Podcast | Bridge to Excellence with Three Rivers Hospital

Episode Transcript

Better Never Stops | Bridge to Excellence with Three Rivers Hospital

Brenda McLeod: Thank you for joining us for Better Never Stops, our podcast for healthcare leaders and everyone committed to transforming healthcare. We interview leaders from our clients and partners around the world, as well as leaders right here in Seattle who work to maintain a culture of continuous improvement at Virginia Mason Franciscan Health.

In each episode, we hope to explore a philosophy of “go see, ask why, and show respect.” My name is Brenda McLeod, and I'm the Associate Executive Director at Virginia Mason Institute. I'll be your host for this episode of Better Never Stops. Today, we are talking about continuous improvement at a rural hospital in Washington state.

Three Rivers Hospital is still relatively early in their journey to daily improvement, but they have already achieved some big wins and powerful transformation. Joining us on the podcast today, we have Jamie Boyer, Chief Operating Officer at Three Rivers Hospital, and German Meza, the Quality Director at Three Rivers, as well as Karen Gifford, Executive Partner at Virginia Mason Institute.

Thank you all for being here today.

Jamie Boyer: Thank you for having us, Brenda.

Karen Gifford: Thank you, Brenda.

German Meza: Thank you.

Brenda McLeod: Jamie, I would like to start with you. Can you tell us a little bit about Three Rivers Hospital and the community it serves?

Jamie Boyer: Sure, yes. I'd love to start there. So Three Rivers Hospital is a rural, or sometimes known as a frontier hospital.

We are a critical access hospital located in basically the center of Washington state. Geographically, we have the largest hospital district in Washington state, which encompasses about 2,500 square miles. Because we're so remote, we have lots of challenges with being remote and, folks getting to receive care.

So we definitely have some challenges when it comes to our location. But being a critical access hospital, it's very important to us to serve everyone that comes through our door. You know, it's important for us to serve the underserved as well as constituents in our district.

Critical access hospital, we are a 25-bed hospital.We have a clinic. We have an OR, actually two ORs. We have an emergency department, and we have an acute care wing. In our acute care wing, we also provide swing bed care, so that's kind of the long-term therapy care after surgery and illness. The staff around the hospital wear multiple hats.

We are oftentimes working on many different projects and initiatives at the same time, so it's very important for us to work together and communicate together as a team. We also have constraints when it comes to finances, of course. We are a small rural hospital. And with that being said, resources depend on the people using our hospital.

So if we don't have business coming in the door, then that definitely makes a big difference. And our goal is to keep the doors open for caring for our community for decades to come

Brenda McLeod: Excellent. So as you started exploring the possibility of a management system, what were some of the challenges that you were facing as a hospital that made you want to start that journey?

Jamie Boyer: So we actually, this started with our CEO, Scott Graham. He had a vision for our hospital and our culture, and that included looking at our culture. And he actually really had a passion for working with Virginia Mason Institute. So kinda going back, he and I, years in the past, we had done some work with Virginia Mason, and so we felt that that was a really great experience, and we wanted to really get that back, and have that at Three Rivers Hospital, and share that with the staff.

So, but as I'd mentioned earlier, resources are a concern for us, and we have constraints. But at the time, back in 2024, we did have some grant funds that we applied for and were granted. So we thought, "We're gonna use this money, and we're going to work to better ourselves, better our culture, and our quality improvement management."

So that was why we decided to go with Virginia Mason, was because we had experience with it. We knew the methods worked, and we felt that it would really transform our culture.

Brenda McLeod: I would like to introduce Germán. Germán, can you tell us a little bit about yourself and your role?

German Meza: Yes, definitely.

So I am the quality director at Three Rivers Hospital, and other than quality, I also manage risk management and compliance overall. As a small hospital, of course, we wear many hats, and among the many things that I do, I also serve as the security officer, and currently are mainly involved in our newly launched program for security.

Brenda McLeod: Karen, hello. Can you share a little bit about your role and, and what things looked like initially at Three Rivers from your perspective?

