30% Call light on from 7a-11a = 5.5% Time spent gathering supplies = 20’ 846 1256 126’ 0% 10% 16% 11’ The RN and PCT are spending more time engaged in direct patient care A significant reduction in walking distance (85%) and time to complete the a.m. cycle of work (48%). An increase in patient satisfaction and a decrease in call light use because their care team is present and addressing their needs while they’re in the room. Again, supplies and equipment were brought to point of use, so they’re spending almost 50% less time searching for and gathering supplies. 9

Lindeman Surgery Center Throughput Analysis Before Today % Change Time Available 600 min 600 min 0% (10 hr day) Total Case Time 107 min 65.5 min 39% (cut to close plus set-up) Case Turnover 30 min 15 min 50% Time (pt out to pt in) (ability to be <10 min) Cases/day 5 cases/OR 8 cases/OR 60% Cases/4 ORs 20 cases 32 cases 60%

Primary Care – Flow Stations Creating MD Flow Reduces Patient Wait Times VMPS Concepts of a Flow Station Waste of motion (walking) Continuous flow Visual control (Kanbans) External setup Water strider U-Shaped Cell URGENT CERNER MESSAGE PAPER MAIL DOCUMENT VISIT RESULT REPORT $ CHARGE SLIP $

Stopping The Line

“Stopping the Line” Organization-wide Involvement Staff identify and report issues and concerns using the Patient Safety Alert System Leadership involvement with investigation and resolution Board Quality Committee review and approve closure of high-severity issues (Red PSA’s) Virginia Mason is unique in having a system in place where that occurs – and even more unique in the fact that it starts with the staff and goes all the way up to our Board.

Categorizing Patient Safety Risk Events 3 Basic Risk Sources Evaluation Treatment Critical interactions 27 Specific Risk Categories 3 of the top 5 risks Direct Patient Care Medication Laboratory Order & Collection This past year VM developed a Risk Registry to enable us to use all the information we’ve been collecting over the years to more pro-actively identify areas of focus. Risk registers are tools to systematically identify risks and rank them based on both their impact and probability of occurrence to help organizations make more informed decisions about risk mitigation and intervention. We categorized our PSA into 27 risk categories; we then used VM claims experience to estimate the annual liability costs for each risk category. The last step was to conduct focus groups to obtain staff and manager input to elicit quantitative estimates of rate and relative harm for each risk category. We found that focus group risk perceptions agreed with PSA-based rankings for three of the top five risk areas.

Overall staff response rate Virginia Mason Medical Center 2013 AHRQ Mean = 51% Is this just VM docs, or is it everyone We look “different” since 2009. Why? What might be the benefit and lesson if we go higher?

Reduction of Hospital Professional/General Liability Premiums % change from previous year, with 74% overall reduction in premium since 2004-05 7% 12% 5% 26% 12% 12% 11% 12% 30%

Virginia Mason Medical Center Hospital of Decade: Efficiency and Effectiveness 1. We are pleased that the Leapfrog Group, an association of large employers, has designated VM one of two US hospitals of the decade, based on both effectiveness and efficiency. 2. This designation by employers indicates that we are approaching the delivery of health care in a different manner from other provider groups and this is certainly the case. 3. It was not always so, however,. In 2000, we found ourselves facing a negative margin and part of a health care industry that was clearly moving rapidly in the wrong direction.

