Webinar | Leadership Through Crisis Interview Series – Gary Kaplan and Chris Backous
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In many ways it’s been similar to how we work every day, and that our work together to create perfect patient experiences is fast paced. The stress and the uncertainty and the change that comes with COVID-19 has been a great example of how a learning system and learning organization can function and thrive. I’ve not been able to travel and some of you may know that I’m periodically on the road, and in being here, being present, has had a lot of impact as we’ve gone forward. All of our leaders needing to be very present, very visible, has been critical. Perhaps we can talk more about that but it’s definitely been a change and I’ve gotten to see our team function under intense pressure somewhat out of their element at times because none of us have ever experienced a situation just like that which we’ve experienced with the coronavirus and all of the implications for day to day patient care, staff well-being, and anxieties coupled with fierce determination to do great things for our patients. It’s been a very interesting time to say the least.
There’s no question in our minds that while our management system, VMPS, engages the frontline, those closest to the work, being those who understand the work the best and have the most ideas and identify opportunities for improvement. Leadership is so important to setting the tone, setting the priorities, coaching, and being engaged on a daily basis. What I’ve come to see is how important that is for senior leaders as well. This is not something that we can just delegate to the next levels of management. People are watching us, the most senior leaders in the organization; how do we behave if we’re saying people should wear masks—are we wearing masks? What are the behaviors that we are demonstrating, and then being available because as I mentioned, none of us have really ever experienced anything like this. We’re all learning together and you can’t learn in a vacuum and you can’t kind of step out and then step back in. We’re all in this together. From the moment we set up our command center I have been very visible. That’s different than micromanaging. I have to let our team do their work, but I’ve been told by many of them they appreciate the fact that our senior leaders are so engaged and so visible and so present. It’s a real asset every day particularly during these challenging, and what for many are unsettling times. I’ve heard people speak about COVID-19 as daily sprints as part of a marathon, so it’s like every day we’re sprinting.
That’s a work in progress, it’s always working progress—how do we support our leaders, how do we surround our leaders with talent and support, how do we tolerate ambiguity, and how do we tolerate periodic failures? Because our leaders have to lead, particularly in this organization, the notion of innovation, the notion of we can always improve and always be better, and when you do that you have to take some risk. Tolerance for failure in a way that is focused on harnessing and leveraging the learnings from those failures helps create that climate. Resilience is critically important and that means that even in today’s fast-paced very intense environment we’ve got to carve out space for leaders to have their downtime. A great example is how we rotate our command center leadership so we have one of our most senior executives partnered with a physician leader on weekly intervals in the command center. We have three teams and they’re rotating so they have a week of very intense leadership response, leading all of the different dimensions of our COVID-19 activity, but simultaneously there are dyad command center leaders that are not on point for two out of three weeks. That allows them to get a lot of their routine work, so-called routine work, done, because we’re still taking care of patients who don’t have coded—we still have lots of ongoing opportunities for continued improvement and excellence in care delivery, and so those things are important. In addition, we’re working with our human resources department—we’ve created wellness and well-being programs through HR for both our physicians and our leaders. How do we create opportunities to let your hair down; you can get support at times—counseling, whatever it is that is required in any given point in time. There’s no escaping it—this is a time where those of us who have become senior leaders test our medal. This is where we test what we’re made of, but it’s not about the individual. Just like our management system, it’s not about individual heroics, or what we’ve called the capes looping in solving the problems. It’s about leaders as coaches, as facilitators of this important work, and even that notion helps create resilience and a bit more balance so that our leaders don’t feel like it’s all on them and if they as individuals can’t solve a problem then they’ve failed.
Because it’s our management system, and this is key to think of it as a management system, not as just an opportunity for a point improvement project, it’s all pervasive. I would say from the minute we saw our first COVID patient on February 28th through today where our command center is still functioning, VMPS has really been the cornerstone. It’s been the approach we’ve taken whether it was 5Sing all of the important data elements, understanding all of the intersecting value streams and applying cross-functional management, and very importantly daily management have been essential, but we see it play out in each of our work streams related to our COVID response—we have a common language. We work hard to put in place new processes that are defect and waste-free. We test them in rapid cycle improvements and we’ve done many kaizen events during the past three months as we’ve worked hard to meet the challenges that we’ve faced.
