organisational set up of the hospital sector of region of...

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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

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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

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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

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Transforming Healthcare and World Class Management

Aligning Strategy and Goals throughout the

Organization


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


Requirements for Transformation

Sense of Urgency

Visible & Committed Leadership

Aligned Expectations

OneManagement

System

Technical & Human

Dimensions of Change

Shared Vision

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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

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The Virginia Mason Quality Equation

Q:

A:

O:

S:

W:

Q = A × (O + S)WQuality

Appropriateness

Outcomes

Service

Waste

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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


Promoting Safety and Respect

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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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Healthcare Transformation

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Virginia Mason Production System Success



Leader Compact

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Physician Compact

Board Compact


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



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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


“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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One Management Method


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


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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“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


Management by Policy

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Aligning Vision from Board Room to Front Line


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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Cross-Functional Management

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Periop Flow

Clinic Experience

Inpatient Care

Follow Up Care

Orthopedic Value Stream


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


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


Elements of Daily Management

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Six Principal Elements


Visual Controls

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Patients Can See Status


Visual Controls

ED example: Hospital example:

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Visual Controls

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Responding to abnormalities


Example: Inpatient Orthopedics

Example: Health Information Services

Have daily huddles with your team

Daily Accountability

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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


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


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


Educating & Engaging 5,000+

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“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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Requirements for Transformation

Sense of Urgency



OneManagement

System

Technical & Human

Dimensions of Change

Shared Vision

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Elements of Effective Transformation

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Years 1-3 Foundation For Journey

A lean journey is a learning journey.TM


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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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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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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


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

15-04-2016

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’

15-04-2016

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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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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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4949


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

15-04-2016

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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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4


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

5252

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?”

15-04-2016

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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)

15-04-2016

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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 ?

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15-04-2016

Thanks for listening!

organisational set up of the hospital sector of region of...

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