Webinar | Building a Patient-Centered Culture Through Employee Engagement

Erica Cumbee


After the presentation of our live webinar, Erica Cumbee, MPA answered a few questions from participants:

When many organizations start their lean journey they are focused on the competency of the tools; being technically proficient in the value stream map, the standard work sheet, the percent load chart and so on. Just becoming proficient in the tools does not change the culture. I could train everyone listening to this webinar to be a master of the tools and your culture would not change. It is really the activities and behaviors of a lean leader that changes the culture. Go see. Ask why. And show respect.

For this question, let’s define the zero-sum bias as: the patient gains at the employee’s expense or loss. I think this really goes back to developing as a team the definition of what it means to be patient-centered. Ultimately, our patients’ experience relies on our employees’ experience. And the ideas that we generate for improvement should be coming from the frontline staff. At Virginia Mason, we would coach and mentor our frontline staff using the PDSA [plan-do-study-act] framework to test ideas for improving these systems. Part of this process is ensuring we are using objective metrics, such as lead time and walking distance, not gut feelings, to know whether or not the idea is failing. Again, these metrics should take into account what is the burden of work that is being placed on staff, so there is a win-win, not the perception of a win-loss.

We implemented our Patient Safety Alert System™ almost 15 years ago now, and over time we realized that the amount of reports we were receiving were stagnating and not reaching the levels we desired. What we really heard from our frontline teams is that we didn’t have the culture of respect that we thought we did. And this wasn’t the outright disrespect in terms of cursing or throwing things, this was really the passive disrespect such as rolling your eyes or walking away when someone is speaking. This led us to begin our “Respect for People” work. The goal was to create a culture of empowering staff to speak up.

First, I want to start by saying that employees are individuals, and it is important to ask your own employees what incentivizes them. What makes them passionate about their work? In our organization, we have systems to recognize our people on a daily basis, we have systems to grow and develop them, and we ensure that we are aligning our activities with our vision, mission and values. We are also consistently tying back how the work of the frontline staff connects and moves the organization forward on our vision and mission.

Doctors are people. They have preferences on how they would like to be engaged as well. So again, just ask. We are all health care workers, we all come in to do our best every single day, and it is really bad systems, not bad people, that get in the way.

Our huddle board is a version of the production board shown earlier in the webinar. It is different than the idea wall. Typically we would use a portion of our weekly PeopleLink huddle to request idea generation around various topics. We also use our daily production board to help alert us to abnormalities so that in the moment we can begin to problem solve using the PDSA framework.

Take a look through our knowledge base for multiple examples of engaging staff and implementing daily management in your organization.

In our organization we talk about standardization with the ability to individualize. So at a high level, the organization asks each department to have a process or way for the department to engage staff in daily improvement. It is then up to the leader of that department to co-design with their frontline staff what is the best process, based upon the business, for that department. One common framework used by every leader is PDSA.

In our organization, using the production board and making work visual was one way that we increased accountability. Accountability of not only other employees but accountability of self. Again, bad process, not bad people. People are coming in to do their best work. So using the production board has been one great way where employees have not only held themselves accountable, but also enabled them to see the business at a glance so they are able to level load and support other workers throughout the day.

I would first start by understanding the root cause of low engagement. Many times the cause of low engagement is no response to employee-raised concerns or no process to raise concerns in the first place.

The reason why Virginia Mason uses the term “waste reduction” is because waste is any non-value added task or activity from the perspective of the customer or the patient. If we were to just focus on cost, we may cut a value-added service to our patients.

Some of the tools I shared today, such as wordplay, illustrate simple ways that managers can engage their frontline staff around what patient-centered culture means for their teams, and what activities and behaviors that they want to demonstrate as we begin to engage and improve our processes.

I will start by saying that space is a premium in Seattle, where our medical center is located, so many times we are just trying to find any appropriate space where our team can huddle. For the most part, our production boards are in a staff-only space where they can see and use the board in their daily workflow.

Virginia Mason employees have told us time and time again they want to be engaged by their frontline leaders face-to-face. Many times when we ask for these surveys we send out an email multiple times. So what are some of the barriers that your staff are encountering to actually fill out the survey? Is it time? That is something as a leader that you could carve out and dedicate to them. Is it understanding the importance of why they need to fill out the survey? As a leader, again, that is something that you can do to connect the dots and help them understand, face-to-face.

Every new employee at Virginia Mason has a two hour onboarding session to learn the basics of the Virginia Mason Production System® (VMPS), our lean management methodology. Part of this training familiarizes them with not only the lean terms and tools, but also the “why” behind our journey. It’s very much about trying to get at the mind and the heart behind why we made this culture shift. In terms of sustainability, time and time again we tell our clients that if we could do something sooner in our transformation journey, it would have been daily management.