Karen Gifford: Sure. Thanks, Brenda. So I am executive partner at Virginia Mason Institute, and my role was partnering with Three Rivers in this transformation journey. I had the opportunity to spend some time firsthand at Three Rivers and engage with frontline team members, the executive leadership, and even board members.

And it was meeting with them in both team meetings, observations, as well as doing surveys so all team members of Three Rivers could have a voice in this process. And what I saw, as Jamie has spoken to, was across the team at Three Rivers was a real commitment to their value and mission at Three Rivers Hospital, and you observe this in each meeting that the team started.

It was repeated by every team member. There was a real strong culture in that. But where there were opportunities is all the leaders at Three Rivers have a strong desire of leadership, and they're put into their roles for this purpose. But like all leaders, sometimes we have to unlearn behaviors - we are doers.

We're problem solvers, and we have to kind of switch some of those behaviors. And there was an opportunity to engage more of their team members in being involved in those processes. And the team at Three Rivers had a strong desire to be doing that, and that's what I saw, that appetite to have a management system to support them, a common language that they could all be involved with, and that was the exciting that I saw that spark to begin this journey with them.

Brenda McLeod: So I know that Gemba walks have been a big part of your work, so let's talk about them. Can you explain a little bit about the Gemba walks and how those worked at Three Rivers?

Jamie Boyer: When we started our journey with Virginia Mason, we actually went over to Seattle, and we got to see some things in action.

So not only did we do classroom work over there with mentors, but we were able to go to Virginia Mason, to the actual site and watch how things are done. We watched Gemba walks. We watched workflow and processes. We watched huddles. So that was a really great experience for all of us that were involved, and there were 24 of us that went through that same experience, which was a three-day experience with Virginia Mason.

So that's where we learned how to do Gemba walks. But basically, it's where we... And it can be a leader, it can be line staff, it can be whoever wants to participate in it, but we go to the area where the work is being done, and we go there with big ears, big eyes, and small mouths. So we wanna hear from the people who are doing the work.

We wanna understand what the rocks in their shoes are. We wanna understand what their challenges are and also, on the flip side, what their wins are and what their ideas are. So that's where we started when we came back from our work at Virginia Mason, and that was really kinda where it kicked off for us.

Brenda McLeod: Germán, how about from your perspective. What was the impact of Gemba walks, especially even for the people that perhaps were not directly involved?

German Meza: I truly believe that they were very fundamental in driving the whole project or System because it ensures that those people that are not normally engaged with other departments actually see how their actions essentially cross over to other departments.

Initially we started seeing that we were independently making decisions without really paying attention or thinking in other departments. And so the Gemba Walks really opened up everything for everyone. It brought transparency, and it really pushed the team to start thinking about how I can make this work while also making it work for other departments and not create bottlenecks in the process.

Brenda McLeod: Karen, would you like to add anything?

Karen Gifford: So I think as Jamie and German have explained, I'll never forget as they were learning about Gemba Walks and the team would assign as leaders each other's areas to go and do Gemba Walks too.

So one of these executives was doing a Gemba Walk in the kitchen, and this was not their normal area of accountability. But one, when they went to the kitchen area to do their Gemba walk, one, the team was so excited to see a leader there that isn't their normal leader, and to show them the work that was happening in the area, and to have that leader at Three Rivers to, I think as Jamie said, the big eyes, big ears, little mouth, to be surprised of what was happening in this area that they had never stepped foot in.

Not that maybe they didn't want to, but didn't have the opportunity or didn't think to go in this area, and to really see respectfully what was happening. But also the burden that the team was struggling with: a stove that wasn't working, and for them to make that visible, and for the leader to hear that and show empathy and understanding.

I think that there's not enough words to say what that can mean to a frontline team member for that to happen. And then to share that to other leaders. And then German was saying, cross-functional leaders, when decisions are made in silos to other areas and that impact when you start understanding those connections with Gemba walks, the power between the people and the leaders, how that started cascading, so.

