Scott and I kicked off some fresh thinking about culture and respect for people at our Leadership Conference about five weeks ago. Recently, we sat down to check in with each other about it. We know that culture shifts don’t just happen overnight. It takes small steps over time. And, it takes an ongoing conversation. Here’s what we’ve been talking about.

Where are you getting new ideas for work around people and culture?

Michael: I think we’re willing to get ideas anywhere. A wonderful source of fresh ideas is our staff. Right now I’m in the middle of a series of meetings—by the time I’m finished I’ll have done about 30 meetings with close to 300 of our clinicians—they have great ideas. And we’re looking at other companies and industries too.

Scott: I agree with Michael that the best source of fresh ideas is our people. For the last few years we’ve been more disciplined in our rounding and understanding how work is done. It’s now time to extend our focus when we’re with our staff beyond Lean tools and process boards, into time spent learning more about what it’s like for people to work here. Why do they show up every day? What can we do to create an environment where they feel like they’re really doing their best work? Outside of Group Health, we’re looking at how other employers—typically not health care organizations—are creating a great place to work.

Michael: Scott said an important thing about us intentionally not looking closely at other health care companies for examples. I don’t think there’s currently much innovative people-thinking at other health care organizations. I know of a hospital system in the Midwest that’s looking at some cool environmental things like the lighting and the mood of buildings, but not culture.

Scott: I’d add that learning about Barry-Wehmiller gave us a chance to get outside of the box that limits our thinking and imagine what we might do, but we aren’t looking to do exactly what they are doing. I still believe that if you’re talking about making a workplace the best it can be, the best source of new ideas is going to be the people who work here. [Several Group Health amd Group Health Physicians leaders visited the Barry-Wehmiller Companies in St. Louis to learn about their cuture work]

Is a people strategy created by the people within an organization, or by its leaders?

Michael: Here’s what I think: leadership sets the tone, and Scott and I did that at the Leadership Conference in February, and we’re continuing to do it at every opportunity. We need to clarify initially by our words, and then by our actions, that it’s important, so that it will be important to others. Group Health is the people. It’s not buildings and plans and Epic. People create the culture; we set the tone.

Do we have too many different cultures already for this to work well?

Scott: I’m sure we’ll learn more about that as we go forward. But I think there are certain consistent features of working at Group Health that we want all staff to experience, to understand and advance. Sure, there will be variation in how it feels from area to area. Functions are different, and interactions with out customers are different. But there are basic, consistent principles of who we are and what we stand for that we want to be much clearer about.

How do you move from something that sounds like a checklist or plan, to something that’s actually ingrained in everyday behaviors?

Michael: Really you’re talking about culture, one where people are valued in a variety of ways—including putting high expectations on each other and holding each other to them. Where people are given the support to find solutions to problems, making them feel valued and respected—and they pass it on. We’re early on in this. One of the easiest and most accessible ways to respect people is to ask them how they feel about their work. It’s a powerful first step.

Scott: As leaders we can have some influence in a workplace, but it takes time to act on a new way of thinking, and build that through changing hundreds of actions. Whether it’s policies and the way we build them, or the way we spend our time at work, or the things we recognize and reward. It’s an endless list of small things over time.

Have you had recent moments where you chose to do something differently because ‘respect for people’ is on your mind?

Michael: I was meeting with specialists at Bellevue yesterday and I heard a passionate, unanimous belief in something that’s not working. I thought wow, I’ve been hearing this topic for over a year and it would be absolutely disrespectful at this point to hear this passion and not translate it into action. So in the last twelve hours I’ve had conversations with people who actually have operational accountability around the topic, so I can at least kick off a rapid assessment of what should happen next.

Scott: Yesterday we announced changes to our policy for spending dollars in departments to recognize our staff. And while the memo is just a memo, I think it’s hard to overstate how dramatic the change is that the memo represents. We’re going from specific rules about how much we can spend recognizing people, to asking managers to simply use your good judgment. It’s just one step, and we’ll really start having some traction when we’ve got ten other things like it, or a hundred.

Think about past efforts like this at Group Health. What’s different now?

Michael: We've both been here for a few of these efforts. We’re trying hard to avoid an initiative-based “event” where Scott and Michael say to someone else ‘you’re in charge’ and tell them to go make it work for us. So it’s different because it’s a tone set from the top, but now we actually have a management system to support it. We have a way of carrying something from the board room to the exam room and everywhere in between. We both believe that our business success depends on it. We’ve got very ambitious goals that we can’t succeed at without engaging and empowering the people of Group Health. And finally I think there’s recognition that front line improvement is where we’re going to get the bulk of dramatic improvements at Group Health.

