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WCBF 10th AnnualLean Six Sigma and Process
Improvement in Healthcare Summit
Culture of LeanThe Journey at
Massachusetts General Hospital
Mary O. CramerProcess Improvement Program Director
May 11, 2011
2
Objectives
Describe the Masschusetts General Hospital & Physicians’ Organization Process Improvement Deployment JourneyWithin a Highly Traditional, Firmly Entrenched Culture
Discuss the Critical Success Factors
Describe the Vision - What’s Next?
3
• Establish a Sense of Urgency
• Build the Guiding Team
• Create the Right Vision
• Communicate for Buy-in
• Empower Action Throughout – Encourage Risk-Taking
• Plan for and Create Short-term Wins
• Reinvigorate the Process with New Projects
• Sustain the Changes
Source: Kotter, John P., “Winning at Change” Leader to Leader 10 (Fall 1998)
Kotter’s Eight Critical Stages of Successful Change Management
4
Why is Change so Hard?
• Lack of Shared Vision
• Misaligned Expectations
• Lack of Urgency
• Lack of Commitment
• Culture
• Culture
• Culture
Source: Conner, Darryl R., Managing at the Speed of Change, 1992, 2006
5
What is Culture?
What is Culture; Is it Real?
One Definition:
“Culture in a work organization is the sum of peoples’ deeply ingrained habits related to what they do andhow they do it. It’s the way we do things here.”
Question:
Should an organization’s culture be among the considerations in Process Improvement program design and execution?
Source: Mann, David, Creating a Lean Culture, 2005
6
Culture Matters
You bet!
Massachusetts General Hospital Background
8
MGH Overview
• Founded in 1811, third oldest general hospital in the US• Original and largest teaching hospital of Harvard Medical School• Largest hospital based research program in US – annual research
budget: $550 million• Consistently ranked among top five hospitals in the US News &
World Report• Founding Member: Partners HealthCare – Integrated Healthcare
System
Some Operating Statistics:• 900 Inpatient Beds• 47,000 Inpatient Admissions• 1.5 Million Outpatient Visits• 83,000 ED Visits• 22,000 Employees• 4,000 Physicians
9
Humble Beginnings: Ernest Codman’s End Results Guarantee 1915
10
MGH Quality and Safety Program Recent Evolution
2000: Established Board of Trustees Quality Committee. Launched combined MGH & MGPO Clinical Performance Management program
2003 – Hospital Strategic Planning exercise identifies Quality and Safety as one of 5 institutional priorities. Plan developed
2004-2006 – Execution of plan, focusing on culture
Electronic incident reportingSafety culture surveysBoard presentations focused on the 6 IOM Aims
2005-2006 – Leadership RetreatsNovember 2005 PO Board retreatOctober and December 2006 Harvard Business School retreats
2006 – Proposal to Accelerate Progress
Creation of new leadership position
2007 – Center for Quality and Safety Established
2008 – Process Improvement Program Established
Historically committed to quality improvement at MGH using traditional tools including quality assessment, incident reporting, etc..
11
What Do We Mean By Quality? IOM 6 AimsSafety - no needless death, injury, pain or suffering for patients or staff
Timeliness - waste no one’s time
Effectiveness - care and service will be based on best evidence, informed by patient values and preferences
Efficiency - remove all unnecessary processes or steps in processes; streamline all activities
Equity - all care and service will be fair and equitable – the system will treat all patients equally
Patient Centeredness - all care and service will honor individual patients – their values, choices, culture, social context and specific needs Source: Institute of Medicine
12
Analysis of problem
Conceptual Framework
Performance reporting
Operations design
Executive oversight
Organizational strategy
Performance Measurement
(Signal detection)
Short term implementation
Executive incentives
Practitioner influence and
incentives
Longer term implementation
Research enterprise
Regular Operations
Improvement Efforts
Process Improvement
Design
ImprovementCycle
Operations Cycle
MGH/MGPO Culture
13
Analysis of problem
Vision - the Big Ask
Performance reporting
Operations design
Executive oversight
Organizational strategy
Performance Measurement
(Signal detection)
Short term implementation
Executive incentives
Practitioner influence and
incentives
Longer term implementation
Research enterprise
Regular Operations
Improvement Efforts
Process Improvement
Design
ImprovementCycle
Operations Cycle
MGH/MGPO Culture
Doing Your Job
Improving Your Job
14
MGH Center for Quality and Safety Organization Chart ~2008
15
The MGH Process Improvement Program Deployment Journey
16
Massachusetts General Hospital will lead the nation in
health care quality and safety.
Process Improvement is one important component of the plan to accomplish this goal and will
become part of the way business is done at the MGH and MGPO.
Vision
17
Fasten Your Seatbelt!