Jamie Boyer: An update was that Karen, and we should send you pictures of this, but we just replaced all the kitchen equipment, in the kitchen so they don't have to use their spatula to open the door anymore. They retired the spatula! But they were so happy to get new kitchen equipment that functioned.

And so the foundation actually helped support the purchase of that new equipment. But those things came forward because we did the Gemba walks, and we really heard, listened to them, and and helped them to solve the rocks in their shoes.

Brenda McLeod: Yeah. Or the spatula on the door. German, can you tell us a little bit about the name Bridge to Excellence? Where did that come from and, and what does it mean?

German Meza: Yes. So initially part of the idea was that we needed a name, to unify the program and drive through with everyone going the same direction. And so we turned it into a competition in our facility to essentially vote in names.

And at the end, the name that was picked was Bridge to Excellence, and it was one that was suggested by one of our PAs in the clinic, and it stuck with it. Everyone seems to like it. I think it really shows the purpose of the group and why we're doing this, and we are very proud to use it in our outreach materials.

We have pamphlets that we hand out to new employees and potential employees just so that they are aware of the work that we're doing and trying to do moving forward.

Brenda McLeod: So now I'd like to ask Jamie about some of the specific projects that, that you all have worked on. Let's start with the co-location work that you did.

Can you talk us through what was the rock and, and how did you address it?

Jamie Boyer: Yeah. So the rock was, Well, patient volumes actually was the rock. You know, we're trying to grow our clinic. We're trying to make room for more patient volumes, of course. And with that being said, you have to kind of make sure your schedule allows for that.

As we looked at our physical space, we realized, of course, after learning from Karen and, and the things that we've learned through Virginia Mason, that location really matters. I remember in classroom over in Seattle, we specifically learned how distance between people in a space definitely makes a difference in how quickly you can get things done, how patients can be cared for, how answers can be given things like that.

So we, in our clinic, we have kind of a long hallway, and so everybody was spread out, and they were doing their work. And it was all fine, but the providers were in their own office back in the back of the hallway. So they weren't close together, and they were often having to walk back and forth a lot and wait for responses from teams and things like that.

So that was one of the first things that we did coming back from Virginia Mason as far as a big improvement project was co-location in the clinic. It was really important that we had buy-in from the physicians and the providers and the nursing staff to start with because it was a big change for them.

When you're physically moving providers in the hallway next to their MAs or their nurses that, that can be a little bit you know, definitely different from what they were functioning in. So but we did have good buy-in from the providers. We had three of our providers actually go to Virginia Mason and participate in a three-day workshop.

So they came back with already that momentum that we needed to get started on this work. So we went ahead and we moved everybody close together side by side in the hallway, took them out of their offices, and they have been in co-location, in flow they call it for now gosh maybe not a year now, but it's been probably nine months or so.

And it's improved response time for patient care. The providers and the nurses are communicating better with each other. They have more satisfaction in their job, and the patients are getting better care. And one of our WIGs is providing the ideal patient experience. And so that's what we aim to do every time, and this helps us to do that in the clinic.

So that was the reason that we did that in the clinic.

Brenda McLeod: I actually wanna ask you a little bit about WIGs, and if you could explain what WIGs are.

Jamie Boyer: WIGs are wildly important goals. We talk about them frequently. So we have three of them. So it starts with bringing our best every day, and that's really where this culture change comes in handy because culturally, if we're bringing our best every day, we have a better chance of providing the ideal patient experience.

So bringing our best every day is at the top of our pyramid. And then we have providing the ideal patient experience, which then in turn should equate to operational breakeven, and therefore keeping our doors open to continue the care that we're providing for the community. So those are our WIGs.

We focus on them and they're meaningful to us.

Brenda McLeod: Great. Thank you. Let's move on to the ED charge capture project that you did.

Jamie Boyer: Yeah. So our next one is in the emergency department, and the rock that we see in there is that we have a pretty manual entry process for our charges. We have some challenges with our electronic medical record which means that we have to do manual entries in some of the areas, and things aren't as automated as, as they could be. So with the charge capture- We weren't capturing all the charges that we could have when the service was happening. So we had a staff member capturing all those charges in the background, but she was at times missing some because she didn't know that things were happening.