Tuesday Morning “Stand Up” 19

Our Quality & Safety Journey Patient/ Family Engagement Leapfrog Top Hospital of the Decade Toyota Production System Introduced to VMMC 1st IOM1 Report 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Respect for People Training Falls ST-PRA5 Leapfrog Governance Award Virginia Mason Production System established Declare One Organizational Goal: Patient Safety Mary L. McClinton Fatal medical error 1st Culture of Safety Work Plan AHRQ4 Safety Culture Survey: 81% Participation AHRQ4 Safety Culture Survey: 84% Participation IHI3 5 Million Lives 1st Safety Culture Survey Employee Safety Risk Registry PSA Case Studies CPOE Go Live Q4Q Site Visit Patient Safety Alert (PSA) for clinical events 2nd Safety Culture Survey Move to yearly AHRQ4 Safety Culture Survey Staff & Patient Leader Rounds AHRQ4 Safety Culture Survey: 82% Participation (all staff, all electronic) AHRQ4 Safety Culture Survey: 90% Participation 2nd IOM1 Report MDM RPIW6 Cross Pillar Culture of Safety Work Plan PSA 3P ADEPT2 Preprinted Order Sets Time Out ST-PRA5 As you all know our safety culture journey started quite some time ago; the work I have shared today provide just a few examples of how our journey continues and our commitment to pursuing perfection in all elements of the quality equations grows . CEO Mandates PSA System PSA for non-clinical events Patient Safety Risk Registry VM Board: Business Case for Quality MD Disclosure Training Just Culture Strategic Quality Plan Standard Quality Goal Reporting Process Quest for Quality Citation of Merit 2010 HealthGrades Patient Safety Award Executive Walk Rounds IHI3 100,00 Lives Institute of Medicine Adverse Drug Events Prevention Team Institute for Healthcare Improvement 4. Agency for Healthcare Research and Quality 5. Sociotechnical Probabilistic Risk Assessment 6. Must Do Measure Rapid Process Improvement Workshop

2013 Organizational Goals Quality and Safety: Care Delivery Innovations • Delivering Patient-Centered Coordinated Primary Care • Optimizing Care Transitions • Smoothing Patient Flow • Eliminate Healthcare Associated Infections • Glycemic Control • Prevention of Hospital Associated Delirium We attract and develop the best team People We foster a culture of learning and innovation Innovation We create an extraordinary patient experience Service We relentlessly pursue the highest quality outcomes of care Quality Vision To be the Quality Leader and transform health care Mission To improve the health and well-being of the patients we serve Values Teamwork | Integrity | Excellence | Service Strategies Virginia Mason Team MedicineSM Foundational Elements Patient Strong Economics Responsible Governance Education Virginia Mason Foundation Integrated Information Systems Research Virginia Mason Production System Quality, Safety, Service, People, Innovation • Respect for People Service: Patient Experience • Integration of the Patient Experience People: Team Engagement • Transformational Leadership • Organizational Training & Education First, I’d like to brief you on our key goal areas for this year. As you know, we have a lot going on at Virginia Mason! To help focus our attention and resources on the areas that matter most, we developed these goals – with approval of the board – and have shared them with staff and providers so everyone in the organization knows what we are working toward in 2013. I thought it might be simplest to bring you up to speed by focusing on many of these same areas, so my slides are divided based on our goals and what we’ve accomplished in each area during the past several months. Strong Economics • Growth Integrated I.S.: Technology and Care Delivery Partnerships • Realizing the Potential of Our Electronic Health Record • Update the Enterprise Orders and Documentation Framework • Ambulatory CPOE • Measure and Improve our Results

With engaged and committed staff and doctors! How Have We Gotten Here With engaged and committed staff and doctors!

Benefits of Doctor Engagement: The Obvious and Not So Obvious Contribute knowledge and expertise; solutions will be better for doctor input Develop more realistic expectations of what is possible Have greater commitment to solutions; successful implementation more likely Builds trust and partnership between doctors and management when doctors experience they have influence on outcomes Helps doctors move through psychological transition associated with change

Authentic Engagement Is Difficult Managers or administrators Some like making decisions and controlling outcomes Experience pressure for timely decisions Have not been successful managing efficient and helpful process for engagement Are faced with doctors’ expectation that asking their advice should translate into actions that reflect it Experience sincere attempts have been met with cynicism or disinterest Doctors Perceive that past input has gone into “black hole” which leads to cynicism Paid for productivity, some will not participate in non-clinical work unless compensated Having the option to do what I want to do anyway makes investing time in improvement activity irrational Requires on going commitment to engage even when you don’t get what you want in a given situation

