West Penn Allegheny Health System Diane C Frndak, PhD, MBA, PA-C Center for Creating a Culture of Safety and Quality at WPAHS1
• Admitted to the institution- registration process with a lot of personal information gathered- The Experience Given a unique number to identify you and an arm band• Take all your clothes-Give you an uniform to wear which clearly identifies your role• Declare all valuables-Put valuables in a bag• Gather past records and document new issues through interviews to get facts; talk to others to understand what happened• Examination—sometimes search body cavities• Assigned a room which might be shared with a random individual also in the same uniform• Shared bathroom/shower facilities
• Some people are put in isolation• A person with authority (and real clothes) reviews your case and makes a disposition• Restricted family and visitor hours; certain areas that families cannot go with you• Observations are recorded about you but you do not generally have access to them• Long periods when you are waiting for time to pass• Fairly bare, stark rooms with limited personal amenities given to you• Limited privacy-strangers can enter your room at any time day or night
• Food—if you get any, may range from plain gelatin and broth to institutional food served on trays• Your room can be changed which means you and your stuff are moved without your input or permission• You are escorted everywhere you go within the facility• Have many rules of what you are allowed to do and regulations about how you are to be treated to protect you
• “Things are done to you” -- Determine what and when you can eat, drink, sleep, go for procedures • Length of stay determined by others; If you leave before you are released, you are eloping • Released at the end—have a discharge process that you go through and sometimes need to wait for it to happenPatient or Prisoner?
Is this your life? You are excited about having a great opportunity to make a difference.
Hairball-ology• New Hairballs Mean New Problems• Hairballs tend to oppose their own Proper Function• Hairballs grow and get uglier over time• It sometimes Hurts to Detangle Hairballs• Hairballs Grow to Fill the Known Universe• Navigating a Path within the hairball is hard and the outcome uncertain• A Larger Hairball produced by adding smaller Hairballs does not behave like the smaller Hairball• People within the Hairball do not do what the Hairball thinks they are doing• The Hairball itself cannot understand itself• When you are within a Hairball you sometimes doesnt know you are• The Bigger the Hairball the more it seems you can isolate the more hair that seems to be available Adapted from “the Systems Bible” by John Gall
Hairball-ology• Hairballs Attract Hairball People• Detangling people are generally hanging around hairballs• Sometimes when trying to Detangle the Hairball you get sucked in• Hairballs Happen• If you get tangled into a hairball you may never get out• Smaller Hairballs are less complex than larger hairballs• Hairballs are disorganized but think they are organized• When you are truly in the hairball you can’t change the hairball and may not even know you are in a hairball• Hairballs require dramatic attention when you look at them from a far• When trying to help a hairball you don’t know where to start• You behave differently within the hairball• Detangling the hairball takes 1) cutting it out and throwing it away; 2) A lot of patience and screams. Adapted from “the Systems Bible” by John Gall
Events Sentinel Events Results/ Occurrences Reports Water line Problems Trends/patterns “The way we do things”Mistakes Systems: Activities, Connections, PathwaysDelays Stuff happensService Issues The “Hairball” of the current condition
The Iceberg of Ignorance Problems 4% known to top managers Problems known 9% to middle managers Problems known 74% to supervisors Problems known 100% to front line This internationally acclaimed study conducted by Sidney Yoshida, was initially workers presented at the International Quality Symposium, Mexico city, 1989. It indicated how managements failure to understand its processes and practices from the perspective of its customers, suppressed the companys profits by as much as 40%.
Fixing the Hairball• …few [hospitals] have well-defined paths for fixing broken systems. The whole idea of fixing systems is often seen as time-consuming, expensive and requiring special expertise. It is expected to involve late-night committees, capital budgets, and presentations to (and rejections from) senior leaders. It seems far easier to replace a person than to fix a system--even if it is the system that causes the problem. Hospitals need to make system fixes quick, easy and understandable. The proven approach is frequent, inexpensive, ongoing, short cycle- time experiments. These low stakes trials should be a part of every unit and department. Until they are implemented and well understood, it will remain easier to blame people than to fix system.Breaking the Cycle of FearPhysician Executive July/August 2007
Complex Adaptive System: A collection of individual agents, who have the freedom to act in waysthat are not always totally predictable,and whose actions are interconnected such that one agent’s actionschanges the context for other agents.
The most frightening aspect of complex systematic problems are that they are inherently uncontrollable.This means that prediction and control are not possible which can frustrate managers desiring control of these organizations and processes.Wheatley, Margaret J, “When Complex Systems Fail:” New Roles for Leaders” Leader to Leader, No 11, Winter 1999
The Alexandrian Solution In 333 BC, Alexander the Great attempted to untie the knot, but he could not find an end to the knot, he lifted a sword and sliced right through it.