So we broke down that process. We got the nursing team involved, along with our charge capture person. And then they started just using the PDSA model to do some improvement changes and to try different ways to resolve the problem.

So our nurses were actually really key in making that successful. One nurse in particular led the charge in the emergency department and met with the other nurses and the staff members to help them to understand why it was important to make sure charges were entered, and also talk about the process because the process was broken.

They didn't have the tools necessary to make that process easy. And so that's one of the things we learned there, is we gotta make the work easy, otherwise it's not gonna be done consistently. So we knew we needed to change that process, and we had to give them tools that made it easier for them to enter charges.

So with the PDSA cycles, we went through a couple iterations of change, and we landed on one that worked for the group. And we have seen a significant improvement in charge capture since the beginning of that initiative. I think we went from two hundred manual entry items on average to like, fifty, I think? I don't have the graph in front of me, but it was a significant drop in manual charge entry. So that was a huge win for us. We're continuing to do that. We're monitoring it. With all of these things that we're doing, you have to monitor them.

You can't just leave them and not pay attention to them again 'cause we wanna make sure that we're holding people accountable and that we're helping to improve and, and have that continuous improvement. So that was how we improved the ED charge capture process.

Brenda McLeod: Let's go ahead and move on to the acute care clean utility room

Jamie Boyer: Yes, and this one is still in development too. So this one was a big deal. It doesn't really sound like a big deal, I think, when you see it on paper, but the rock in the shoe was that we have these utility areas where the nursing staff would go to every time a patient needed an item. It could be a care item or it could be even like a medication and things like that.

So they would go to this room to find that item. Well, oftentimes they couldn't find the item that they were looking for. They had to go search in other locations for it. They were potentially even out of stock with whatever that item was. So the problem, the rock, was just not finding the items they need for patient care in a timely manner.

So we decided to pull a team together, and we included central supply, we included the nursing staff, and we included others that were interested in the process and kind of wanted to be involved with brainstorming how to fix this. So we started with this one utility room actually, and we removed things from the cabinets and the cupboards.

We created par levels for each item. We have labels on each drawer, each cupboard that says what's in those items. And we are also making the cards that will remind you to order more stock once you've gotten low in a specific item. So now they can go to the room, they can find what they need, they know it's gonna be there, and they know that it'll be restocked when it's time to restock the item.

So that has improved the nurses' workflow tremendously, and we get to hear about it in our weekly meetings how things are going. So patient satisfaction, of course, is improved because people are able to get the items that they need, and the nurses aren't wasting time and movement and frustration.

Yeah, so those were three big things that we've been working on over the last several months

Brenda McLeod: I heard you talking about the reaction of patients and staff in those processes and that it was positively received and, and stuff, which ties nicely to one of your wildly important goals, so that's really good as well.

Can you, can you tell us around the, I guess, how you guys feel about generally this process? 'Cause oftentimes with you being a smaller hospital and Virginia Mason being in Seattle, can you talk to us about kinda your connection to “not just for big hospitals”?

Jamie Boyer: Yeah, and that was one of the concerns maybe heading into this program was will this work for us? But we quickly learned after just hearing from Karen and Abel that it doesn't matter the size of the hospital or business or home, you can do these things anywhere. They're tools, and they're a way of thinking through a problem or a rock in your shoe.

So we had to get to a place of understanding that which took a little bit of time because when we came back We had probably three or four different courses kind of happening not all at once, but they were kind of coming to us, and so we had to assign people to be in those classes.

And at first it was a bit overwhelming because people were learning a lot about the improvement program, and so there was a little bit of, I think, an overwhelming kind of feeling at first. But once we really started to see the improvements happen and the open communication that that brought forward, I think that's where also people just really started adopting this way of thinking, and we all started to come together and understand that we're here together, we're doing this improvement, these improvement efforts together.

And it doesn't matter if you're the CEO, the housekeeper, the receptionist, or the doctor. We're all in this together, all our goals are the same. The size doesn't matter. You can do this anywhere.