Scott: We’ve been on an exciting journey for the last several years, and we’ve learned a lot. We’ve seen evidence that our results can be improved by paying attention to incrementally improving work at the front lines of our departments. So unlike anytime before, this focus on our work environments is a very natural continuation of a learning process. It’s not just a cool thing to do because employers are supposed to do it. It’s another component of something that we already have confidence in and momentum and excitement around. We’re doing it with a conviction that’s heartfelt. We really believe it will help Group Health be an organization fulfilling its mission for decades to come.

You kicked off this work at the leadership conference on February 1, 2011. When February 1, 2012 rolls around, what’s the biggest change you hope to see?

Michael: I think we’ll see a real spread in Front Line Improvement, or FLI, which is a structured, cross-functional team method for creating the flows and care environments that really work for the people in a site. At any given site, the FLI team rotates membership so everyone gets exposed to it. It happens really fast—process walks, testing solutions, implementing. More doing, less debating. I predict the culture will be changing to one of ‘we solve problems’ and ‘we’re heard and valued’ and that our Gallup scores will show it.

Scott: We should see a new and clear investment in developing the level of skills we’re going to need from people. To make Front Line Improvement really work, we’re going to need more consistency from our managers and chiefs and supervisors—the people who are so influential in what local work environments are really like. My hope is that a year from now we’ll have gotten really smart about a consistent curriculum to help staff create and sustain that work environment.

What are your questions about people and culture at Group Health? Tell us what's on your mind.

Questions or comments? Respond to Open Mike

 

With seven buildings, Group Health Capitol Hill Campus in Seattle is a big place. But Hospital Administrator Jane Hutcheson didn’t let the size and complexity of the area stop her determination to work on safety. She knew that daily information-sharing could cut the time it takes for incidents to be reported, escalated and solved. So in January she implemented a daily safety huddle with a manager representative from every campus department—even the gift shop.

Administrative Assistant Charlene Jose and Hospital Administrator Jane Hutcheson update the campus safety whiteboard with the week’s developments.

The 25-member group works briskly through issues like staffing, equipment, and building environments in 15 minutes each weekday. Daily huddles have been underway in primary care clinics for close to two years, but this kind of multi-department huddle is new for the Capitol Hill Campus.

“One of the great things is how it helps managers—especially new managers—get un-stuck,” says Jane. “I can connect people with each other right here in the room. They don’t have to start an e-mail chain or feel like they aren’t empowered to solve a problem.”

Hutcheson adds that she’s been amazed by variety of things that come up, like ordering exam room stools with slower-turning wheels, to prevent falls. Turns out the fast-rolling stools were a big temptation for the new big brothers and sisters who visit Family Beginnings.

Real-time communication and more accountability for getting it right the first time is also improving sample labeling accuracy at Capitol Hill. “Repeating a biopsy or a blood draw due to a labeling error is uncomfortable and distressing for our patients,” says Hutcheson. “Labeling is an area where everyone’s work really matters, every day. We’re working very hard on accuracy with managers, and tracking our error-free days on our huddle room board.”

Facilities Manager Tina Davis reports in at the Capitol Hill Campus daily safety huddle. Ron Becker, Radiology, and Mary Lou Calise, Quality, listen as Tina describes signage changes that may impact patients

Medical Director for Patient Safety Richard Hert, MD has seen how safety galvanizes team performance. “When your team is working on a common goal like safety, it really does boost that feeling of shared contribution, and draws the team together,” he says.

Dr. Hert notes that safety plans are featured in Group Practice Division business planning at the highest levels. “Group Health is taking great strides to emphasize patient safety in our care. It’s on everyone’s radar as a priority. As patient safety becomes part of our normal work, the culture of safety will continue to grow, and the quality and safety of our care will continue to improve,” he says.

The week of March 6-12 is Patient Safety Awareness Week, sponsored by the National Patient Safety Foundation. The foundation encourages patients and families to commit to their own safety by staying involved, informed, and invested in their own care. What’s our role? Communicating openly and proactively with our patients, making sure they understand their care plans, and inviting their questions and concerns.

Questions or comments? Respond to Open Mike

 

Is your patient pleased or ecstatic? A little nervous, or completely terrified? If you’re thinking about the difference—and how to respond with words and body language—you’re demonstrating empathy, one of the “Four Habits” for effective patient communication.

