Sniff the Cheese

Jim Hornell

March 1, 2013

Handwriting on the wall

• They keep moving the cheese

• Get ready for the cheese to move

• Smell the cheese often so you know if it is getting old

• Quicker you let go of old cheese,

the sooner you enjoy new cheese

• Move with the cheese

• Savor the adventure & enjoy the taste of new cheese

• They keep moving the cheese !

Leadership

The first role of a leader

is to define reality

Health Care is a massive business

Largest scientific enterprise in history of our species

Also an act of love/compassion/comfort for people we don’t know

Locally – 1500 employees; $155m+

Challenges in health care in the 21 st. century:

• Safe

• Sustainable

• Affordable

• High Quality

• Accountable

• Coordinated

• Linked

• Holistic

• Confident

“Medicine used to be simple, ineffective and relatively safe.

Now it is complex, effective, and potentially dangerous!”

Sir Cyril Chantler

Anatomy of Health Care Environment

• Most complex, difficult to manage org in the world

• Multiple practicing professionals and experts merged into a single organization

• Medical mystique

• Different cultural backgrounds & values [Gen Y]

• Divergent perspectives towards goals & objectives

• Sophisticated, expensive ever-changing technology

• Competition for limited resources in a service industry with an infinite capacity to consume

Anatomy Continued…

• Demand is random, unpredictable and often supply generated

• Increasingly turbulent external environment

• Increasing public expectations [quality, safety, availability, speed, outcome]

• Public misinformed about the factors that can have a significant impact on the health status of the population

• Criteria/indicators for measuring outcomes & results not well developed nor agreed upon

Sniff the cheese!

Search for markers.

BCHS - Surveys are Us! • Accreditation Canada:

– Worklife Pulse Report, Patient Safety Culture Report

• NRC Picker: – national, OHA/MOH Patient Satisfaction

• Metrics@Work: – Employee & Physician Engagement Survey

• Polarity Associates – strategic planning

• Survey Monkey – Transitions, Board

• Departmental – 100% departments with 40% response

• Feedback Pro – compliments & complaints tracked

• Social Media

General comments on surveys

• Draws attention & encourages dialogue • Takes emotions out • Hard to argue with yourself! • Sets a tone [beware the cynics – we have earned it!]

• Provides a platform for learning, reflection and action • Establishes a baseline • Planning tool [pre & post implementation of project (smoke free property):

feedback concerns, barriers upfront v. reactive]

• Guides through transition – helps OD speak to bosses

• Opportunity to adjust or be proactive • Technology [done at home]

Surveys - Barriers

• Staff concerns: – Confidentiality [shared links] – Brevity [little bites] – Curiosity [how to be used?] – Motivation [incentives]

• Fatigue – too many!

• Accountability [genuine – don’t ask my opinion if you are not going to use it]

• Accessibility : – Want paper – Access to hardware – On company’s dime

• Practicality [don’t get too fancy & not have resources/steam to interpret & act]

• Readiness – leaders rationalize results ; tough to take

Slide 13

Presentation by:

John Yardley, Ph.D., President, Metrics@Work

Brant Community Healthcare System

2011 Employee Survey Results

Senior Management Presentation

June 28th, 2011

Slide 14

BCHS Bullying Frequency

Supervisors, Managers, Senior

Management as Perpetrator Coworker as Perpetrator

Using this standard

14.0% nearly 1 in 7

is a victim of a

Bully Coworker

Using this standard

7.3% approx. 1 in 13

Is a victim of a

Bully Boss

1. “Once a week” and “daily” considered to be at a level where psychological health is

likely to become impaired (Leymann, 1990; Mikkelsen & Einarsen et. al., 2002)

2. At that level “bullying” from a Coworker is nearly three times as frequent (N=114

victims) compared to from a Person In Authority (N= 57 victims)

3. More opportunity (time and numbers) for Coworker, so not directly comparable

Mixed Messages

• High employee engagement,

• Enviable safety record

• Financially stable

• High quality care & providers, yet low % would recommend ???

• High wait times, complaints & loss of incentive$

• Top heavy

• Staff & provider frustration, bullying, haves & have nots

• Some broken and old processes, provider-centric, work arounds

Strategic Planning

• Significant consultations, environmental scans

• Turbulent and uncertain environment:

– LHIN

– MOH funding regime

– IPC

• Ear to the ground – high performing organizations

BCHS True North

BCHS…Your partner in lifetime health

Patient First

No adverse events No waiting 100% patient

satisfaction Leading practices

Great Place to Work

No injuries/harm Developing top talent Seeking better ways

together

Using Resources Wisely

Zero waste Innovation Data driven decisions

The Challenge

• The existing healthcare model is no longer sustainable – There is no more money

– Our patients are not satisfied

– Providers are frustrated

• So how can we deliver better quality outcomes and experiences for patients, as well as better experiences for staff, with fewer resources?

“Every system is perfectly designed to get the results it gets. If we want better outcomes, we must change something in the system. To do this we need to understand our systems”

…Don Berwick, IHI

“ Faced with the choice of changing one’s mind or proving that there is no need to do so; almost everyone gets busy on the proof ”

A leader’s job is to look into the future

& see the organization not as it is,

but as it should be!

Performance Excellence

at BCHS

Healthcare Benefits of Taking the Journey of Lean

• Less waste leads to better patient outcomes with shorter stays

• Decrease in incidents causing medical harm

• Focus changes from being about money (whose cost centre is this from?) to the patient experience (patient-first)

• For employees - a collaborative team focus, a no-blame culture and a spirit of improvement

The Toyota Lean Example

“Brilliant process management is our strategy.

We get brilliant results from average people managing brilliant processes.

We observe that our competitors often get average (or worse) results from brilliant

people managing broken processes.”

