Notes From My First Day at #IHI 2011

This is just my second time attending the annual Institute for Healthcare Improvement annual forum – one of about 6,000 medical professionals, leaders, and patient advocates in attendance. For those of you on Twitter, I've seen familiar faces here, including @LeanThinker, @ePatientDave, @timeback, @paulflevy, and others. I met many readers of my blog and my book (which is now sold out at the IHI bookstore), so thanks for saying hi!

It's an interesting and energizing event for learning and networking. I'll share some of my thoughts and notes from the first day here in a somewhat raw form.

The day was, of course, started with a hearty breakfast, including oatmeal. Yesterday, Paul Levy blogged about some process design problems with the self-serve oatmeal stations and his observations of the workarounds that developed (yes, healthcare people are great at workarounds – a trait that sometimes interferes with getting to the root cause). Today, Marriott took some steps to fix the process, although they threw people at the problem (as Paul pointed out – again, something healthcare people would recognize as a common response to a problem). Seemingly trivial stuff, but good teachable moments about kaizen and process design.

The formal day was kicked off by new IHI CEO Maureen Bisognano and her keynote. Paul Levy shared some detailed notes and reflections here.

My notes:

• Maureen highlighted how we have three options for “fixing” healthcare: 1) cut costs 2) ration care 3) new designs of the system (which, considering the content of this event, would include the Lean methodology). I'd much rather take process and system redesign (including making care less fragmented) over mindless cost cuts and over rationing or denying care.
• She highlighted the improvement work of ThedaCare (primary care and inpatient care redesign), Denver Health (saving $71M in the last few years, $30M in the last year with Lean), and Virginia Mason.
• She quoted Dr. Paul Batalden as saying, “We have yet to develop a sense of embarrassment over healthcare waste.”
• IHI has a new “waste identification tool” for use by front-line hospital staff (I will take a look soon)

Next, I went to a session by SSM Healthcare (one of the systems highlighted in The Nun and the Bureaucrat/Good News…How Hospitals Heal Themselves Book/DVD Set) and their use of integrated Lean design methods in the building of a new hospital.

My notes:

• SSM combined Lean and IDEO methods to engage a diverse cross-functional team in analyzing their current process and creating the future state.
• They were looking to reinvent the healthcare experience for the patient and for the staff – from the ground up
• They had to observe and study the interactions between space, tools, processes, and people – they spent TWO MONTHS understanding current workflows and processes
• As other hospitals have done, SSM visited a factory to learn and be inspired by better processes (in this case, Boeing)
• They spent time scripting out the ideal patient experience, creating very detailed descriptions
• All of this was done in the spirit that it's better to “discover yourself rather than having ideas imposed on y0u.” Amen to that. Another way they articulated that was “We're changing ourselves rather than having you change us.”
• They said “eliminating wasted motion leads to an inherently safer environment.”
• Employee satisfaction increased dramatically – they claimed it went up from the 2nd percentile to the 94th percentile. The largest increase in Press Ganey history. A friend challenged if 2nd percentile could have possibly been correct, since SSM was a Baldrige award winner in the past.

The final presentation I'll write about was a talk by the COO of Virginia Mason Medical Center, Sarah H. Patterson.

My notes and thoughts:

• Sarah started by talking about the safety, reliability, and excellence of a nuclear aircraft carrier she visited, the USS Nimitz. This is a topic and example that Steve Spear has covered in his book The High-Velocity Edge: How Market Leaders Leverage Operational Excellence to Beat the Competition. She said “the greatest safety tool they have is people knowing their jobs well.” She emphasized that healthcare can learn a lot from aircraft carriers, especially the idea that the only acceptable goal is zero defects in healthcare – rather than accepting that errors are just going to happen sometimes.
• She talked about how VMMC spent the first five years of their Lean efforts (starting in 2002) by focusing on tools and principles. They had only overlaid new tools on top of the old organization structure and culture. So, they had problems sustaining the gains from Rapid Process Improvement Workshops because they hadn't focused enough on daily Lean management (they used David Mann's Creating a Lean Culture: Tools to Sustain Lean Conversions as a primary reference)
• VMMC has improved their sustainment rates from years past, reaching about a 90% sustainment rate of key improvement measures at the 90-day post-project point (she wishes that could be higher). She suspects sustainment rates are lower (50%?) when you look six or 12 months out. She asked “why are we re-doing RPIWs because people aren't following standardized work?” More on this below.
• They now focus on three core elements of a “World Class Management System”: 1) Management by Policy, 2) Cross Functional Management, and 3) Daily Management
• My editorial question: Do organizations not focus enough on “daily management” because these process and people management fundamentals aren't sexy? This is basic process blocking and tackling, not the exciting interesting stuff that managers and leaders want to focus on typically (or get rewarded for).
• 1) Management by Policy: A key point is that they spend SEVEN months planning for the next year's goals and strategy. Sarah said they could do this much faster if it were a strictly top-down communication. It takes them so long because of the employee engagement and interaction (using the “catchball” approach). They are using a lot of 1×1 employee meetings instead of blasted out emails from management. People appreciate the 2-way communication and get to communicate “here's what's getting in the way of us doing our work.”
• 2) Cross Functional Management is a matter of breaking down silos and looking at end-to-end value streams
• 3) Daily Management is “changing how we do our work as leaders on a daily basis.” VMMC was impressed with the support that Toyota provides their employees – when there is a problem, they get help within 30 seconds. VMMC is more focused now on detecting problems and giving help immediately rather than waiting for a metric or a monthly report.
• They are focused on getting out of crisis management and freeing up time for managers to be out there with their employees, seeing if standardized work is being followed and what problems need solved. They have the correct response to seeing that standardized work isn't being followed – they ask WHY? Maybe people weren't trained, maybe the standardized work isn't adequate, maybe they've made improvements — all good questions to ask, not just go punishing people. Great mindset there.
• They are doing more small continuous improvement with employees through their “People Link Boards” that post hospital and departmental metrics and goals along with employee ideas. These boards and daily/weekly huddles are used to gain alignment around “how does our work connect to the organization?” The daily huddles empower staff and engage managers.

It was a very full, interesting, engaging day. Continue following #IHI on Twitter to see the notes, quotes, and thoughts being shared by others.

Also – thoughts on anyone from the IHI forum or otherwise about this Health Affairs blog post?  Why We Still Kill Patients: Invisibility, Inertia, And Income

Continue reading my notes from my Second Day at IHI.

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