FEA­TURES

Lead­ers talk qual­ity, change needed for im­prove­ment at Vir­tual Con­fer­ence

Modern Healthcare - - NEWS -

On June 11, Mod­ern Health­care hosted its first Vir­tual Con­fer­ence of 2013, Pa­tient Safety & Qual­ity. One com­po­nent of the con­fer­ence was a ple­nary ses­sion ti­tled “Im­ple­ment­ing a Cul­ture of Con­tin­u­ous Im­prove­ment,” hosted by Mod­ern Health­care re­porter Mau­reen McKin­ney.

The ses­sion fea­tured three ex­perts: Jef­frey Sel­berg, ex­ec­u­tive vice pres- ident and chief op­er­at­ing of­fi­cer of the In­sti­tute for Health­care Im­prove­ment; Dr. Peter Pronovost, di­rec­tor of the Arm­strong In­sti­tute for Pa­tient Safety and Qual­ity at Johns Hop­kins; and Dr. Gary Ka­plan, chair­man and CEO of Vir­ginia Ma­son Health Sys­tem, Seat­tle.

What fol­lows is an edited tran­script of their re­marks. To hear the en­tire ple­nary ses­sion, visit modernhealth­care.com/podcasts.

Jef­frey Sel­berg: I’m speak­ing about the cul­ture of con­tin­u­ous im­prove­ment. And when I think about cul­ture, I think about be­liefs and be­hav­iors both in­di­vid­u­ally and col­lec­tively.

I think all of (my points) rest on two foun­da­tional ele­ments. The first is what I’ll call con­stancy of pur­pose, and that is a be­lief that no mat­ter how good the prod­uct or ser­vice is, it can and must be im­proved. This is one of Dem­ing’s first prin­ci­ples, and it re­ally has to be a deeply held be­lief for there to be a cul­ture of con­tin­u­ous im­prove­ment. You need to be­lieve that no mat­ter how much you know, you can learn more.

The sec­ond prin­ci­ple is co­op­er­a­tion. If you don’t have an en­vi­ron­ment of co­op­er­a­tion, both the learn­ing and im­prove­ment will slow to such a de­gree that peo­ple will lose in­ter­est. So, those are the two foun­da­tional ele­ments, pur­pose and co­op­er­a­tion.

At IHI, we be­lieve in the science of im­prove­ment, which is to say to es­tab­lish an aim, iden­tify your met­rics, define and de­velop a changed pack­age and then ini­ti­ate a se­ries of Plan-Do-Study-and-Act cy­cles to learn, re­fine and ap­ply on a con­tin­u­ous ba­sis. This is re­ally the ba­sis of con­tin­u­ous im­prove­ment.

I think there are two prin­ci­ples here that are im­por­tant. One is, never leave a meet­ing with­out com­mit­ting to a small test of change that you can ini­ti­ate in a week. If you don’t think you can do it in a week, then make the test of change smaller so that you can. Ap­pli­ca­tion is crit­i­cal in con­tin­u­ous im­prove­ment. And se­condly, I think as we all know, data is a must. No data, no mea­sure, no un­der­stand­ing of cause and ef­fect, no learn­ing, and there­fore, no sus­tained im­prove­ment. So data be­comes crit­i­cal to the process.

Dr. Peter Pronovost: It’s re­ally key for us to re­al­ize what we mean when we say “cul­ture,” be­cause we act as if or­ga­ni­za­tions are one beast with one cul­ture, but the re­al­ity is when you peel the onion of an or­ga­ni­za­tion, the cul­ture varies about six- to eight­fold more on ev­ery unit in that or­ga­ni­za­tion or clinic than it does in the or­ga­ni­za­tion.

Now, ev­ery qual­ity mea­sure we’ve looked at has the same dis­tri­bu­tion, whether it’s hand- wash­ing, core mea­sures, pa­tient sat­is­fac­tion. The magic is in the units. But yet as lead­ers we need to be ac­count­able.

