Culture conscious

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 president 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 con nected 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 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.