Brenda McLeod: Yeah. And I understand you were able to present this at a rural health conference. Can you tell us a little bit about that?

Jamie Boyer: Yes, we did. Germán and I presented at the Northwest Rural Health Conference in Spokane, Washington. He and I normally attend that conference as just spectators to the conference. We've never been presenters before. It was really exciting.

Nerve-wracking a bit, yes, but exciting to do that because we really feel this is important information to get out there, and I think that was what we wanted to share with the audience, was how this has worked for us. One of our board members actually encouraged us to present, and so I think word just got back to that organization, and they tapped on us to do it, and we did.

We had a really nice reception. We're really proud of ourselves for doing that, and proud to be able to tell the story of Three Rivers Hospital in that forum.

Brenda McLeod: Yeah. Congratulations on a successful presentation. So when you think back about this work, what are some of the big surprises that you or people in your organization had?

Jamie Boyer: I hate to admit it, but I feel like some of the biggest surprises are really how many rocks in shoes there were. I mean, every place you go there's... We have communication boards, which are just big Post-it papers on the wall. And so they're separated out into quadrants, and so you can visually see the rocks and the shoes.

Some are small, some are large. But every department that you would go into or area you'd go into, you would learn so much from them, and again, learn what's not going well. And, and that's not a bad thing, because we were there to help them to improve it, and connect them with people that could help them improvement.

Another, I guess, takeaway is that we, as the people that are doing the Gemba Walks or maybe the leaders, we weren't the ones solving the problems. As Karen would say, we're framing the problems, and then we get those people in the right place at the right time to help solve those problems.

So we really had to shift our way of thinking in that. So that was a little bit of a surprise. Germán, did you feel like there were some surprises?

German Meza: Yeah, I mean, other than the rocks in the shoes, I think the other aspect was the multiple workarounds that we were not aware of. And in addition to the fact that- It was invisible.

Like they were there, but people doing the job, it just became their normal daily routine and assumed that that was it. They didn't voice the issues, and so the Gemba walks really opened up the Pandora boxes of every department. And the fact that not... Well, different departments visited other departments. We were able to see departments with different eyes, different flows and really were able to pinpoint issues that had become a daily routine for that particular department.

So it really opened up the transparency and communication among departments.

Brenda McLeod: We know how powerful some of the early wins can be when embarking upon this journey. Can you tell us about an early win and what happened and the impact it had?

German Meza: I wanna say that it goes back to the Gemba walks.

I think just having administration being mingling and really being visible and really showing that they care for the work of the frontline people really opened people up and really trusted this program and, and really saw that we were legit in terms of trying to really wanting to know about their issues and willing to help solve them

Brenda McLeod: Karen, you actually come from operations at Virginia Mason.

You spent years and years right in the operations of Virginia Mason in an urban hospital. What was your big takeaway from going into the rural hospital setting?

Karen Gifford: One of the takeaways I took is the power of doing consistent daily huddles and making the work visible.

I think back about their engineering department, and every day, same time, the team would be all assembled. It wasn't anything fancy, doesn't have to be, but it was a daily huddle, lasted between five and seven minutes, but they always had their metrics, what was gonna happen this week, if there was gonna be shutdowns, if there was call-outs.

But everyone counted on those. And there was standard work, so if the leader maybe wasn't available to lead, someone else could step in and lead the huddle. And I think just the power of daily huddles in the departments and having that consistency, and a senior leader could go and observe and know what was going on I think was big because also then that promotes communication, not only in that department, but across departments as well.

And I think that just, again, builds that teamwork between the hospital to their ambulatory side, surgical side, so it's seen as one cohesive team, I think was a big win.

Brenda McLeod: Jamie or Germán, is there anything you wish you'd known before you, you dove into this journey?

German Meza: Not being afraid to just get started. There's never gonna be the perfect time to do things, and if you overthink it, you're never gonna get started.

And so it's just a matter of going for it and make it work.

Jamie Boyer: I guess that for me, I wish we would've done it sooner. I wish we would've known sooner. We've had such great momentum with the program that the hospital has benefited so much from it.

