Implementing Process Improvement by Focusing on Culture

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Why do many organizations spend a great deal of time and resources on process improvement but many fail to sustain those results over time? The answer is that these organizations put a great deal of focus on method and tools but not on changing the culture in which those tools are being implemented.

Why is culture important? Culture, which involves thought and behavior at a workplace, is no more likely a target than the air we breathe, and it is not something we target to change. Culture is an idea arising from experience — that is, our idea of the culture of an organization is a result of what we experience there. In this way a company’s culture is a result of its management system. Culture is critical, and to change it you have to change your management system.

At Virginia Mason we have found that a focus on both culture and adopting lean production as a way to manage all aspects of the business are the keys to the long-term reliability and sustainability of process improvement. Instead of adopting lean for project or process improvement, we adopted it as the way we do our work across all work units, engaging all staff through our management system.

How world-class management drives culture change

As part of our management system, we have adopted the concept of world-class management, which defines a systematic approach to a) policy development and deployment, b) cross-functional management and c) daily management. All three aspects of world-class management drive the culture change — the way of thinking and doing. We often summarize this as “top down and bottom up.” The senior team is accountable for setting the direction for focus, allocating resources in the pursuit of those areas of focus, and then checking and reviewing to ensure all areas of the organization are making progress on those areas.

Using cross-functional management, the team works to break down the silos between different parts of the organization. In the areas they focus on, such as the orthopedic model line, they focus the improvement on how the patient experiences care from the time of the first call to when the bill for services is paid.

Finally, and most exciting, is how the team engages staff in daily management, which is a focused approach to engage those who do the work to improve the work. In a lean management system, line supervisors are expected to run their business and improve their business, which means applying the lean production method and tools to the work. This means the supervisors frame problems and then coach staff to come up with ideas to fix these problems. They also conduct daily huddles with all staff to discuss the business of the day and engage the team in ideas for improvement.

“As someone who has led quality process improvement for the past thirty years — and lean management for 15 years — the tipping point of our culture change came when we implemented the world-class management approach. Today, employees are knowledgeable about the method and tools, regardless of their position in the organization, and they apply this method to their everyday work.”

– Cathie Furman

How world-class management influenced culture and enabled us to decrease CAUTI rates

In an example of management by policy, the organization declared as one of its 2014 organizational goals the elimination of health care-associated infections and specifically targeted eliminating catheter-acquired urinary tract infections (CAUTIs). Virginia Mason allocated resources to provide project coordination and created an executive-led cross-functional guiding team — composed of members from the medical group, the hospital and corporate — that was accountable for implementation. Support came from information systems, quality measurement and infection control. In another example of management by policy, monthly reports were expected to be sent to both the board and the senior team describing progress with explicit metrics, enabling the senior team to ensure accountability and remove barriers.

The guiding team provided the cross-functional management to ensure that all aspects of the improvement were supported and coordinated across the continuum. The medical clinics focused on hand hygiene and the use of personal protection equipment in general, and the surgical areas worked with anesthesia and inpatient nursing to create standards on when a Foley catheter is appropriate. In the hospital, the team found many examples of catheters being placed because of tradition, rather than appropriateness — and soon the culture changed as surgeons, nurses and anesthesiologists started working together to improve the processes. To help both the medical clinics and the hospital, the corporate areas produced the data on use rates and compliance with hand hygiene and personal protective equipment.

Using daily management, nursing units at the daily huddle discussed how many patients on the floor had indwelling catheters, kept track of CAUTI rates, and raised concerns that the team decided how to address. Each unit’s manager was held accountable for reducing the rates of infection, and there was even some friendly competition between the nursing units to see which unit had the lowest rates. Every nurse who had a patient with an indwelling catheter felt accountable and empowered to get the Foley catheter discontinued.

With every successful report showcasing fewer and fewer CAUTI infections, the nurses were encouraged, celebrated and recognized by their teams, the surgeons and the unit supervisors.

The connection of leadership to culture

As someone who has led quality process improvement for the past thirty years — and lean management for 15 years — the tipping point of our culture change came when we implemented the world-class management approach. Today, employees are knowledgeable about the method and tools, regardless of their position in the organization, and they apply this method to their everyday work. The leader is no longer responsible for solving the problem but now frames the problem and coaches the individual team members as they use lean production methods and tools to make improvements.

Consider your organization’s current culture and process for engaging all staff and providers in the work. How would your style of leadership be changed if you framed problems instead of trying to solve them? Can you imagine a culture in which silos do not exist and the entire organization is focused on the same work?

Cathie Furman, RN, MHA, is an executive faculty member at Virginia Mason Institute. In her work in Seattle and worldwide, she helps health care executives and leaders understand how a lean method such as the Virginia Mason Production System can dramatically improve safety and quality. Prior to joining Virginia Mason Institute, Cathie was one of the executives who took Virginia Mason’s first trip to Japan to learn the benefits of using lean tools and a lean management system. After the trip, she and her executive colleagues led the initiative to adopt the Toyota Production System to health care. She also created and implemented the Patient Safety Alert SystemTM, a groundbreaking method to engage all employees to report any incident or situation that could cause harm to a patient. Cathie is certified in the Virginia Mason Production System®.

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