Currently we do use production boards across multiple sites; one example is an electronic board where the team would huddle via a conference line. This is just one example and I am sure your frontline staff have many great examples as to how they would like to solve that issue.

All of the leaders in our organization, supervisor and above, go through what we call VMPS for Leaders. This training empowers leaders with not only the lean tools, but the activities and behaviors of a lean leader; what is the change management process and how do you engage your staff in that process? I would also suggest taking the time to truly understand your employees. Why do they come into work every day? What is their sense of urgency? What are the rocks in their shoes? One board that you can see in many of our facilities is a simple white board with “Rocks in Your Shoes” written at the top. This white board is available for staff to walk by at any time and add the issues that are occurring. The frontline leader then rounds on that board and does some root-cause analysis with the team and begins to problem solve.

One method we use is called experience-based design (EBD). This method uses questionnaires, focus groups, interviews and direct experience observations to understand, in real time, our patient’s experience. We use these observations to then feed our daily improvement as well as our workshops. We also create metrics from these observations so as we are directing our improvement work we can understand if we are improving the experience for our patients and our staff. At Virginia Mason Institute, we deliver a course called Using Patient Experience to Drive Improvement where we train on the tools of EBD.

Some ways we engage leaders are through patient stories, sharing our story and sharing the “why” behind the change. We also share with them many of the process metrics that I shared with you earlier today to demonstrate how lean reduces the burden of work on staff and improves the patient experience.

We do have many examples of the production board. I encourage you to visit our knowledge base to view other examples and read articles around daily management. At Virginia Mason Institute, we can create a custom workshop for your organization to help you create a production board, as well as leader daily standard work.

I always approach employees with a curious mindset. What are the barriers they are encountering? Why don’t they want to engage? What is their past experience? Seek to understand and involve your employees in the conversation.

We use multiple process metrics as well as experience-based design to understand the experience. We also partner with The Advisory Board to help us understand the staff experience and Press Ganey for our patient satisfaction.

Yes, education and training tie in nicely with continuous improvement and understanding if the education we are producing creates the intended outcome.

First I would take the time to understand what your employees think a patient-centered culture is. Again, wordplay would be one activity you could use. As a leader, you could then reframe the conversation around what a patient-centered culture means for your organization and create a definition as a team.

One method we would use is the “see, feel, change” process. This creates an experience for that individual to understand the importance of change. One experience I can share with you from my past is that our department was considering moving to a new system. The old system took six to eight minutes to send a page to an employee and the new system took one to three minutes. In front of the employees, we tested both systems and then connected the dots around the importance of being able to serve our patients in a timely manner. Creating a “see, feel, change” experience is just one way that you can start to get staff to buy into the new change and understand the reason behind it.

There are many articles on our knowledge base around how respect is the foundation for creating a reliable patient-centered culture. One exercise that we do with many of our clients is to have them turn to each other and demonstrate respectful listening behaviors. We then give them a few seconds, and then ask them to switch to demonstrating disrespectful behaviors. At that point we look around the room and ask, “How many of you have demonstrated these behaviors to one another before?” This exercise serves as a foundation to beginning the conversation around respect and why it is so important to patient safety and staff morale.

Many times people need to feel with their heart the impact of the change. One way that you can do that is to bring higher management to Virginia Mason Institute. We offer an Executive Lean Leadership Retreat where we take executive teams on tours of our medical center to experience how lean impacts culture. Clients not only get a chance to engage with frontline staff, but we also outline for them the structure required to support culture change, and how it impacts the staff and patient experience.

This is a great opportunity to use the affinity diagram to understand why residents and medical students do not have the time.

Currently we have many ways to recognize employees in our organization. Recognition is one of the agenda items in our daily huddle, and we encourage anyone in the huddle to share a quick thanks for another employee. We also have an online applause system where you can send a more formal thank you note that is available for all leadership and staff to see and read.

Erica Cumbee, MPA, Transformation Sensei

Erica Cumbee, MPA, Transformation Sensei

Erica Cumbee, MPA, is a transformation sensei at Virginia Mason Institute. Erica trains clients from all over the world to effectively practice lean tools and methods, develops operational leadership emphasizing the importance of acting and thinking in a lean framework, and embeds lean management methodology into healthcare cultures. Erica is certified in the Virginia Mason Production System®, experience-based design (EBD), training within industry (TWI) and focus group leadership.

Erica Cumbee, MPA, is a transformation sensei at Virginia Mason Institute. Erica trains clients from all over the world to effectively practice lean tools and methods, develops operational leadership emphasizing the importance of acting and thinking in a lean framework, and embeds lean management methodology into healthcare cultures. Erica is certified in the Virginia Mason Production System®, experience-based design (EBD), training within industry (TWI) and focus group leadership.

Our team of lean healthcare experts can help you identify how to achieve a sustainable patient-centered culture.

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