Now a pilot project on service excellence is training full care teams in the Four Habits and other techniques. Focusing on communication supports both patient satisfaction and team dynamics. In the two-clinic pilot, nurses, medical assistants, patient care representatives, clinic administrators and physicians are working on improving their patients’ experience together.

Orthopedics Service Line Chief Dr. Charlie Jung, Bellevue Orthopedics Department Chief Dr. Tom Stoll, and Clinic Operations Manager Judi Hubbard pulled the whole Bellevue orthopedics team together to train in collaborative patient communication and other ways to build service excellence.

“We do lots of mentoring among the surgeons in our group, but don’t often bring the entire spectrum of staff into the same room to really learn from each other,” says orthopedic surgeon and department chief Tom Stoll, MD. “I’m getting ideas from staff in this setting that we normally don’t have a chance to talk about.”

Bellevue Clinic Operations Manager Judi Hubbard agrees. “Our daily clinic flow is very busy. It’s nice to step back and think about what each of us can work on to help patients understand their condition and care, and feel heard when they have concerns or problems.”

Bellevue Medical Center’s orthopedics department and the primary care team under Dr. Marty Levine’s leadership at Northgate Medical Center were the pilot teams.

Practice and Leadership Development Director Maureen Haley says research into patient priorities helped get the pilot going. “Patient focus groups showed us that the three highest priorities for health care were actually related to communication,” she explains.

“Our patients place a high value on the quality of their initial interaction in a clinic, whether they receive clear and warm communication from staff, and the quality of their care instructions. Working on the ways we interact, and choosing the right words for the right time, is a way to build trust and stronger bonds with our patients,” Haley says.

About the Four Habits Model

Group Health Physicians’ Practice and Leadership Development team has trained our clinicians in the Four Habits Model for many years.

It teaches these key behaviors:

1. Invest in the beginning of the visit to build rapport
2. Elicit the patient's perspective
3. Demonstrate empathy
4. Invest in the end of the visit, involving the patient in their treatment plan

Developed by an internal medicine physician at Kaiser Permanente in Northern California, The Four Habits Model started as training and tools for physicians to use with patients who were angry, or who wanted tests or treatments the physician felt were not in the patient's best interest. It evolved to comprehensive method for building relationships with patients based on high-quality conversations and a collaborative partnership.

Questions or comments? Respond to Open Mike

 

Group Health has contributed a strong voice to legislative debates on health care. But if you follow politics you know that the Patient Protection and Affordable Care Act of 2010 is neither simple nor completely set in stone. So what’s new in our post-reform world, and why is it important for Group Health to stay visible and vocal?

“The new law went a long way on coverage, making sure that Americans can get insured. Now comes the hard work of shaping the nature of this coverage, which is influenced by regulatory agencies, states, and organizations ours,” says Diana Rakow, Executive Director for Public Policy.

It’s difficult when budget cuts and job losses affect the patients we care for—especially those who are most vulnerable. Our state’s Basic Health program for low-income residents wasn’t cut as deeply as feared this biennium, but it’s hard to predict what the next two-year state budget will bring.

Rakow says she tries to stay positive by looking beyond the spend-and-cut cycles that dominate politics. By 2014 there will be a more robust federal infrastructure to support Medicaid, small businesses, and individuals. And while the law is just that – law – there may be some twists and turns in the road.

“We must be forward thinking, looking not just at individual programs and budget challenges that are top of mind for legislators, but also about the bigger picture. It’s about keeping people healthier and holding health care cost increases down. So while we are continuing to fight for very real concerns like continuity of care, we’re going have to keep working on the long term view by perfecting, modeling and sharing our innovations in patient care, says Rakow.”

The difference, she says, is that as a system Group Health meets the burden of proof. This brings greater funding eligibility and more influence in policymaking circles. Over many years we’ve built not just a story to tell about our value, but the data to show that our integrated system and evidence-based practices really make a difference.

How we’re telling our story: innovation and proof of value

Our work helps inform the work of policymakers on many levels. As we work to implement the health reform law through internal operational changes, we also use policy advocacy to influence related federal regulations, state legislation, and proposals in Congress to tweak the law.

Governor Gregoire recently challenged the state’s health care organizations to limit cost increases to four percent annually–half the national average. In Feburary she invited Group Health Physicians President and Chief Medical Executive Michael Soman to a roundtable with U.S. Department of Health and Human Services Secretary Kathleen Sebelius and other regional health care leaders. Dr. Soman showed how Group Health innovations in virtual medicine, shared decision-making, EDHI, and high-end imaging analysis help businesses and individuals control their health care costs.  Read more about the roundtable here.