I think so. We can’t ignore the fundamentals, the blocking and tackling the foundational elements of VMPS and general management principles. But the fact that we have been at it for so long and have deeply embedded the management system, it’s just natural. That’s how we do our work and so it quickly fell into place. I think it allowed us to jump the learning curve in terms of how we are set up. Also the fact that we drill on our command center using our VMPS principles with constant PDSA approaches I think helped us very early on as the management system was the anchor of that work.
I would say that VMPS was instrumental in our supply chain management. Many have asked me, "How’d that just-in-time time supply chain process work for you guys?" and I would say that one of the things we’ve learned is that perhaps in certain critical PPE categories we might need to raise our par levels, or the amount of supply we keep on hand. Our just-in-time supply channel necessitated very close working relationships with our vendors and assumed a deep understanding of our supply chain at all levels, and that was important. Our supply chain leadership who live and breathe VMPS every single day were very well prepared and so they kicked immediately into gear. Their procurement skills were amazing and the ability to understand our suppliers, understand their challenges, the pressure they were under, and to partner, I think was very effective and to a great extent a result of the VMPS work that’s gone on over many years with our supply chain. All in all, I think it was a huge asset, and yeah, I’d raise our par levels a bit but it wouldn’t have changed a whole lot, because when you have a pandemic of this magnitude you’re going to need to increase your supply chain whether you have a just-in-time or a just-in-case approach to supply management.
It’s critical to have a single management system. There are thousands of organizations that are doing lean, and when you get under the hood what that often means is they’re working on a project; they did a project in the lab, they’re doing one in the OR, but it doesn’t hang together as a management system and it doesn’t manifest itself in daily management and daily work. Having a single system gives you a common language, a common approach. People who don’t work together very often have that very much in common and so when you bring together unusual interfacing service lines and with cross-functional management having a single approach was invaluable. I’m bullish on a single management method during normal times—during this pandemic experience I would say it was as critical as it’s ever been. And the alignment—very important so that when we would communicate in a certain way, people would understand their role in sharing that information in a communication cascade which is very much part of creating that alignment. It’s one of the things we’ve had to do often as part of this pandemic. I personally believe we cannot overcommunicate, meaning that more and more communication in new and different ways is essential to keeping everyone engaged as they need to be.
This notion of expanding our surge capacity, which was one of the requests of the state of Washington, being the first region in the country to stand up and to have COVID patients and to need to stand up the capacity. I think there was considerable concern we needed to create more surge capacity and quickly using kaizen, using the principles of 3P, and using innovation and idea harvesting techniques. Our team quickly went to work to convert one of our med-surge areas to new ICU beds and an isolation unit with reverse airflow and all the other requirements. This was an innovation—we hadn’t done this before. We hadn’t expanded ICU capacity by half and done so in a in a totally new location. I think VMPS really helped that to happen. Another example which really touched so many patients and their families, as we know during this pandemic we’ve had to be unusually restrictive on people coming into the hospital. This is one of those things that made many of us, many of our team members, very sad because we’d be caring for patients at the end of life, not just COVID patients but patients with other illnesses, other disease processes—and the norm at Virginia Mason is we’re very transparent, we’re very open, we want to create very special experiences even at some of the most saddest times in one’s personal life. Our nurses in particular, but all members of the care team, were really frustrated and disappointed at what they saw happening—they understood our visitation policies were working to protect our the community, to protect visitors, to protect staff and to protect patients and so we needed to set limits. Our nurses took it upon themselves to create an entirely new program or system where they would meet family members, they would serve as companions and educate those family members, they would screen them for any symptoms, fever other areas of concern, and then they would help them be prepared to actually don personal protective equipment, gowns, masks, gloves, goggles and face shields, things that you’d more typically see healthcare providers wearing, so that they could be with their loved ones. They became their personal companion. This was so touching and so remarkable and it was a series of kaizen events and a real innovation that was in the moment, spurred on by the creativity of our team members.
