Sunday, December 06, 2009

Steps to change a culture

#IHI09 John Toussaint, CEO of the Thedacare Center for Healthcare Value, presented a session called Leading a Continuous Improvement Transformation at the IHI National Forum.

What does it really take to change a culture? He outlines several steps, requiring a focus on purpose, process and people, based on the Toyota Production System, or Lean, philosophy. Examples of success are Group Health of Puget Sound, University of Michigan, Thedacare Collaborative, and Gunderson Lutheran. All have made significant reductions in the cost of delivering care while improving quality. Bolton, in the UK, likewise showed dramatic improvements in clinical quality indicators.

Here are the steps.

Purpose: This comprises a general statement of mission -- e.g., to improve the health of the citizens of the communities we serve -- but it also must be translated into a more detailed strategy, and still more detailed goals.

Strategy: Deliver measurably better value to customers. For example, we want to achieve reliable quality, measured as 3-4 defects per million opportunities.

Understandable goals: Focus on only three! For example, Quality: Decrease defects and waiting time by 50% each year; Business: Increase productivity by 10% each year; Engagement: Number of suggestions implemented (number/employee). Set the bar high but pick clearly understandable measures.


Transparency of data drives change. (By the way, in terms of reducing harm, he notes, "Zero is possible, and from a leadership perspective, we should ask for nothing less.")

Metholodogy for achieving results: It is the leader's responsibility to create the system that allows people to solve problems. Use of A3's creates a rigorous approach to problem solving. This formalizes PDSA ("plan, do, study, act"). (There are 5400 active A3s going on in Thedacare!) This approach makes it easier to persuade others and understand others, to foster dialogue, to develop thinking problem solvers, and to do all this on the front lines.

Other TPS activities include: value stream analysis; rapid improvement events; continuous daily improvement; visual tracking. Improvement results in less staff "hunting and gathering." New standard work improves both logistics and care.


White coat leadership <-- versus --> improvement leadership.
All knowing, in charge, autocratic, buck stops here, impatient, blaming, controlling <-- versus --> patient, knowledgeable, facilitator, teacher, student, helper, communicator, guide.

Continuous improvement is based on respect for people. The leader's job is to develop people.

Can you say yes to these three Paul O'Neill questions every day:

--Are my staff treat with dignity and respect by everyone, regardless of role or rank in the organization?
--Are they given the knowledge, tools and support they need in order to make a contribution to our organization and that adds meaning to their life?
--Are they recognized for their contribution?

New habits are needed by managers and leaders: Help define the problem; ask questions instead of providing answers; think of problems as golden nuggets instead of opportunities to blame; teach subordinates how to solve problems; mentor subordinates to replace you; be humble.


Mark Graban said...

If people want to read more, it's Bolton Hospital from the NHS in England:

Link to Google Search on Bolton and Lean

Thanks for blogging about John, he has a lot to offer the healthcare community!

Engineer on Medicare said...

Re: Mark Graban post: Bolton from NHS
Is there such a thing as too lean?

There is a report on performance of NHS trusts in England and it is not all positive.

Bolton is second highest on a list of hospitals with high Hospital Standardized Mortality Ratios, and is indicated as having had a high ratio for the past five years.

Quote from news report linked above:
"A trust with an HSMR above 100 means it has a higher-than-average score. For example, 110 indicates a death rate 10 per cent above average.

Dr Foster said the following trusts had “significantly high” HSMRs in 2008/09. Those marked* have had high ratios for the past five years."

Basildon and Thurrock University Hospitals NHS Foundation Trust* 131

Royal Bolton Hospital NHS Foundation Trust* 122

Tameside Hospital NHS Foundation Trust* 119

Mark Graban said...

For a video of a very similar talk by John Toussaint, click here (Lean Enterprise Academy website)