Group Health CEO Scott Armstrong was recently in Washington DC for a MedPAC meeting, talking about ways to improve the Medicare fee-for-service program toward more value-based payment and coverage. He used lessons and examples from our Total Health program and clinical integration work to inform the Commission’s discussion. He also spoke at the 2011 Bipartisan Congressional staff retreat on Capitol Hill. There, he talked with Congressional and federal agency staff about our work on medical home, EDHI, and shared decision-making, the principles that guide our model of care, and how we are thinking about translating that model of care out into the community through innovative partnerships.

Ideally, Group Health’s own successful innovations that improve care while reducing costs could one day translate into ways for state and federal health care programs to do more with less, providing more people health care coverage and care in the long term.

Questions or comments? Respond to Open Mike

 

Our members let us know when we’ve delighted them. Whether through tweets, texts, surveys, calls, or Post-It notes, we’re getting news of your good work.

Olympia Eye Care Services looking good

This letter of praise for Olympia Optometrist Kim Hoover came in to the Group Health Governance Services in-box. Great work, Dr. Hoover!

Last Friday, I went to the Group Health in Olympia for a 5:30 P.M. eye glass exam. Because I was interested in learning about Lasik, I thought I would ask the doctor about his views on this fairly new form of surgery.

After the exam, I asked Dr. Hoover about the feasibility of Lasik surgery. Instead of simply giving me a five minute spiel about Lasik, he took the time to discuss the various types of laser surgery. He even made up "glasses" for me to try with "before surgery" and "after surgery" results cautioning me that I might still need reading glasses with the procedure I was favoring. Needless to say this all took time.

When I finally left after 6:30 P.M., the clinic was empty. On the way home, I wondered how many people would spend, unpaid, an extra 30 plus minutes on a Friday evening to discuss procedures that are not even offered by Group Health. I could only think of one: a true professional who cared about his patient's well being.

I would like to thank you and Dr. Hoover for the quality of care that I received.

Aloha.

* * *

Emergency surgery at Central Outpatient Surgery Center brings praise via Post-Its

Surgical Services Director DeAnne Rolls received a great patient experience story through a post-surgical survey and in hand-written comments on three green Post-It notes!

Anesthesiologist Steven Lavine adds that in this case, the availability of a new ultrasound machine that day allowed this patient, who had eaten recently, to avoid general anesthesia. She had the procedure painlessly with a local pain block, and was ready for immediate discharge.

The patient writes:

I woke up in excruciating pain on Dec 19. I went to the Group Health Urgent Care that night, and saw my Primary Dr next day – got pain meds. I met with a surgeon next day. She examined my hand for 15 minutes, left for a few minutes and came back and said I needed surgery “now”. So, bam I was prepped and taken in for emergency surgery – on my wrist. I ended up having “gout” on my wrist – within 5 minutes of my surgery I could move my fingers – before surgery I couldn’t move my left hand at all. I would scream in pain. But thanks to Dr. Cara Beth Lee, I can pretty much do everything with my left wrist. I’m going to hand therapy right now.

I have friends that are members of Group Health and they don’t have anything good to say about them. I do!! I’m telling everyone my story and how wonderful everyone was. They all coordinated my appointments and then my emergency surgery – Life is good! Thanks to everyone at GH!

And from the patient’s Press-Ganey survey (a questionnaire filled out by patients who have surgery in our facilities or in one of our contracted hospitals)

Registration - “Great – easy – actually my husband took care of that. I was in excruciating pain”

Facility – “was very clean and neat”

Before Surgery or Procedure – “OUTSTANDING! I felt like I was the most important patient ever – my surgery was looked at done within an hour of meeting my surgeon and her wonderful - they stayed O/T to tend to me”.

After Surgery or Procedure – “It all happened so fast my surgery but everyone was so nice and caring. I felt very lucky to have such a great team provide me with everything I needed”.

Overall Assessment – Your highest grade is a 5 very good, you really need to go to a 10 because that’s where this surgeon and all their staff should be”.

Questions or comments? Respond to Open Mike

 

 Dr. Wennberg is author of Tracking Medicine: A Researcher's Quest to Understand Health Care, and the founder and director emeritus of the Dartmouth Institute for Health Policy and Clinical Practice. His keynote at this conference for health care leaders and researchers will explore the economic impacts of geographic variations in care, and more. Register and spread the word.