I thought you might at some point ask me what would I have done differently in the first few days, and the answer to that question is I would have stood up and accelerated telemedicine before we ever knew that COVID existed. Prior to COVID, over the last few years, we have felt good about where we were and where we were going in our remote visits. We were doing telestroke, we were looking at tele-ICU, we had very few but some service lines that were doing some televideo consultation, but once we realized that we were really going to it and our governor made a proclamation that basically eliminated non-urgent care, the interpretation of that was that meant non-urgent clinic visits, we said we have to have an alternative—we have to have an alternative because patients didn’t stop getting sick, patients didn’t stop needing us. Again, cross-functional management, the technology, the care delivery, ambulatory care, inpatient care, primary care, specialty care—everyone engaged and within a few days’ time we had all of our providers trained. We understood that and were able to access and functionally utilize the technology, we were getting paid for what we do through virtual video visits and began to do thousands of video visits every week. It was exciting and it continues today. Interestingly, this was a huge satisfier for our patients and they really were appreciative. That’s half the battle when you want your patients to really feel they’re getting what they need and learning that the ability to do that during these times remotely was working effectively. It was also satisfying for our clinicians. I know I did a video visit and seeing my patients at home, seeing their pets, seeing them in their kitchen, it made me think, “Why did we stop doing house calls?” because when you get to see your patients in their living context, in that situation, I think it makes you more empathic and I think it can make you a better clinician and at a minimum facilitate your ability to do your best for your patients.
What’s going to be important is that expression, "You need to be able to walk and chew gum at the same time." Whereas in those first few weeks, the first month or two of this pandemic, if I just think about my own energy, my own disk space in the brain, what we’re working on, it was kind of all COVID all the time, and the rest of our care delivery was more on autopilot. COVID is going to be with us for a long time, it’s going to be with us for many, many more months and perhaps longer where we’re going to need to be able to address COVID and be able to keep our patients safe, operate within appropriate CDC and infectious disease guidelines and policies, and be wide open for all of the things that people want and need to see us about. That’s going to be part of the challenge, and particularly it will fall on leaders, because we’re going to need to shift our focus from COVID all the time to sharing the priorities with other priorities that we want and need to be working on to serve our patients in our community. I think that’s going to be challenging at times. At Virginia Mason, we like to think that we’re doing this all the time but I think COVID has resulted in another quantum leap in unleashing the creativity and the ideas of everyone in the organization. Another expression, you can’t put the genie back in the bottle, and that’s now the norm and I think we’re going to have to take full advantage of it. While some leaders may say, “Okay, we’re done with that now let’s get on with the next thing or the next body of work,” I think we need to honor and respect and continue to nurture the ideas and creativity of our team members, and I think that’s never been more apparent and more critical than during COVID. Now, I think we’ve got to continue that work. That’s the real importance of not only engaged leaders but engaged staff at all levels.
I think it’s critical. It’s critical in normal times and even more critical given the fast pace that was required. You asked the question and my mind can go take this in a variety of different directions. I think it ties to the visibility and presence of leadership. I think when there’s high anxiety, whether it’s anxiety about redesigning work or anxiety about ensuring that you as an individual are safe at work and not carrying the virus home to the your family—having your leader front and center with you says a whole lot that sends that sends a huge message and is a huge source of support and helps to build resilience in the frontline team. It’s critically important. The other thing that’s happened that I’ve alluded to, the rapid pace of change during COVID and the leadership competence related to ambiguity. I had staff members say to me, "Dr. Kaplan, it seems like you’re speaking out of both sides of your mouth." I don’t like to hear that because I try to be consistent and try to be truthful and honest and transparent. I said "Well, what do you mean?" and they said, "Well, you told us one thing about this yesterday and now you’re telling us something totally different." My response to that was and still is, "You are right, and that’s because the environment today is different than it was yesterday, the CDC guidance today is different than it was yesterday, the PPE supply today is in a different state or a different status than it was yesterday," and so part of what we need to be about is embracing that ambiguity, realizing that things are moving fast and we need to adopt the adage that I’m proud of which is, "I reserve the right to be smarter today than I was yesterday," or "I reserve the right to be smarter tomorrow than I am today." If we are all trying to learn and improve and get better, tomorrow’s going to look a little different than it does today. I think having your leader front and center on the genba, whether it’s the senior leaders messaging and visible and present or even more importantly your local leader helping to interpret, helping to translate, helping to make sense out of it what doesn’t seem to make sense, is critically important to the ability of frontline team members to execute during times like this.
