Promoting Safety: Creating the culture needed
to achieve system improvement
Gary Kaplan, M.D.
Cathie Furman, RN, MHA
International Forum on Quality and Safety in
Healthcare
April 24th, 2015
© 2015 Virginia Mason Institute
Learning Objectives
• Identify fundamental leadership methods and
structure to promote a culture of safety
• Design strategies to promote and enhance the
culture in your organization
• Explain how a culture of respect connects to the
delivery of patient-centered, safe, high-quality
care
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© 2015 Virginia Mason Institute
Virginia Mason Medical Center
•
•
•
•
•
Virginia Mason
• Integrated health care
system
• 501(c)3 not-for-profit
• 336-bed hospital
• Nine locations
• 500+ physicians
Integrated healthcare system
336 bed hospital
6,000 team members
Education & Research
Eight Regional Centers
• 5,500+ employees
• Graduate Medical Education
• Research Institute
• Foundation
• Virginia Mason Institute
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© 2015 Virginia Mason Institute
The Healthcare Culture Problem
•
Blame, denial, scapegoats
•
Hierarchical structure
•
Lack of trust, fear, victimization
•
Frustration, anger
•
Helplessness, hopelessness,
resignation
•
Apathy
Copyright © 2012 Virginia Mason Medical Center. All Rights Reserved.
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© 2015 Virginia Mason Medical Center
The VMMC Quality Equation
Q = A × (O + S)
W
Q: Quality
A: Appropriateness
O: Outcomes
S: Service
W: Waste
Copyright © 2012 Virginia Mason Medical Center. All Rights Reserved.
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© 2015 Virginia Mason Institute
Requirements for Transformation
Improvement Method
Applied to ALL Processes
Critical mass
feels urgency for
change
Executives address
technical AND
human dimensions
of change
Visible and committed
leadership
New compact
aligns expectations
with vision
Broad and deep
commitment to
shared vision
Copyright © 2012 Virginia Mason Medical Center. All Rights Reserved.
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Vision Is Context for Compact
• Societal needs
• Local market
• Competition
• Organization’s
strengths
STRATEGIC
VISION
Physicians give:
Organization gives:
• What the
organization
needs to achieve
the vision
• What helps
physicians meet
commitment
• What is
meaningful to
physicians
Copyright © 2012 Virginia Mason Medical Center. All Rights Reserved.
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Align Expectations
Physician
Compact
Leader
Compact
Board
Compact
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The Road to Transformation
Source: Gareth Morgan
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The Virginia Mason Production System
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
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Stopping the Line
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Patient Safety Alert Process 
• Leadership from the top
• “Drop and Run” commitment
• 24/7 policy, procedure, staffing
• Legal and reporting safeguards
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Patient Safety Alert
Goal: zero defects
Based on VMPS
Continuous Improvement
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Culture must support reporting
Weick and Sutcliffe “Managing the Unexpected”
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A Defining Moment
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© 2015 Virginia Mason Institute
Count of PSAs Reported per Month
All PSAs (Inpatient and Outpatient)
SOS
Process
#2
1200
1000
New
Leader
Orientation
800
Mistaking
Proofing
Sharing
of
Immediat
e PSAs
Safety
Briefings
Kaizen
Share
Point
Standard
of Care
Improvement
Kaizen
Respect
for
People
PSA
3P
Quick
Entry
Screen
Good
Catch
Award
Making
Safety
Local
SOS
Process
#1
Lab
PSA
Entry
Optimizing
Trending
Awareness
Kaizen
600
400
200
Jan-15
Nov-14
Sep-14
Jul-14
May-14
Mar-14
Jan-14
Nov-13
Sep-13
Jul-13
May-13
Mar-13
Jan-13
Nov-12
Sep-12
Jul-12
May-12
Mar-12
Jan-12
Nov-11
Sep-11
Jul-11
0
50,000th PSA Reported
September
September 2014
2013
October
2012
50,000th
July
2005
March
2008
February
2011
40,000th
30,000th
20,000th
1,000th
10,000th
End of February 2015: 54,921
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Assist, Celebrate & Recognize People
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Share the Lessons
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Why Culture is Important
First McClinton Award winner
“Mary provided the face to
all the statistics”
“How do I tell them? I don’t
”
even know what
happened
yet, what if they blame me?”
A provider
A surgeon recently had to use
Seattle Surgical for a procedure
and realized no other staff were
engaged in the time out
“I realized I can no longer
practice without the surgery
attestation we use at VM”
“You began with “I am sorry,”
“ I can’t tell you how important it
and after that, I could listen
was to stop the line - It was
because I knew you cared.”
amazing to see the resources
A family member
get pulled in to support us”
One of the involved team
members
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© 2015 Virginia Mason Institute
“Stopping the line”
Organization-wide Involvement
Number of PSAs Reported per
Month
1. Staff report issues
using the Patient Safety
Alert System
2. Leadership investigates
and resolves issues
3. Board Quality
Committee review/
approve closure of
high-severity issues
1000
900
800
700
600
500
400
300
200
100
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
0
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© 2015 Virginia Mason Institute
Effectiveness of Safety Program
12000
100
90
10082
86
10000
79
80
9277
78
70
70
67
8000
66
60
60
6196
6000
50
5386
40
4322
4000
3500
30
3079
2954
2726
2697
23
19
2000
16
20
10
0
0
'04-'05
'05-'06
'06-'07
'07-'08
'08-'09
PSAs Reported
(Excludes claims closed without payment.)