Can You Orbit Your Hospital’sa Giant Hairball? “But hairballs can be effective. They provide necessary stability. It is not the job of the hairball to be vibrant, alive and creative. Orbiting is vibrancy…it is pushing the boundaries of ingrained corporate patterns.” www.fastcompany.com “How is Your Company Like a Giant Hairball
What Does It Mean to Orbit the Hairballverb (past and past participle or·bit·ed, present participleor·bit·ing, 3rd person present singular or·bits)Definition:1. transitive and intransitive verb move aroundastronomical object: to move around anastronomical object in a path dictated by the forceof gravity exerted by that body2. transitive verb put something intoastronomical orbit: to send something, especiallya spacecraft or an artificial satellite, into orbit http://encarta.msn.com/encnet/features/dictionary/DictionaryResults.aspx?refid=1861635322
What Does It Mean to Orbit the Hairball3. intransitive verb follow regular path: tomove regularly or repeatedly along the samepath, especially a circular path[Mid-16th century. < Latin orbita "wheel-track"]go into orbit to become suddenly extremelyangry and upset (slang) http://encarta.msn.com/encnet/features/dictionary/DictionaryResults.aspx?refid=1861635322
The Path of Least Resistance •Energy follows the path of least resistance and is looking for the next path of least resistance •People always, always, always do what makes the most sense to themhttp://www.baddesigns.com/path.html
Simple Approach to the Design of the Patient Experience• Identify area of focus• Observe and map process• Understand customer requirements and what would “wow” the customer• Do an “ideal” redesign (no defects, immediate, on demand, without waste, 1x1, safe)• Can we change the entire process at once?• Set up experiments to get closer to the ideal— progressive rapid experiments• Compare results to past and world-class• Never stop asking “How could we do this better?” and then do it.
Traditional New High PerformingHealthcare Systems Healthcare Systems ThinkingTop down hierarchy Front line ownershipFunctional silos Streams of value (as defined by the patient)Reactive ProactiveExternal motivation Internal motivationRules, regulations and Simple guidingpolicies principles
Traditional New High PerformingHealthcare Systems Healthcare Systems ThinkingHealthcare is unique We can learn from othersPatients are passive Patients design their careMaximize unit efficiency Eliminate patient delays and waste of time“Doctors will be doctors” Everyone has a roleLong planning cycles— Rapid cycletaskforces, committees, input… improvements
Traditional New High PerformanceHealthcare Systems Healthcare Systems ThinkingRetrospective data Real-time dataIs the performance No defects impactingacceptable? patients are okayTake the problem to the Take the meeting to themeeting (3 weeks to get it problemscheduled)Sentinel events create an Identify G-L-I-T-C-H-E-Sorganizational responseWorkarounds/heroes P-D-C-A everythingrequired Mini experiments
Traditional New High PerformanceHealthcare Systems Healthcare Systems ThinkingMission, vision, values Mission, vision and valuesimportant to the board drive all decisions“Captain of the ship” “Leader of the team”How do I get them to follow How do we learn fromthe standards? the best way we developed so far?Quality, risk management/ patient Support the front linessafety act like the policeTools and technology are Process redesign—let’ssolutions try it first
Traditional New High PerformanceHealthcare Systems Healthcare SystemsSystems ThinkingAre mechanical like Are living organismsmachinesAre controllable and Are messy andpredictable unpredictableAre rigid and self-preserving Are adaptable, flexible and creativeControl behavior through Teach/coach/createbudgets and numbers opportunities to learnFind comfort in structure Expect challenges and questions
The traditional thinking• The organization as a top-down hierarchy.• Work designed in functional silos• Decision-making is separated from work – decision- making being management’s job• In making decisions, managers use measures of budget, activity, productivity, and standards• Managers believe their job is to manage budgets and manage peopleMost organizations are designed and managed this way. The news is this doesn’t work very well. www.lean-service.com/systems
Who do you work for?• If the patient is the focus of everything we do- everyone of us works for the patient. – If managers think vertically to optimize their area, department or function, the horizontal flow of value to the customer can easily get lost
Organizational Chart CEO Human FinanceResources Vice President Director Manager Supervisor Front lines taking care of the patient
The Patient is the Focus of Everything We DoFront lines taking care of the patient where the value exchange occurs Supervisor Human Resources Manager Finance Director VP CEO
Blister analogy• Organizational problems are like poorly fitting shoes on a foot• First a red spot occurs with pain—if no response – A blister—sterile inflammatory response – If no response (numbness to the pain) • Ulcer – Amputation
“Real-time is the best time” - immediate problem identification - real-time data - real-time response
Workaround Waste• We accept preventable, needless events, by creating workarounds.• Workarounds are symptoms of a system or process problem• Many acts of modern day heroism are immediate preceded by acts of utter insanity requiring the very acts of heroism that we are bragging about in the first place• Instead of workarounds, why not respond, “since we can’t ____, let’s find out why and do something about it”