I think again, like our management system, Respect for People is foundational to our management system, very much part of what we call our VMPS House. During times of stress, respect sometimes goes by the wayside or is not top of mind—I’m proud that that rarely happened at Virginia Mason. I won’t say that it never happened during this pandemic. What the Respectful People framework does for us is, even when in the heat of the moment, something might not be as respectful as we would like it to be—it gives it gives an individual a framework, a foundation, or a basis for which to provide feedback in the moment. "I get where you’re coming from but I felt disrespected in how you said that." That is much more easily said than years ago, and that feedback in the moment is critical, and actually, as opposed to creating more conflict which is the fear, it actually helps resolve conflict constructively and respectfully and that’s important. In other areas that come to mind, in some of this cross-functional management that I talked about earlier, one of the respectful behaviors is "Walk in their shoes," and when you actually display the intersecting value streams and workflows and come to understand the colleagues’ processes and body of work it makes it so respectful, it’s so honoring, it’s so valuing, and I think it furthers the effectiveness in the execution of cross-functional management. Daily management is really an exercise in daily respect and listening to understand which is another Respect for People behavior. It’s one that I’m working on—how do I be a more active listener, how do I really use humble inquiry, genuinely wanting to know and better understand another person’s reality, another person’s work? I think Respect for People is pretty much all pervasive in Virginia Mason; it doesn’t mean we don’t have pockets or episodes of disrespect but I think having that basis and foundation to stand on is very helpful.
I would think about that in in many different ways and first and foremost I come back to staying true to our method. Whether they were formal kaizen events, RPIW events, or daily kaizen where we’ve made these innovations, or we have seen those new wins precipitated by the COVID crisis—we have to hold ourselves accountable to holding the gains and so that then translates to me to things like our 30-, 60-, 90-day follow-ups, sponsors of work where we have used formal kaizen activity, staying connected to that work and realizing where we’ve made progress, where we maybe slid a little bit and how do we keep moving forward. This inch-wide and mile-deep. It’s a rare work process that is improved with a single kaizen event and so I think it’s in a very planful organized deliberate fashion, codifying and harnessing though the events, the learnings, the innovations, the improvements that are made, and then using our accountability approaches to ensure that they are sticking and where we’ve slid or where we have opportunities for further evolution and that we have follow-on events. I think that’s critically important. The other thing that I would mention—we are very much a learning organization at Virginia Mason what that means, and the management system is so conducive to that and has really propelled that, is it’s continuous PDSA cycles. We are constantly rapid-cycle improving and going back and improving it some more. Measurement, improvement, and as part of a learning institution we are also somewhat academic and many of our clinicians and other leaders published frequently and are very academic, and through our Center for Health Services Research we are coordinating the academic pursuits of many of our team members who are writing articles. There’s a book that’s being considered because we want to contribute. We learn best when we’re sharing and receiving feedback and so we will be putting out a series of articles on a variety of topics I’ve already, through interviews and others, contributed. Several of you may see them in variety of areas in the industry press in coming weeks but I think it’s a commitment to capture the learnings and to build on them. They’re not stagnant, the learnings are the learnings but I think they’re just the platform for the next improvement, for the next innovation.