Webinar | What Does It Take to Lead Culture Change? The Executive’s Role

Virginia Mason Institute


After the presentation of our live webinar, Diane Miller answered a few questions from participants:

Executive leaders should be on the genba within their own areas of accountability a minimum of once a week so that they can round in every area at least once a month. Executives’ organizationwide rounding in areas not their own should also occur — a minimum of once a week is best practice.

We ask the leaders to generate their own standard work within the guidelines of must-haves identified as best practice. For example, all leaders must have a minimum of one huddle for five minutes at the beginning of the day to ensure everyone on the team has what they need for that day. In another example, each leader must decide what time the huddle will occur and whether more than one huddle is needed based on the work. (Because of shifts in hospitals or clinics, for instance, one huddle in the morning and one at noon may be necessary.) We suggest that leaders begin by documenting what they do daily — to list what they believe they should do daily, weekly and monthly and then make that the checklist. Then the leaders track what does get done and what doesn’t so that they can determine how to best manage that it all gets done. This often requires that leaders work with their own leaders to determine the best approach to accomplishing what is needed. These checklists will change over time; this is the learning cycle.

All visual display of work is helpful for transparency. Production boards have been particularly helpful at the daily huddles, but also the improvement boards we use at weekly huddles are helpful for engaging our team to create ideas for improving our work-unit goals.

First of all, physicians are intimately involved in operations; they are the front line. Daily huddles and weekly improvement huddles should involve physicians. Keeping these huddles short is key as well. It’s also important to involve physicians in improvement events (events that last one, two or five days) to achieve sustainment and commitment to changes — this is where you need leaders to remove barriers to participation. We also know that the improvement of “rocks in their shoes,” or the things that continually bother them in their day-to-day work, can lead to them wanting more improvement.

Leadership will need to require their engagement and ask them if this is the place they want to be. Leaders need to assess the urgency that these individuals feel about solving their performance gaps, and they need to listen to their concerns and fears, and find out whether they’re happy with their performance now. This is about change management, usually, but in the end it just may not be a place that works for you both, and this again is why executive leadership and commitment to the changes are critical.

Is this person a learner who has curiosity for how things could be and the willingness to try something even if it doesn’t work the first time? Is this person committed to the vision, to putting the patient first?

Establishing expectations is key, and then it’s important to give leaders the access to new tools and practices that support the generation of ideas, such as our weekly PeopleLink huddles for work-unit improvement, our Everyday Lean Ideas and our PDSA [plan-do-study-act] practices. I find it is usually the leaders who must change their behaviors before the staff can change theirs.

It is important to understand that the means by which you can accomplish improved productivity is to eliminate waste. This is about ensuring that we have the number of people we need to meet demand — not more and not less — and this means we must understand where there is waste. Managing attrition is one way also; we should not replace a staff member who leaves without first asking if there is waste we can eliminate so that we do not need to replace this staff member. Health care has high attrition rates, so this is manageable if you are intentional, and it requires executive commitment to manage this.

Apply this method to eliminating the waste in the process. Whenever we want to improve, we use our method.

Begin. Learn by getting started and through reflection revise the strategy. Get a mentor or coach. This is very hard to do just internally because we are at a high risk to excuse ourselves; it is helpful to have “outside eyes” to point out where you’ve lost the urgency.

Systems are important in establishing structures, resources and methods to deliver the behaviors aligned with the culture you aspire to. If genba rounding helps produce more sustained results, you need a system to ensure that people have the skills and the discipline to do this easily.

The most successful lean philosophy involves these five elements: • Customer-first • Quality and safety (zero defects) • Full engagement of staff • Strong economics • Eliminating waste in all we do

Begin to lead using this philosophy. Read about and follow practices promoting the philosophy and demonstrating the improvements. Take a study tour to places that use the management system and not just the lean tools. Invite speakers to events to share their stories of an improved culture.