Doctor Engagement in Your Organization: Current and Future States Current state: When people say “doctor engagement” what do they mean? What picture do they have in mind? Descriptors of current state doctor engagement Preferred future state: When people say “doctor engagement” what will it mean? What picture will they have in mind? Descriptors of preferred future state doctor engagement

A Helpful Perspective on Change 26

Two Kinds of Challenges Ronald Heifetz Technical Problem is well defined Solution is known can be found Implementation is clear Adaptive Challenge is complex To solve requires transforming long-standing habits and deeply held assumptions and values Involves feelings of loss, sacrifice (sometimes betrayal to values) Solution requires learning and a new way of thinking, new relationships

An Easily Adopted Change Technical not because it’s technological but because: Its use involves no angst or challenge to personal identity Adoption is intuitive or similar to other successful changes. Past experience provides a “road map” or sense for how it works There’s always the Genius Bar – someone does know what to do.

An Adaptive Challenge

Wisdom from Ronald Heifetz “The most common cause of failure to make progress is treating an adaptive problem with a technical fix.” Technical fixes New payment scheme for doctors Incentives or bonuses Reorganization Issuing new vision statement Adaptive solutions Giving authority to solve problems to the implementers Discussion that allows respectful airing of difference Bringing conflict to the surface and constructively resolving it 30

Adaptive Work “Solutions are achieved when ‘the people with the problem’ go through a process together to become ‘the people with the solution.’ The issues have to be internalized, owned, and ultimately resolved by the relevant parties to achieve enduring progress.” - Heifetz and Linsky, Leadership on the Line

Foundation for Engagement Single method for improvement Engaged Doctors Modernize compact Co-create new gives and gets Increase urgency Turn up the heat Enhance leadership Develop doctor leaders who sponsor change Share a vision Inspire action with clear picture of future

Foundation for Engagement Single method for improvement Engaged Doctors Clarify new compact Co-create new gives and gets Increase urgency Turn up heat Enhance leadership Develop doctor leaders who sponsor change Share a vision Inspire action with clear picture of future

Time for a Change – VMMC 2000 Issues Leadership Change Survival Retention of the Best People Loss of Vision Build on a Strong Foundation Leadership Change A Defective Product 34

Urgency for Change at VMMC “ ” We change or we die. — Gary Kaplan, VMMC Professional staff meeting, October 2000

November 23, 2004 Hospital error caused death Investigators: Medical mistake kills Everett woman Hospital error caused death Mary L. McClinton

I would like to talk to you about Mary McClinton I would like to talk to you about Mary McClinton. Mary was a patient of Virginia Masons – she had who died at Virginia Mason of an avoidable medical error. 37 37

The Challenge of Ongoing Urgency In a time of constant and tumultuous change, avoid complacency

Principle 1. Change Has to Start With Urgency “When people have a true sense of urgency, they think that action on critical issues is needed now, not eventually, not when it fits easily into a schedule.” - John Kotter, A Sense of Urgency

The Status Quo is Like Gravity The invisible hold of the status quo is very strong The case for change has to be compelling if it is to move others to take action

“Distress” and Adaptive Work Limit of tolerance Adaptive challenge Disequilibrium Productive range of distress Threshold of learning Time Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108

Urgency: Make the Invisible Visible HOW Self-discovery” – experiential More than facts: John Kotter’s see/feel/change approach WHAT Cost of doing nothing exceeds cost of change Cold, hard facts on performance and lack of sustainability Gap between aspiration and reality The personal impact of incidents

Leaders’ Role in Signal Generation “Leaders are signal generators who reduce uncertainty and ambiguity about what is important and how to act.” — Charles O’Reilly III OR 43

Back Home Discussion About Urgency What signals do leaders in our organisation send regarding urgency for care improvement? Are leaders’ signals consistent? What is the impact of the signals sent on doctor engagement in improvement?