© 2015 Virginia Mason Institute
'09-'10
'10-'11
'11-12
'12-13
'13-14
Reported Claims
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Leaders Sustain the Rigor
Tuesday Stand
Up
Friday Report
Out
Standard Work
for Leaders
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© 2015 Virginia Mason Institute
Standard Work for Leaders
Virginia Mason Leaders Have Two Jobs
1. RUN their business
2. IMPROVE their business
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Change is Hard
“People change what they do less because they
are given analysis that shifts their thinking than
because they are shown a truth that influences
their feelings" John Kotter
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Leadership on Genba
“It’s just saline.”
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Respect for People
Patient Safety Curriculum
2010
2011
Mandatory
Service
Training
Respect for People
2013
2012
Mandatory
RFP Training
Lucian
Leape
Visit
Transformational
Leadership
2014
LEADERSHIP ROLE
AND
ACCOUNTABILITY
Integration of RFP
Change Management
TeamSTEPPS
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Defined as:
How we treat one
another as we work
together to create the
perfect
patient experience
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Top 10 Ways to Show Respect
Listen
to
understand
Share
Information
Speak Up
Walk in
their shoes
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Aligning Vision with Resources
Long Term Vision
Annual Goals
VMPS Priorities
Department Priorities
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It is a Journey
− Mrs. McClinton
− Adopted TPS
− Implemented PSA
system
− First culture of
safety survey
− Implemented First 5
year Strategic
Quality Plan
2002
2003
− Adoption IHI
100,000 lives
campaign
2004
− Established CME
course – EBM
− Created Must Do
Measures criteria,
information flow and
accountability
− First Top in region
Leapfrog survey
− HealthGrades
Distinguished
hospital award
− 2nd series of
Disclosure
workshops
− Revised PSA
database
− Just Culture
training
− 1st major
decrease in
central line
infections
− Falls ST PRA
2006
2005
− One goal
− First clinician
disclosure training
− Adopted mandatory
flu vaccine policy
− CPOE adopted
across the inpatient
setting
− Top Hospital of
the Decade
2008
2007
− Published peer
review article on
PSA system
− CDC
Immunization
Excellence
award
− QOC began
reviewing all red
PSAs
2010
2009
− Surgical time
out ST PRA
held
− SSI team
McClinton
Patient Safety
Award winner
2011
− First Worker
Safety Risk
Register
− First Good
Catch Award
− Respect for
People Training
− Standard of
Care Process
Kaizen
2012
− PSA 3P
− Completed first
Patient Safety
Risk Register
2013
− ACPOE
− 50,000th PSA
− 108 Patient
Family
Partners
2014
− Established
Synchronized
Ongoing Support
Process
− Achieved target
of 1000 PSAs
reported in one
month
− Began PSA
Pointers
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© 2015 Virginia Mason Institute
Strive for the Highest Satisfaction
Levels
Medical Center Overall
Satisfaction and Likelihood to
Recommend
Hospital Patient Overall
Satisfaction and Likelihood to
Recommend
100
100
91st
Percentile
95
90
30th
Percentile
22nd
Percentile
90
89th
Percentile
85
80
95
76th
Percentile
15th
Percentile
85
67th
Percentile
23rd
Percentile
80
75
75
70
70
2007
2008
2009
2010
Hospital Patient Satisfaction
2011
2012
2013
Likelihood to Recommend
2007
2008
2009
Clinic Patient Satisfaction
2010
2011
2012
2013
Likelihood to Recommend
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© 2015 Virginia Mason Institute
Maintain a Successful Economic Enterprise
$60.0
$55.0
$49.4
$50.0
$45.0
$40.9
$ (Millions)
$40.0
$38.0
$35.5
$35.0
Shared Success
Program
$30.0
$29.4
$25.6
$25.0
$22.5
$18.4
$20.0
$15.0
$12.0
$10.0
$5.0
$3.2
$0.7
$0.0
2000
© 2014 Virginia Mason Medical Center
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Safety Culture Question
Staff Speak Up Freely*
82%
81%
80%
80%
79%
78%
79%
79%
77%
78%
76%
76%
74%
74%
72%
70%
*Question: Staff will speak up freely if they see something that may
negatively affect patient safety – using the AHRQ rating method
© 2015 Virginia Mason Institute
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Lessons Learned
 Large scale organizational change
requires leadership, perseverance
and alignment
 Communication is not sufficient
 Accountability
 Reinforcement
 Training
 Focus on continuous improvement
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Questions?
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A lean journey is a learning journey.TM
© 2015 Virginia Mason Institute