My first reaction to any improvement question is to approach the issue using our methodology. Gather the people who are involved, assess the current and future-state processes, and eliminate wasteful activity.

To be honest, it’s based on job classification. We began with the executive level, our CEO, and include all the vice presidents, all the chiefs of service, all the section heads and the administrative directors. We eventually review all the way to the supervisory level to find our top 200.

It’s certainly harder the higher you go up in an organization to understand what we’re “producing.” I think it’s about tracking what you do every day. We’re producing budgets; we’re producing meetings. So I think it’s really just using your expertise and going out to the genba — and hearing what the managers are producing — that can lead to great discussions. It is a challenge, but I think we work together and often learn in a collaborative way to understand as executives what we’re producing.

This is a great question, and often one asked of any training that happens. One of the ways we measure is demonstrated by how the leaders actually operate on a daily basis — so the training involves some skills and then we require that the leaders demonstrate those skills. So it’s not just classroom training; they really have to operationally demonstrate their skills. Part of our genba rounding is looking for the evidence that they’re using the methodology. Are their boards active? Do they look current, or do they have data from last quarter? A big part of the training is demonstrating that they are actually using the methodology.

Currently the role of our kaizen promotion office (KPO) is to accelerate the adoption of our management method. The KPO’s role isn’t necessarily to achieve the improvements but to support and facilitate. It’s the operational leaders who are responsible for all improvement. The KPO has expertise in helping to lead the events and to support the daily operations in coaching our leaders in this methodology. The KPO is also responsible for training leaders in the Virginia Mason Production System (VMPS) and our fellowship program. So we have individuals who lead improvement events as well as do the teaching and training. As we’ve grown, we’ve also engaged our operational leaders to lead events, teach and train.

I think traditionally in health care, leaders are hired for their skills and the knowledge that they bring forward. So I would say in the beginning that leaders can usually lead with their own best practices. I would become a student of this philosophy, of the management tools, and I would gain that skill and begin practicing. Make things transparent, have a production board, coach PDSA [plan-do-study-act] and engage in the improvement work. As an individual work leader, you can demonstrate that but there are limitations to how far you can go. Typically what I see is once you begin to show real improvement and real engagement of staff, and better outcomes for internal customers and direct patient customers, the executives start to take notice. So I begin with myself, which is true for all transformation. Transformation begins with the individual having a different mindset and a different philosophy and belief. This is true whether you’re working at an organizational level or an individual level.

There are many ways that improving quality of care, processes and staff engagement can have an impact on financials. Improving quality in the management system is focused on eliminating defects — and it is these defects that have a financial impact. Specific examples in the clinical world are patient falls and infections. These defects in care lead to longer lengths of stay and often nonreimbursement for those days. When we have defects in our supply chain — too much or too little in inventory, for example — there is a cost of staff time as well as costs when the supplies become outdated. Standardizing for best practice to improve quality can also reduce costs by reducing training time and rework when a process doesn’t go as planned the first time.

We have both. At the medical center, in our primary care and specialty clinics, they’re employed, but at our hospital we also have independent physicians who utilize our facility. We do require any physician who works at Virginia Mason, either employed or independent, to follow the guidelines of our physician compact.

Most health care organizations have some kind of database system. We have our Patient Safety Alert System as our reporting system, and we don’t just track that a harm occurred, but all potential harm or safety concerns regardless of whether harm has occurred. So our safety department is tracking and trending those patterns of reports. The complaints come in through our patient relations department, and they help us track and trend those complaints as well. We use Press Ganey for our patient satisfaction surveys.