Foundation for Engagement Single method for improvement Engaged Doctors Modernize compact Co-create new gives and gets Increase urgency Turn up heat Enhance leadership Develop doctor leaders who sponsor change Share a vision Inspire action with clear picture of future

Our Strategic Plan

Principle 2. Engagement is Facilitated When A Destination is Shared Everyone needs to share the same destination to make optimal use of all resources

Lack of Shared Vision Reflects Silo Orientation and Value on Autonomy

Challenges to Having Vision that Is Shared Often relationships between administration and doctors are wobbly or strained. Built on and reinforced by individual transactions Doctors don’t readily acknowledge their interdependence Vision process is often superficial; an exercise with a narrow purpose (e.g., for PR) Little connection between vision on paper and daily life No clear method to achieve vision

Requirements for Developing Shared Vision Doctors develop deep appreciation of interdependence (to provide best, safest patient care) There is a process to develop vision – not a one-off meeting: Deepens understanding of the various imperatives the organisation must respond to including quality, value, safety Encourages different points of view to be heard Builds commitment Vision is: Strategic and granular Perceived as a stretch, but not a fantasy

Basis of Vision is Shared Interests Organisation’s Interests Doctors’ Interests SHARED INTERESTS Commitment to patients’ care and safety Positive reputation Recruit and retain talent

Back Home Discussion About Shared Vision To what extent do doctors, staff, and management share the same vision of where our hospital is heading? Little Great 1 2 3 4 5 Why did you choose the number you did? What impact does this have on doctor engagement?

Foundation for Engagement Single method for improvement Engaged Doctors Increase urgency Turn up heat Modernize compact Co-create new gives and gets Enhance leadership Develop doctor leaders who sponsor change Share a vision Inspire action with clear picture of future

Typical Views Doctors Hold of Their Leaders Advocate Protector Communicator – go to meetings to represent our views and keep us informed of important news First among equals, “not one millimeter above”

Consider Two Mental Models Range of Leadership Activities Advocate for my peers Other Leadership activities Advocate for subordinates Professional managers’ view Doctor leaders’ view

Reinforcement of Traditional Doctor Leadership Preference for leadership that doesn’t threaten personal autonomy There are times when advocacy or protection is appropriate Doctors make leaders pay a price for stepping out of advocate/protector role Election to leadership roles Short tenure in role limits development of a wide range of leadership skills

VMMC Doctor Leader is a Real Job Appointed, not elected Clear expectations/job descriptions Performance feedback Training and development Succession planning Dyad model pairs administrative leader with doctor leader at every level

For Doctor Leaders to be Effective, Administrative Leaders Need to Change It’s not just doctor leaders who shift mindset and actions Working collaboratively with doctors represents an adaptive change for many administrative leaders Need to move away from language such as: “We need to gain their buy-in” and “We’ll roll it out”

Principle 3. Investment in New Model of Doctor Leadership is Critical Current Dilemma Doctors don’t easily accept legitimacy of leaders’ authority Hospital needs doctor leaders to sponsor change

Redefine Role of Doctor Leader “Leadership now is the ability to step outside the culture that created the leader to start evolutionary change processes that are more adaptive.“ - Edgar Schein Sponsor change and engage colleagues Demonstrate personal commitment to quality and safety improvement Be a role model and among the first to adopt the new way Provide encouragement and acknowledgment to those who get on with change Hold colleagues accountable to engage in the organisation’s quality and safety initiatives Make practice life more efficient for clinical colleagues Able to make and keep commitments on behalf of doctors Build network of leaders for peer support and identity development

Back Home Discussion About Doctor Leadership What model of doctor leadership is most common in our hospital: Advocate and protector of status quo for doctor-colleagues? Facilitator of change and skilled at engaging colleagues? What is the impact of this model of doctor leadership on our hospital’s ability to change?