18
Process Improvement Framework
ServiceService
Quality &Quality & SafetySafety
EfficiencyEfficiency
PROCESS IMPROVEMENTPROCESS IMPROVEMENT
Program Director:Program Director: Mary Cramer
19
Time
Suc
cess
ToolsTools
- Training- Modeling
Systems & StructuresSystems & Structures
- Org. Structure- Business Strategy
Culture & BehaviorCulture & Behavior
- Engagement- Continuous Improvement
- Sustain
Key Program Elements
Where We Started
Source: GE Healthcare
2020
Mobilizing Commitment
Why bother?Need sufficient support and involvement from key stakeholdersMust win-over critical mass
Tactics:Identify and analyze sources of support and resistance• Early Adopters• Late Adopters • Resistors
Develop Strategies for:• Encouraging Support • Overcoming Resistance
21
Initial Model
At the Outset:
Building upon rich project management experience throughout Massachusetts General Hospital, developed full time Process Improvement Project Facilitators with competency to lead Process Improvement projects through training and application.
Curriculum:
Lean Tools and Concepts Change Acceleration Process©
Work-Out©
Project Design, Project Execution and Follow-up
22
• Process Improvement Champions Group comprised of Senior
Leadership served as a Steering Committee charged with general
program oversight including prioritizing projects, championing and
supporting project teams as needed, overseeing project outcomes
and assuring that adequate and appropriate resources are allocated.
• Process Improvement Working Group comprised of directors of
operational areas providing project management support charged with
assuring effective design and implementation of the MGH/MGPO
Process Improvement Program including: project selection criteria,
project design, project management oversight, training plans, results
warehousing, communication, and recognition activities
Program Governance
23
Comprehensive Training Curriculum
• Change Managementshaping a vision, mobilizing commitment, designing, implementing and sustaining change
• Value Stream Mappingend to end process diagram including process steps, interdependencies, information flow etc.
• Lean Tools & Techniques
• Project Workshop Design and Executionone day & four day formats
24
40+ individuals selected from across the MGH and MGPO
Admitting Administration
Cardiac Services Center for Quality & Safety
Emergency Department Finance
Human Resources Infusion Center
MGPO Patient Care Services
Perioperative Services Police and Security
Practice Improvement Professional Billing Office
Radiation Oncology Research
At the Outset: Identified the Best and the Brightest
GE Healthcare engaged as Process Improvement skills transfer partner.
25
Other Leadership Training
MGH/MGPO Leadership:Process Improvement Champions, Process Improvement Work Group, Senior Leaders, GEC/Clinical Chiefs, Patient Care Assessment Chairs, Others
• Process Improvement for Leaders • Engagement Overview & Process Improvement
Program Roadmap
26
Other Ongoing Training
• MGH Leadership AcademyProcess Improvement PrimerProcess Improvement Practicum
• Patient Care Services Leadership DevelopmentOptimizing Core Processes
• Physician Leadership Development Process Improvement Capstone Course
• Practice Improvement CourseProcess Improvement Practicum
• Clinical Process Improvement ProgramProcess Improvement Course
27
Learning Objectives
• Process Improvement Overview
• Project Selection
• Project Scoping
• Create and Facilitate a Team
• Manage the Change Process
• Conduct Root Cause Analyses
• Pilot Improvements
• Measure Outcomes
• Fully Implement and Sustain Improvements
~250 Employees~ 35 Discrete Depts
~ > 50 Projects
28
Initially
Proof of Concept Awareness
Point Projects … driving project specific results & awareness
Dept Process
Dept ProcessDept Process
Project WorkshopProject Workshop
Project Workshop
Project Workshop
Dept Process
Project Workshop
Project Workshop
Dept ProcessDept Process
Project
Workshop
Project
Workshop
29
Process Improvement Projects - Results
EP INPATIENT READINESS
0
0.5
1
1.5
2
2.5
# Patient Delays
Tim
e (
Days p
er
week)
Before
After
CARDIAC CATH LAB Patient Readiness
0%
10%
20%
30%
40%
50%
% Patients Completely Ready
Before
After
CHELSEA HEALTH CENTERUse of Outside Interpreter
0
200
400
600
800
1000
# of minutes per month # of calls per month
Before
After
CANCER CENTERFront End Check-in Process
0%10%20%30%40%50%60%70%
RRC Express PhoneRate
Co-pay Collection Rate
Before
After
30
LEAP OUTPATIENT PSYCH
0
1
2
3
4
5
6
7
Cycle Time to Renew Meds
Tim
e (h
ours
)
Before
After
MEDICAL WALK IN CLINIC Informed Wait Time
0%
20%
40%
60%
80%
100%
Pre and Post % of Patient Negative Comments
Before
After
PAYROLL PROCESS
02468
10121416
# Manual Checks Issued
Before
After
PALLIATIVE CARE
0
100
200
300
400
500
600
Minutes Spent Meeting per Day
Tim
e (m
inu
tes
per
day
)Before
After
Process Improvement Projects - Results
31
PBO PAPER CHARGE PROCESS
0
1
2
3
4
5
6
# Days from Claim Receipt to ChargeEntry
Tim
e (D
ays)
Before
After
SDSU PREOP PROCESS
0%10%20%30%40%50%60%70%80%
% First Cases Ready for Transport by 6:45am
Before
After
USA WORKFLOW
0
10
20
30
40
50
60
70
# Mins to Obtain Cleaning Supplies
Tim
e (
min
ute
s)
Before
After
Process Improvement Projects - Results
32
Process Improvement Projects - Results
33
Observations:
• We all have a lot of information to share, we just don’t share it
• We’ve been hearing about these problems for years; we’ve needed a common way of problem solving
• When we’re all together, we can build on each other’s ideas
• Previously we’ve attacked this by working in our silos; now we’ve put our heads together to solve the problems
• We’re all part of the solution
• Regardless of role and level, everyone’s voice counts
Process Improvement Projects - Results
34
Now What?