We made a commitment very early on that this was not a management system separate from our physicians, because of the way the physicians work in health care. Our executive team said from the very beginning that physicians would be a part of our improvement events — and that was very challenging. It’s hard to imagine how to break away staff for five whole days, particularly physicians, but also nurses, technicians, etc. We had to consistently help people understand that people do take time away for vacations and continuing education, and we manage through that. I think the strategy really is holding to the principle and the knowledge that when they are involved in these events, we really can make huge strides in our understanding and our improvements. So, breaking away for those intensive improvement activities was a big challenge. The other challenge we faced was the worry from staff that they were going to lose their jobs. That’s why we made the bold statement right up front that people’s jobs would be safe. We held training and rotated people into the kaizen promotion office early on when we didn’t need as many people involved in certain processes anymore.

In addition to the Good Catch award, we also have annual recognitions. One of our outstanding recognitions is our Mary L. McClinton Patient Safety Award, which is given annually to a Virginia Mason team that has done the most to improve quality and safety in the past year. Mary McClinton was a patient who died while in care at Virginia Mason by a preventable error. We’ve recognized and honored her each year with this award, and it’s the most prestigious award at Virginia Mason, and it’s based on feedback from our staff. Mary McClinton’s family comes annually to help us celebrate continuous improvement in quality and safety, and we’re honored that they do so.

When we establish our annual goals each year, we scan our environment for all kinds of data that would inform us about our current performance level. This includes our patient satisfaction and experience data that tell us what areas we need to work on to really improve and close the gap between what we are today and what we want to be in the future, and what our patients and families are telling us. We do that related to patient satisfaction data as well as environmental concerns, regulatory concerns and our own growth and development.

That’s a hard question because we all know the difficulties in health care. Will we ever get to zero defects? Maybe not. But we have many examples in health care where we have made huge inroads in eliminating defects. At Virginia Mason we know that there are mistakes. We’re human, and mistakes can happen. But a defect is when a mistake reaches our customer. There are many strategies around mistake-proofing, and how to eliminate defects before they reach the patient. That’s our strategy: constantly working towards mistake-proofing. If we have a belief that defects are acceptable, then we have to accept that a patient, a family member, a sister, brother or mother can suffer from a defect. And for us, that’s not acceptable. So it’s an aspirational goal, but an important one to continuously work to achieve zero defects.

I could see the Toyota Production System method was solid and had an application to health care almost immediately. What needed to be different this time to truly transform our culture was the alignment and commitment of the senior leaders to lead the change and not just delegate the change — that is, not to just train the managers and expect them to implement a new way to lead. So it isn’t about the tools. And when you realize it isn’t about the tools but it’s about the philosophy, that’s when you realize that when you’re leading from those beliefs, it becomes personal. The staff and management team watch us for congruence between what we say and what we do — that makes it personal and it’s a commitment we have to make over and over again. None of us is perfect, and none of us leads perfectly every day, so we also must be willing to reflect and learn from what we do.

We would never want to compromise safety or quality for our patients, so we wouldn’t take people offline that would do so. However, as I mentioned, we all take time off for vacation, for continuing education and other leaves. So we need to see the time spent on events as an investment in improving quality and safety and reducing the burden on the workforce to achieve that quality. Our experience at Virginia Mason, and at other organizations we’ve worked with, is that it is possible and does not reduce quality or safety. Start with those clinicians who do want to engage. You know who they are, so begin with them. They will become your champions for the power of this method and for letting the people who do the work become the ones to solve the problems. Our job as executives is to remove the barriers to engaging the right people to solve the problems, including time for the clinicians to participate. Trying to make lasting change without the right people is waste.

Diane Miller, MBA

Diane Miller, MBA

Diane Miller, MBA, served as vice president at Virginia Mason, the executive director of Virginia Mason Institute and an executive sensei. As a key member of Virginia Mason’s executive team, she helped design the infrastructure to support the organization’s adoption of the Virginia Mason Production System as its management method.

Diane Miller, MBA, served as vice president at Virginia Mason, the executive director of Virginia Mason Institute and an executive sensei. As a key member of Virginia Mason’s executive team, she helped design the infrastructure to support the organization’s adoption of the Virginia Mason Production System as its management method.

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