Foundation for Engagement Single method for improvement Engaged Doctors Increase urgency Turn up heat Modernize compact Co-create new gives and gets Enhance leadership Develop doctor leaders who sponsor change Share a vision Inspire action with clear picture of future

Compact Expectations members of an organisation have that are: Unstated yet understood Reciprocal The give The get Mutually beneficially 63

Traditional Doctor Compact GIVE GET Treat patients Provide quality care (personally defined) Autonomy Protection Entitlement 64

Clash Of “Promise” And Imperatives Traditional “Promise” Legacy Expectations Imperatives Improve safety/quality Implement electronic records Improve efficiency and value Be patient-focused Improve access Autonomy Protection Entitlement 65

Old Compact at VMMC Not Working Despite the fact things weren’t working, most doctors clung to the fundamental “gets” they felt due them Protection Autonomy Entitlement Doctor-centered world view prevailed

VMMC Compact Process Doctor Retreat (Fall 2000) Broad based committee of providers: primary care, sub-specialists Focus of retreat: doctors-changing expectations, tools to manage change Jack Silversin served as our consultant Spent time at VMMC talking to doctors

Compact committee drafts compact VMMC Compact Process Doctor Retreat (Fall 2000) Compact committee drafts compact (Winter 2001) Broad based group of providers Administrative Involvement: CEO, JD, HR, Board Member (also a patient) Starting point: “Gives” and “gets” from the Retreat Evolving Strategic Plan: patient centered

Compact committee drafts compact VMMC Compact Process Doctor Retreat (Fall 2000) Compact committee drafts compact (Winter 2001) Departmental meetings for input (Spring 2001) Committee met weekly Reality Checks Management Committee Doctors Multiple Drafts until we reached the “final draft”

Virginia Mason Medical Center Doctor Compact Organization’s Responsibilities Foster Excellence Recruit and retain superior doctors 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  Doctor’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, doctors, 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

Hardwiring Compact Recruitment Orientation Job Descriptions Feedback Chief Section Heads Doctors Feedback

Principle 4. A New Compact Is an Adaptive Change Journey as important as destination Iterative process for understanding and buy-in Mutual accountability (2-way street)

Vision Is Context for Compact Doctors give: What the organisation needs to achieve the vision Organisation gives: What helps doctors meet commitment Societal needs Local market Organisation’s strengths Competition STRATEGIC VISION

Compact Supports Alignment with Vision Compact discussions as foundational – basic to moving us toward vision Compact is revisited, made alive, reinforced Periodic assessments/dialogue as to how both “sides” are living up to compact commitments

Back Home Discussion About Doctor-Organization Compact In what ways does the unwritten compact between our hospital and doctors: Support change and improvement? Serve as an impediment to change and improvement? Should we undertake a process to work with doctors to create a new one? Who do we need to involve?

Foundation for Engagement Single method for improvement Engaged Doctors Modernize compact Co-create new gives and gets Increase urgency Turn up the heat Enhance leadership Develop doctor leaders who sponsor change Share a vision Inspire action with clear picture of future

“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

Readings Bohmer R. and Ferlins E. Virginia Mason Medical Center – Harvard Business School Case 9-606-044, President and Fellows of Harvard College, 2006 Bridges, W. Managing Transitions. Addison-Wesley, 1991 Edwards, N, Kornacki, MJ, and Silversin, J. Unhappy doctors: what are the causes and what can be done? BMJ 2002; 324: 835- 838 Heifetz, R. and Linsky, M. Leadership on the Line. Harvard Business School Press, 2002 Kenny, Charles. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. CRC Press, 2011 Kotter, J. Leading Change. Harvard Business School Press, 1996 Kotter, J. and Cohen, D. The Heart of Change. Harvard Business School Press, 2002 Kornacki, M.J. and Silversin, J. Leading Physicians through Change: How to Achieve and Sustain Results, 2nd edition, American College of Physician Executives, 2012