Webinar | Moving Forward Through Transition – Lessons to Stay Nimble in 2021
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Robbi: I had the privilege of being the Director of General Thoracic and Vascular Surgery. So it’s a large clinic, ambulatory setting. We have services in multiple buildings downtown and then had providers who went to regional medical centers. That’s a great question, Chris because it reminds me of what we all were experiencing in the beginning of COVID. There was a lot of confusion. The things we take for granted now just the importance of social distancing, the importance of masking the importance of washing our hands. Not all that was apparent in the beginning. So if you put yourself in the shoes of a patient, they’re trying to balance their safety with their medical condition. For us, we were working to conserve PPE and to conserve hospital beds for potential spikes in COVID patients. So, a number of surgeries had to be paused. And so patients were having to balance that, right. And then as an organization, we were seeing changes in demand. I like to say, “cancer doesn’t stop for anyone.” So our oncology services kept going. We saw those services still needing a large team to support them. And some of our medical specialties where some of our surgical and procedural specialties saw a decrease. So we saw the changes in demand. And then just as an individual, frontline team member, the things that people had to deal with. They were worried about their safety, but they’re also balancing that with their mission to serve others. And to come to work, and to serve others. Things were changing on where they worked, how they worked, when they worked, all of those things were changing to meet the demand. And then just life. So the life of our kids having to do remote learning, or our spouse might have been furloughed are laid off, potentially. So you’re balancing that. How I get to work is changing because our bus system was changing in Seattle. So people were coming into it with a lot of evolution and a lot of newness to it and just the, the anxiety of the safety. A quote that I’ve used over many, many years to help myself and to help my teams is, I think it’s “everybody is fighting a battle that you know nothing about, so be kind, always.” I think this is a great, this was great for me, and my team, as we were working through this. I don’t know what’s happening in someone’s personal life for the challenge that they’re facing so let’s use our Respect for People principles, as we move forward. That’s really a good perspective to start with, is with all the things that were happening, and continue to happen for people, is we have to be kind, we have to work with each other to get through it.
Val: Thank you, Chris. I served in a role with the executives of the hospital Command Center that supported the Incident Command Center. We’re a 240 bed hospital. The thing I was struck with and was grateful for was the structure that had been in place – standard work, prior to the event – which kind of leads to the ideas of Daily Management and Cross-Functional Management. As you said, the very strongest piece is this daily safety huddle and I’m sure many of you in the audience have that, or some maybe have different parts of it. We have a safety huddle that has cross-functional management from clinical, operational, support services. And so, what was really great was that as the incident Command Center was getting up, the information could go right to the safety huddle that day, and then create communication and standard work. That led into Daily Management at the unit level, so we immediately had that, and from that different huddles occurred. And for the hospital Command Center, we did the same thing. We did daily huddles in the beginning of the day and end of the day, that then synchronized with the Incident Command Centers so that standard work and communication can come out. I reflect on that time, and I think every day, there was a different piece of standard work that came out that was revised every day, because there was so much we didn’t know. We utilized daily huddle cards and those pieces, but that safety huddle, which was a really transparent way to share information earlier in our experience, just served as a great piece. And I know that many of you found that when you were working with your management system, having that huddle structure was critical.
Melissa: Consistently, client to client, past and present, there is consistent reflection about, how they can rely on some of the tools and the concepts that they have learned from the Virginia Mason Production System. Most specifically it was that the general concept of Daily Management. Many of my clients were talking about how they had, to Val’s point, huddles previously in place or they had visual management boards that originally was meant to manage the work that they typically were accustomed to, whether it was an inpatient floor, if they were a corporate service department. And then when COVID hit, they kind of looked around, and said, “how can we reconfigure this board? There’s a portion of our work that is no longer emergent. It’s not at the front of mind for us, but we still have other things we need to do to respond to the pandemic now. So how can we reach it, or some of that? Or how can we modify our huddles that we had in place?” It was really great to hear folks thinking about, “What can we rely on from some of the previous things that we put into place from the World-Class Management system?” But there was also some opportunities where I think people have also reflected on, “Wow! We thought we knew our business and that was supposed to be the point of Daily Management and we have no idea how much PPE we actually have. No idea where is. We have no idea who has a surplus in one corner of the hospital versus there others.” So there’s been some reflections as well of panic purchases, because they didn’t know. I think there are some really interesting opportunities with my clients today, talking about, “Hey, we’re about to hit the second wave, but we’re better prepared now because we have better management boards in place to help us really be able to make more informed decisions.”