So I wish we would've known about it sooner and been able to have that opportunity. But that's about it. I think it's been just a really great experience.

Brenda McLeod: Is there anything else that any of you would like to make sure we talk about today?

Jamie Boyer: I would like to just say that you know, we meet every week.

We have a Bridge to Excellence meeting every week, and we have stayed consistent with that meeting since we started the program. And I think that that has been a key to keeping the momentum going. It's a safe place for people to come talk about what's not going right and connect people with people there.

The administrative team shows up to that meeting each week. We have a paper reduction initiative right now, which is led by our CEO, and he's really passionate about reducing paper. So we're just pulling together and just the synergy that's coming from the group is just still continuing to be something that I'm really proud of and proud to be a part of.

We are also out in the community and sharing what we've learned with the community. We used our parade last year for an example of that, and so that was really exciting. We got a trophy out of it. German did a wonderful job of making that happen, and we're right now getting ready to get into parade season, so we had to switch gears.

So we didn't have the same concept, but it was a little challenging because we really liked last year's. I think that those things have been really meaningful. And it just really, like I said, it's really transformed the way we do work.

German Meza: I think our Bridge to Excellence meetings have really funneled issues to specific meetings.

Like for example issues come up or rocks come up in, in meetings, and we identify it as a Bridge to Excellent issue, and it's like, it needs to go to Bridge to Excellent, and then we, we keep focus on, on what matters at that point, and leave it until that meeting to discuss further.

Jamie Boyer: And what's great about that meeting is that we have all different kinds of people in there.

So we've got Mike Oberg, who is a whiz at knowing how to get things out of the system and create graphics and things like that, and maps. And then we have the nursing department. So it's just this multidisciplinary room full of people that really can make a difference when things aren't going right.

We're right now talking about electronic order entry, which we have struggled with in the past, and so we've got a group of people working on that initiative. There's so many initiatives happening right now. Our next Gemba, we're gonna go to mammography because we know that there's some rocks and some shoes there.

And so anyways, it's just really spiraled into this... People wanna be a part of it, they wanna participate in it, and they wanna be on the list of, when are we gonna do a Gemba in your area, so that they can get some wins from it too.

Brenda McLeod: Karen, any, any final thoughts from you?

Karen Gifford: Well, I think as just both Jamie and German have demonstrated today, it starts with the leaders, and they really role modeled it there at Three Rivers and walked the talk.

And they supported the staff, they empowered the staff. And as Jamie said, they started with the small wins, and then it just cascaded and fed, and now the staff are empowered and know they can make the changes, and also know sometimes those changes don't work, and that's okay. It's about that failing forward, and they've made it that safe environment to learn, pivot, and try again.

And that has really reinvented that culture at Three Rivers in an even different, more powerful way there, and it's exciting, so... even greater, bigger things are gonna happen.

Brenda McLeod: So I think the biggest things I'm taking away from this conversation is really that senior leadership moving to that problem framing mindset and using the Gemba Walks in areas outside of their accountability to understand the work.

Both of these things empowered the people of Three Rivers and showed respect to the team to lead the change forward. How important it is for leaders to start to think about being problem framers instead of problem solvers. Reinforcing how people closest to the work know the work and can improve the work.

Also that importance of starting small, celebrating the wins as you go along, and how important that is just for the sake of the people that are a part of that process. And then really making those rocks in the shoes visible so that they can be addressed.

Thanks so much Jamie, German, and Karen for joining us on the podcast today.

Jamie Boyer: Thank you for having us. It was fun to share our story with you guys.

German Meza: Thank you.

Jamie Boyer: Thank you.

Brenda McLeod: Thank you for listening to Better Never Stops. You can stay up to date with our latest episodes by subscribing on Apple Podcasts, Spotify, or wherever you get your podcasts. You can also find us on social media or send us an email at info@virginiamasoninstitute.org.

Thanks again for listening, and remember, transforming healthcare is not just about pursuit of perfection, but a mindset that we can always do better, because better never stops.