So, how might we cre­ate a sys­tem that con­nects all th­ese en­ti­ties? And the way we’ve been mod­el­ing that is this con­cept of a frac­tal. So think about a frac­tal like a fern in which ev­ery unit is con­nected to ev­ery other unit both ver­ti­cally and hor­i­zon­tally, and at ev­ery one of those lev­els there’s an in­fra­struc­ture where there’s peo­ple with skills, with ac­count­abil­ity and with train­ing to im­prove qual­ity. And that’s what we’re go­ing to need to con­nect with if we’re go­ing to cre­ate this cul­ture be­cause it’s not enough to say we have a leader who gets a cul­ture.

Dr. Gary Ka­plan: As many of you know, we have been re­ally en­gaged in more than a decade of what I would call—and what has been al­luded to al­ready this morn­ing—as large-scale change. That’s re­ally been what this has been about and build­ing on a strong cul­ture but re­ally help­ing that cul­ture to evolve in a way that is not only sup­port­ive but re­ally crav­ing con­tin­u­ous im­prove­ment. And I think that’s re­ally what’s been most re­mark­able about this

work over the past decade is build­ing a cul­ture where ev­ery­one thinks of when they come to work hav­ing two jobs, do their job and im­prove their job.

It re­ally started with work that was led by our board of di­rec­tors back in 2000, 2001. One of the key steps in that jour­ney was our board’s ques­tion to all of us, the se­nior lead­er­ship, “Who’s your cus­tomer?”

Like ev­ery­body in health­care, we said the pa­tient. But as it turned out, the board didn’t let us off the hook with that and ba­si­cally said, well, if that were true, why do things look the way they do with sys­tems de­signed around the doc­tors and the nurses and the man­agers and all of the staff rather than the pa­tients?

So we got very clear about who our cus­tomer is. We crafted a vi­sion that sounds like ap­ple pie and mother­hood but re­ally was all about be­com­ing the qual­ity leader in re­ally a bet- the- farm strat­egy around qual­ity. And the ini­tial plan had no man­age­ment sys­tem. And as some of you know, we went look­ing for a man­age­ment sys­tem in health­care and didn’t find one that we felt would al­low us to re­ally trans­form the cul­ture and move things for­ward, and that’s when many years ago now, al­most 13 years ago, we heard what Boe­ing was do­ing and be­gan the process

“It’s re­ally key for us to re­al­ize what we mean when we say ‘cul­ture,’ be­cause we act as if the or­ga­ni­za­tions are one beast with one cul­ture, but the re­al­ity is when you peel an onion of an or­ga­ni­za­tion, the cul­ture varies about six- to eight­fold more on ev­ery unit in that or­ga­ni­za­tion or clinic than it does in the or­ga­ni­za­tion.”

—Dr. Peter Pronovost, Arm­strong In­sti­tute for Pa­tient Safety and Qual­ity at Johns Hop­kins

of adopt­ing what we call the Vir­ginia Ma­son Pro­duc­tion Sys­tem as our man­age­ment sys­tem.

What we’ve learned is that when you elim­i­nate waste in non-value-added variation, qual­ity gets bet­ter and cost goes down. And like­wise, you can do a great pro­ce­dure with a great out­come and de­light your pa­tients and their fam­i­lies with great ser­vice. You can ac­tu­ally do it ef­fi­ciently with no waste.

But if the pa­tient didn’t need it to be­gin with, there re­ally is no qual­ity. And so, ap­pro­pri­ate­ness is now deeply em­bed­ded in our work­ing def­i­ni­tion of qual­ity here at Vir­ginia Ma­son and has be­come very much part of our cul­ture.

The peo­ple clos­est to the work are the ones that re­designed the work in the Vir­ginia Ma­son Pro­duc­tion Sys­tem, and so it en­gen­ders a very high level of staff en­gage­ment, staff part­ner­ship, and I think ev­ery­one re­al­ized it’s a very suc­cess­ful eco­nomic ap­proach.

The re­sults have been very grat­i­fy­ing. Our pa­tient sat­is­fac­tion re­sults con­tinue to climb both in our hos­pi­tal and in our clinic set­tings around western Wash­ing­ton, and you can see the dra­matic trend in our hos­pi­tal im­prove­ment and pa­tient sat­is­fac­tion.

McKin­ney

Sel­berg

Pronovost

Ka­plan

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