Robbi: For me, my learnings within with COVID were about the importance of going back to the basics. As you and I talked about strategic staffing, we really had a conversation about understanding your demand – the importance of “where is the demand within the organization and what are the skills needed to meet that demand?” We needed a setup process as to both understand the demand and also the skill set of our resources within the organization. And for us, how we looked at demand – this goes to Melissa’s point – we thought we knew it but we had to dive a little bit deeper. For example, in some sections they were seeing a huge spike in phone calls so they knew their day to day phone volumes, but they really focused on the inpatient visits. But with COVID, the importance of rescheduling was a new piece of demand, the importance of triaging and setting up processes for virtual visits was a new demand for the team. Understanding that was critically important. It wasn’t always about the patient who was in front of you in person. It might be the virtual patient or the phone call triage, or the surgeon who has to continually follow up with the patient who’s surgical case has been delayed because of PPE shortages. You need to understand your demand in new ways, and then work across departments and think of our team as a resource. For example, the next step working with the hospital was to do contingency planning. So, what are the skill sets of the nurses, who are in the clinic, and what can they do to help support the hospital if we did see a significant surge? So, that contingency planning had to go on, but you had to understand at a nurse by nurse level, his or her skill sets. And then the hospital needed to know where they could use those resources and what the type of need will be. So those connection points were really important – understanding it on a department level, an organizational level, and then across departments.
Val: Yes. Demand and capacity is based on the flow of patients that are coming into the hospital, and as many of you all know, we don’t know exactly how many will come. What we developed was demand a capacity based on conventional, contingency and crisis – and looking at the volumes of what that would mean, which would then relate to the number of COVID patients that are positive, the number of ones that are infectious, and then places that you need the PPE and the resources to support the patients. I think about where that was developed and that was developed in the hospital Command Center. Taking a step back – the leadership in that Command Center was executive and administrative leadership with very strong VMPS skills to develop visual controls, to actually collaborate with analytics, to develop models and those pieces, and then the Kaizen Promotion Office providing that information. It was really kind of chunky at first – we just had pieces of paper on the wall. But now, today, every day, we get a projection of how many cases we have today based on what’s happening in the region. If it’s going to be low, medium or high. We can project where those patients are going to fall in conventional, contingency, crisis – which then relates to the resources – if the people, the space, or the PPE. The PPE Team was very integrated and it’s just amazing to see the tools that they utilize to both manage demand and capacity and also manage donations – to figure out how you utilize those different tools that you may think are right but probably aren’t the right one to use. Again, it’s that big part of the management system about demand and capacity and being a step ahead of the game with leadership that understands how to apply those methods.
Melissa: I know there’s been a lot of work in the NHS as it relates to Speak Up Guardians and really trying to inculcate that environment where it should be safe to be able to say, “Hey I think we might be embarking on something that might be dangerous for the patients, might be dangerous for our team.” So how do we continue to support that type of culture? I think one of the things that we have to acknowledges is how we embrace those early signals of something that might be going wrong in an organization? It’s the one or two little data points around trust or your healthcare system that we need to be capturing. If we can kind of change our mental model of, “It’s that person who just is always complaining, is always talking about what’s not working,” to “Hang on a minute, this person might be the early detector of a huge root-cause problem that is going to really just shut down the entire organization.” What an incredible opportunity to have a good catch and to be able to avoid something tremendously dramatic to the organization. Considering ways of maybe encouraging speaking up, whether or not that is through celebrating people who mentioned something, offering tickets of “applause” or what have you, or if you already have a culture of continuous improvement, that participants, participatory nature of, “Hang on, a minute, I get to speak up and I get an opportunity to actually solve the problem too? How incredible that would feel – to have ownership of taking care of our patients.” I think there’s a couple of different ways to support that “speak up” culture.