Underpinned with a management system that develops every employee into a problem

solver

5%

40%55%

Non Value Added

but Necessary:

Any work carried out, which is necessary under current conditions but not something the patient (funder) would willingly pay for. Transcription / dictation

Non Value Added:

Activities that the patient (funder) would not want to pay for if they knew they were happening. Searching for equipment / supplies, redrawing blood

PATIENTS FOCUS ON WHAT IS OF VALUE TO THEM!

Value Added:

Activities that the patient (funder) would be willing to pay for. Med administration, Tests performed, Test results

The Three Divisions of Work

What is a Value Stream? • Value Stream

– all the activities and actions (value added and non-value added, information and material) that are required to bring a patient through the essential requirements needed

Value Stream (labour, equipment, supplies, support services, facilities)

Value Stream Improvement

Operating Room Supply Chain Project

• Goal – Optimize the flow of materials that support the

Operating rooms while minimizing the inventory levels.

• Project Pillars – Improved Communication

– Improved Flow of Materials

– The Right Person Doing the Right Job

Value Stream Improvement

• Before • After

Value Stream Improvement

• Before • After

Errors – MDR & Stores

Returned Items to Stores

Nursing Dollars on Supplies

System Improvement

• Seeing the hospital as a collection of value streams, not departments

Changing our structure

to better reflect how patients receive care, how hospitals are funded,

and how leading organizations are operating.

Acute & Transitional Care CCU & C5, B6, B7 & B8, ISU / Rehab, CCIP

Episodic Care Mental Health, Emergency & Urgent Care, Outpatient Clinics

Planned Care Maternal Child & Surgical

Care Support DI, Pharmacy, Lab, Infection Control & Medical Device Reprocessing

Finance & Supply Support

AP/AR & General Finance, Contracts, Home O2, Purchasing,

Stores, Bio-Med, Environmental Services

and Nutrition Services

Knowledge & Information Support

Decision Support and IT

Patient Registration & Information, Flow, HIM & HIS

Facilities and Maintenance

People Development

HR, Payroll, Volunteers

Occ Health & Safety, Float Pool, & Scheduling

Quality, Risk & Professional Affairs

Strategy Deployment (Phase 1)

Community Engagement & Partnerships (Phase 1)

Acute & Transitional Care

Episodic & Outpatient Care

Planned Care

Care Support DI, Pharmacy, Lab, Infection Control & Medical Device Reprocessing

Finance & Supply Support

Knowledge & Information Support

People Development

Quality, Risk & Professional Affairs

DI

Lab, IP&C, MDR

Pharmacy

DI

IP&C, MDR

Lab

Pharmacy

Transitional Care

CCU & C5

B6, B7 & B8

ISU/Rehab

C5 CCU

B6 B7 B8

CCIP

RN, RPN, PSW, SW, DCP, OT/ PT, Unit Clerk, SLP, Dietician, RT, Pharmacist

Maternal Child

Surgical

B3 & B4

Pre-op, DS, PACU

OR B5

RN, RPN, PSW, SW, DCP, OT/ PT, Unit Clerk, SLP, Dietician, RT, Pharmacist

Outpatient Clinic

Mental Health

ER & Willett

Amb, WHC, Onc, Pulm

Mental Health

ER Urgent

Care/Willett

Dialysis, Diabetes, Ortho & OutPt

Therapy

RN, RPN, PSW, SW, DCP, OT/ PT, Unit Clerk, SLP, Dietician, RT, Pharmacist

Supplies Food

Services

Finance & Purchasing

ESA

Material Mgmt

Patient Info & Flow

Facilities & Maint.

Decision Support & IT

Maintenance

Occ. Health, Float &

Scheduling People Professional

Practice

Community Engagement & Partnerships (Phase 1)

Strategy Deployment (Phase 1)

Biomed/Stores

– Studied the change

– Able to express how I feel

– Clear change is necessary

– Comfort steps taken to create lasting, sustainable change

– Clear on the vision

– I know what I might lose

– How frequently should we meet

– “Jim would like your feedback, questions”

Value Streams Transition surveys Followed each group meeting

Focused questions based on “transitions”

• Leader readiness to operate in

new VS

• Supports needed for success

• Extent VS seen as assisting strategic directions

• What do we need to do, change to realize opportunities

• Best of past to carry forward

• Most important message you took away from Jim’s RIMs

Survey 1 Survey 2

Survey 1 Summary

• People know why we are making changes & why necessary

• Opportunity to build right structure • Need to deal with sense of loss • Need to be clearer about future state/vision • Need to be mindful of the details • Morale & workplace issues • Skepticism • List of questions Recommended next steps

Transition Survey #2 - Results

• How ready are leaders to operate in the new value stream organization?

– 45% not at all/a little

– 55% - somewhat/very

• What supports must be in place for leaders to be successful?

1. Clear role descriptions (92%)

2. Group Leadership discussions (76%)

3. Coaching between VSL and MVSL (76%)

4. Leadership development (62%)

5. Standardized work (60%)

The Win-Win-Win

• It is actually possible

• The theory and principles are tried and tested in many industries

• This all depends on people being willing to rise to this challenge – and convince their colleagues

• BCHS has a history of innovation and pioneering

General insights ... To date

• Build the platform to change by listening, seeking, learning

• Find balance between signalling early & often and pulling off the band-aid

• Some fear change and anticipation of change means loss of “good people” – but “good people” will want to work in the new way!

People are very open-minded about new

things…

As long as they’re exactly like the old ones!

In a time of drastic change

it is the learners who

inherit the future.

The learned usually find

themselves equipped to live in a

world that no longer exists. Eric Hoffer

I ain’t what I ought to be and I ain’t what I’m going to be

But I ain’t what I was!

jhornell@bchsys.org