Let’s Ride the Wave
35
Moving Forward
36
Using Strategic Planning as the Context
Overall Direction and Goals of an Organization Developed as Informed by Effective Strategic Planning
One Common approach:
• Establish Mission/Vision/Values • Conduct Environmental Scan• Complete Internal Assessment – Perhaps SWOT
Analysis• Establish Goals• Develop Strategies, Objectives, Responsibilities &
Timelines
37
What’s Next for the Process Improvement Program?The Process Improvement program is now at the next level
Key Attributes:
Program Focus; Alignment with Strategic Priorities
Robust Senior Level Oversight Body
Active Senior Level Sponsorship
Key: Alignment with Organization’s Strategic Priorities
38
One Compelling Priority: The Patient Protection and Affordable Care Act
39
And Most Importantly, the IOM 6 Aims:Safety - no needless death, injury, pain or suffering for patients or staff
Timeliness - waste no one’s time
Effectiveness - care and service will be based on best evidence, informed by patient values and preferences
Efficiency - remove all unnecessary processes or steps in processes; streamline all activities
Equity - all care and service will be fair and equitable – the system will treat all patients equally
Patient Centeredness - all care and service will honor individual patients – their values, choices, culture, social context and specific needs Source: Institute of Medicine
40
Current Process Improvement Focus Areas
Strategic Initiatives End–to-End Focus
#1 # 2 #3 #4 #5 #6 #7 #8
Patient Affordability
#1 # 2 #3 #4 #5 #6 #7 #8
Care Redesign
End-to-End Process Emphasis
Driving Improvements Deeply Within Select Areas of Focus
41
Process Improvement Program Timeline – The Work Continues
2008 2009 2010 2011
PlanningPlanning
Wave I Wave I Recruitment & TrainingRecruitment & Training
Coached Coached ProjectsProjects
Wave II Wave II TrainingTraining
Coached Coached ProjectsProjects
Centralized
Staff Deployment
Program Development, Training & Ad Hoc Project SupportProgram Development, Training & Ad Hoc Project Support
42
Suc
cess
ToolsTools
- Training- Modeling
Systems & StructuresSystems & Structures
- Org. Structure- Business Strategy
Culture & BehaviorCulture & Behavior
- Full Engagement- Sustained Outcomes
- Continuous Improvement
Process Improvement Program Trajectory
Where We’re Where We’re HeadedHeaded
Where We Started
2008 2009 2010 2011+
Where We Are
Source: GE Healthcare
43
Critical Success Factors
Within the Context of Strategic Planning Activities and
Consistent with the Culture of the Enterprise:
• Actively Engaged Executive Sponsorship
• Compelling, Well Understood Organizational Priorities – Aligned with Organization’s Strategic Vision
• Highly trained, Capable Process Improvement Practitioners
• Fully Engaged Workforce
44
Lessons Learned
First, Critically Assess the Organizational Culture.
Next, Leveraging the Infrastructure Already in Place:
Build a Program Which Will Resonate Within that Culture and
Which is Designed to Enable the Organization to Advance Strategic Priorities
4545
“It must be considered that there is
nothing more difficult to carry out, nor
more dangerous to conduct, nor more
doubtful in its success, than an attempt
to introduce innovations.
For the leader in the introduction of
changes will have for his enemies all
those who are well off under the
existing order of things, and only
lukewarm supporters in those who
might be better off under the new.”
“It must be considered that there is
nothing more difficult to carry out, nor
more dangerous to conduct, nor more
doubtful in its success, than an attempt
to introduce innovations.
For the leader in the introduction of
changes will have for his enemies all
those who are well off under the
existing order of things, and only
lukewarm supporters in those who
might be better off under the new.” Niccolo Machiavelli
1469 – 1527“The Prince and The Discourses”
1513, Ch. 6
Niccolo Machiavelli1469 – 1527
“The Prince and The Discourses” 1513, Ch. 6
It’s not Surprising -
46
Thank You
Questions?