Robbi: When you talked about our Flows of Medicine I think about something similar with our Respect for People behaviors. A “speak up” culture really starts with a leader who’s sharing information. They’re sharing what they know and they’re also showing what they don’t know. That’s a critically important piece of being vulnerable as a leader. It’s sharing what you don’t know especially, in times of crisis. I think the importance of sharing information and also the importance of listening to understand – so as someone shares a concern, there’s the concern that they’re saying but you have to really listen to understand it, because there may be a couple more layers underneath that. So, talking about the importance of understanding what people are going through individually, there may be concerns around safety that they’re expressing but they’re not saying it. You really have to ask a few clarifying questions and really dive into what they’re really trying to say, because those three are connected – the importance of sharing information and listening to understand creates that culture that allows people to raise a concern because they know it’s going to be listened to. Speaking up, and people feeling comfortable with that doesn’t just happen – it happens because you focus on the other nine foundational behaviors of Respect for People. Val: In my work with about two or three different organizations with Virginia Mason Institute – the beauty of is that all of them are integrating Respect for People concepts: listening to understand, walking in other people’s shoes, all those elements – and they’re integrating it with their management training. I know that others have heard at Virginia Mason, we didn’t do that early on. In fact, the Respect for People concepts came later, and if we were to do it over again we would have done it earlier, but it was just part of our learning journey. I think that the blend of the Respect for People, and kaizen just kind of continues to get back to that idea that you listen to the people, they are the ones that know the truth, that’s where the truth stands. That that’s a key piece, and I just want to take a moment to go back to the question that Melissa answered. With the crisis I know that when we did debriefs with different organizations, they struggled with command and control and then “speak up,” and how do you balance that? Because in crisis you do need a little bit of command and control, but then how do you bring that together? In the beginning it felt a little uncomfortable because it’s a little bit counter to that. With the debriefs that we did with our clients (referred to as hansei in the Toyota Production System), it was a way to kind of reflect on that and think about how do you do a better job with that and be a learning organization?
Robbi: I’ve been working with a brand new client in the UK, and we’re trying to teach them on a weekly basis,. We have about 60 to 90 minutes with a group, every single week. And we create coaching opportunities also. Basically, twice a week, we have a formal session, and formal coaching, and we’re seeing people come to their coaching sessions with these practical applications that we’ve asked them to look into and apply to their work – just going full on, and really deep into using it. So, we had a provider who went into a challenge that they were facing. He had his waste walk completed, he looked at his Flows of Medicine, and he really needed some coaching about, “How do I take this information forward?” We emphasize the importance of understanding your current state first and so we coached him on the importance of this being the first step in understanding your current state – there’s a more steps that we have to do so we walk them through what that could look like, and then we talk through the importance of getting the people who do the work around the table so they can hear this information, and then you can work with them to come up with a solution. For example, there was a process where the patients were coming in and checking in the clinic and there was a challenge there with screening certain information. So he brought that whole team together and that one piece – requests from the provider to that team – that they come up with the solution was mind blowing for them. It was transformational for a small clinic where that’s never been done before. Those small steps of giving people a different way of looking at it really makes a huge difference.
Robbi: I would say my biggest learning is the importance of going back to the basics and applying them in new ways. Our demand is changing so we need to apply them in new ways. I’m thinking through the request our Executive Director Sarah Paterson gave; because we were seeing more demand for our virtual delivery of our APIT (Advanced Process Improvement Training), she wanted to bring a team together to get ideas about how we could continue to have high quality for the participants but continue to meet that demand. So within about a 10-day period of this becoming a challenge, we brought a small team together and I led them through a three-hour idea generation session which allowed us to then start to plan out how we might use some of these ideas. So, there’s three hours – we use some key principles that we would use in a Production Preparation Process (3P), which is a formal process of re-inventing services but we applied it on a smaller scale. So really, again, going back to the basics, what’s the challenge? What can I use within the Virginia Mason Production System to address this challenge – be it the key principles of innovation or our basics of 5S? We’ve been talking with a number of our clients about 5S and the importance of understanding that. We talked about demand and capacity. So that that’s a key learning for me – going back to that base knowledge and looking at how you can apply it to this new challenge, because the challenges are always going to come and our base knowledge is a great place to start. Val: I think on a lot of what you shared, Robbi, I would agree with you because the system is just a gift. For me, what I’ve learned is that the management system is a gift for you to continue to move forward. I remember way back, when Chris, Robbi and I were beginning with Virginia Mason, is that whole idea fail forward quickly and just be nimble. I have to admit there have been times where I’ve been really uncomfortable, like when we did this 3P – I thought, “You got to be kidding me. Me, doing a virtual 3P?” And then it’s like, “Wow, it’s great.” It gets your greatest creativity out with the management system. Then I really appreciate the importance of some of those Respect for People principles like listening to understand. And with the people I work with across the country – to really listen to them, and even though it’s virtual, you’re not present, to really understand where they’re at, and how to move forward using the management system. I just hear, Gary’s voice at the beginning, where he talks about the silver lining, and the fact that the system helps you move through. And it’s something I take for granted, it’s been a part of my leadership for the past 20 years, but it’s such a gift. Melissa: There’s one thing that just keeps on coming back to me, over and over again, and it’s that there’s no better time than right now to re-evaluate and redefine value in a post-COVID world. I think we’ve had these mental valleys and pre-conceived notions and industry-wise or whatever health system that you’re operating in, we’ve had these very specific ideas of how you can deliver care or where we’re going to get paid in order to do this care etc. And to some extent, I think given the urgency of a global pandemic, we’ve had some gifts that come with that silver lining. And so, there’s now an opportunity for every one of us to say, “What does the patient actually value today?” Because I can guarantee you that it’s so very different from what it was eight months ago. And virtual visits is the easiest example – we had a pre-conceived notion that you had to go to the doctor’s office, we had to go to a hospital to see your physician or your provider, get that consult and then maybe move forward through the rest the process. And now, to think that a lot of that “type one” waste, the assumption that you have to try to go find a parking space, and all those things are completely out the window now. So, what else can we do to apply similar ideas? We don’t have to make decisions by committee anymore because it turns out, if you use the process, if you actually used your management system, you’re probably actually finding the best solution out of it. And so, how do we embrace that accelerated decision making? But also to Robbi’s point, let’s make sure that we’re using the basics to make sure that we’re using our tools and understanding the current state so that we can create a way better future state for ourselves.
Melissa: I’m going to go higher level, and it was just because you reminded me of it as you were talking, Chris. I’m hoping that we can learn from this pandemic and what we can take forward and not let go of that feeling is that changes are happening every day – we get new information every single day – masks, no masks, aerosolized, not aerosolized, who knows what it is, but there’s always this constant change and the environment. And so, I’m hoping that, for all of us, as we think about what we can take back and continue to improve our own health care organizations, is that change is always happening. Embrace that opportunity to improve what you know today. Because if you don’t – and I think the pandemic made it super real for many of us – is that if we wait until the dust settles, people die. And so there was that sense of urgency that really created that hyper focused staff at all of the organizations that we’ve been working with amongst our clients. And so how can we use that? The idea that things are always going to be changing, so don’t wait to make it perfect. Don’t launch a year long process to decide and plan something out. Because who knows what will happen from there. So, I think many of us constantly use the quote “don’t let perfect be the enemy of the good.” And I think, hopefully, we’ll have embraced that truly from the pandemic, because if we had waited, I can’t even imagine what the toll would have been globally for all of us. So let’s continue with that. Robbi: I was writing down the importance of the PDSA cycle and this just kind of goes to what Melissa was talking about. It’s truly understanding your objectives. I have a client in the UK and they were working through this process of a referral coming from us, of a primary care team to a specialty team – and they were looking at the referral process. The general practitioners weren’t sending the right information in a timely manner. We just talked a lot about, “What’s the objective you’re trying to achieve versus this one specific process that you’re attacking?” Because you think that that’s the process, that if you just fix that, you’re going to be fine. So, we took a step back and the objective was they wanted timely, quality care. The objective was they wanted timely care, and this referral was an important piece to them. And so, we just talked about, on the objective, don’t own your perception of the solution. The solution in their mind was, “We just got to fix this referral process.” They need to own the objective, which is timely, quality care. Time meaning, we can contact the patient. Quality, meaning we have the right information in order to schedule them in the right way. So that was important to them. So taking that step back. And then just in the importance of a Plan Do Study Act (PDSA) cycle is, to Melissa’s point. is try something. You’re not going to have every piece of information you would like, but get a plan, try it out, study the results, have a change in your thinking and either implement that new process, or run a new Plan Do Study Act cycle. So, those are the two things that come to mind when you asked that question. Val: So, as I think about both what Melissa and Robbi said, I would concur with that. And then, I think that what my advice would be is – as much as you can, as you progress, to embed things in standard work. So, some organizations are kind of keeping their incident command as a place where everything happens. And this COVID situation is here for a long time. So, how do you embed things in operations and standard work rather than keeping it in our response system in the incident command? Then just one of the things I feel I didn’t say earlier, was the role of leadership and the power of reflection and debrief many times to see about what you can do, what are the gaps, and how can you accelerate forward? A lot of people are choosing to say I can’t do Kaizen because of COVID. Well, the reality is there’s so much waste. And there are areas where perhaps you can improve where it might be the hotspot of where your organization is, some maybe re-prioritizing areas to continue to remove waste because there’s so much and organizations have to continue to perform at the highest level of excellence. So that role of leadership, reflection, moving forward, and then just getting things into standard work from the PDSAs that Robbi is talking about as well.