Healthcare Economics
When Worlds Collide
Creating a Service Line Culture
Penn State Hershey
Inaugural Dimensions in Heart and Vascular Care: Advancing your Scope of Excellence
October 18, 2013
Presenter
Linda Larin, FACCA, FACHE, MBA
Chief Administrative Officer
University of Michigan Frankel Cardiovascular Center
Responsible for programmatic design, building and activation of 420,000 sq. ft. Cardiovascular Center that opened in June 2007. Currently responsible for strategy and operations for the Frankel CVC.
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Objectives
• Identify the link between culture and service excellence.
• Describe five or more interventions that can be utilized to improve workplace culture
• Understand and interpret metrics that can be used in evaluating culture.
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University of Michigan Health System
People: 27,000 faculty, staff, students, trainees & volunteers
Patient care: 3 hospitals, 40 outpatient locations with >120 clinics, 1.9 million visits, 45,000 hospital stays in 990 beds
Education: The UM Medical School and School of Nursing are ranked in the top 10
Research: $466M research budget ‐ one of the nation’s largest
Facilities: >11 million square feet
Financial performance: Total operating budget > $3.3 billion
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UMHS and CVC Activity
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Background
In June 2007, UM created a new physical identity for a comprehensive Cardiovascular Center(CVC) co‐locating: • Cardiovascular Disciplines: CV Med, Cardiac Surgery, Vascular Surgery, Interventional Vascular Radiology, CT imaging and Cardiac and Vascular Anesthesiology
• 48 beds in the CVC (with 78 beds in University Hospital)
• 9 operating rooms; 1 IR procedure labs
• 4 cath and 5 EP labs (plus 3 shells)
• 36 exam rooms adjacent to diagnostics
• Nuclear studies in CVC; CT/MR imaging in UH
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Establishing our Identity
Mission Statement
The University of Michigan Frankel Cardiovascular Center will be a premier center creating an understanding of cardiovascular disease across the life span, through multidisciplinary collaboration between clinicians and scientists to achieve:
‐ Superior compassionate patient‐ and family‐centered care
‐ Innovative science and discovery
‐ Excellence in education
Vision
The University of Michigan Frankel Cardiovascular Center will be the best academic heart and vascular center in the world.
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CVC Core Values
We, the staff and faculty of the Frankel Cardiovascular Center team are committed to advancing medicine and serving humanity through living and teaching our core values of:
‐ Respect and Compassion
We honor and care for one another as individuals.
‐ Collaboration
We honor the synergy of team, built on trust.
‐ Innovation
We honor individual and collective creativity.
‐ Commitment to Excellence
We honor the intrinsic desire to be “Leaders and Best.”
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Prior to the Move
Though Employee Satisfaction scores weren’t bad…
• CV services had a reputation of being “difficult places to work”
• Faculty were frustrated and increasingly vocal
• Outbursts were generally conducted by individuals of “power”
• Anecdotal “Larger than Life” stories became pervasive • Staff felt afraid and vulnerable causing increased turnover
• Managers were not sufficiently armed to handle outbursts
• The lack of leadership intervention was viewed as endorsing the behaviors, i.e. “If you permit it, you promote it.”
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“It’s Not About the Building”
• We thought the building would fix long‐standing issues bringing people together and adding service excellence training.
• In fact, it made matters worse – it created challenges due to the new environment, new teams, new staff, and the pace of growth.
• We learned that each work unit had its own subculture.
• Sharing the Core Values and service expectations empowered staff and faculty to “speak up” about how we weren’t living our values.
• Disruptive behavior escalated and magnified. We created the perfect storm.
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The Perfect Storm
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The Data
Reflected our “toxic” culture •
•
•
•
•
Significant activity growth and many new staff
Keystone ICU Culture Data
AHRQ Safety Culture Data
Employee Engagement Scores and Comments
Increased number of “Disruptive Behavior Incident Reports” 12
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Activity Growth
CVC Activity % Change
FY07 vs. FY08 Avg. Annual GR FY07‐FY13
6.4%
2.7%
OR/Endovascular cases
16.3%
4.3%
CPU/IR Procedures
21.0%
5.0%
Clinic Visits 10.6%
6.2%
6.7%
5.4%
Inpatient discharges & observation
cases
Non‐Invasive and Radiology
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Keystone Safety Questionnaire 14
AHRQ Safety Culture Survey
Nursing TICU to CVICU
2005 vs.
2007
Patient Safety Grade
Frequency of Event Reporting
Overall Perceptions of Safety
Super/Mngr Expectations & Actions Promoting Safety
Org Learning-Continuous Improvement
Teamwork Within
2005 N=7
2007 N=6
Communication Openness
Feedback & Communication About Error
Nonpunitive Response to Error
Staffing
Hosp Mngmt Support for Pt Safety
Teamwork Across Hospital Units
Hospital Handoffs & Transitions
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
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AHRQ Safety Culture Survey
Nursing CVC-OR
Just
months
after
opening
CVC
building
Patient Safety Grade
Frequency of Event Reporting
Overall Perceptions of Safety
Super/Mngr Expectations & Actions Promoting Safety
Org Learning-Continuous Improvement
Teamwork Within
2007 N=17
Communication Openness
Feedback & Communication About Error
Nonpunitive Response to Error
Staffing
Hosp Mngmt Support for Pt Safety
Teamwork Across Hospital Units
Hospital Handoffs & Transitions
0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 100%
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UMHHC Patient Relations Report
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Employee Engagement
Prior to
Move
Satisfaction
After Two Yrs Current*
Open
Later
2007
2008
2010
2013
CVICU
90.7
72.7
69.6
4.00
4C
74.2
66.0
73.4
3.49
7C
72.6
79.8
87.2
3.97
7D
70.8
65.8
80.3
3.67
CVC5
91.7
91.7
83.3
3.94
-
76.4
54.7
3.93
Cath Lab
78.8
75.6
54.8
3.87
EP Lab
78.8
59.5
55.6
3.71
-
80.8
86.7
3.86
79.2
72.9
77.3
3.57
> 76 & Tier I
70-76 & Tier II
CVC Operating Rooms
Outpatient (CVC clinics)
Echo/EKG
* In 2013, UMHS moved to Press Ganey survey tool.
< 70 and Tier III
CVC Units
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Image of CVC Physicians
• Search for insignificant patient care imperfections, overlooking competent care
• Demeaning body language (finger pointing, eye rolling)
• Interrupting
• Dismissive
• Foul language
• Referring to patients or staff in derogatory terms
• Speaking through someone else to accomplish a task…when the person is standing right there
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Ripple Effect
Indirect exposures are just as powerful as direct exposures
• Many suffer
• Climate of fear
• Avoid humiliation
• Becomes a life of its own
• Referred to as “tsunami”
• Nursing staff avoid rounds
• Afraid to “speak‐up”
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“The Team, The Team, The Team”
Our people are
our greatest
asset and
deserve a
healthy,
productive
working
environment
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Without intervention
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Advocating for Change
Our vision for the future: • Promote open, respectful communication
• Establish greater empowerment on the part of staff
• Improve accountability • Increase transparency • Gain greater “trust in room” • Foster internal resolution of issues whenever possible
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Creating the Plan
• First, we organized a core group of leaders to focus on culture
• Developed a “CVC Culture Enhancement Plan”
• Provided updates to the Office of Clinical Affairs and the CVC Executive Group
• Established a CVC Culture Steering Committee with each unit’s medical director and administrator
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Culture Interventions
• Most importantly, leaders held individuals accountable. • Second, addressed immediate operational issues (e.g. lockers for staff)
• Implemented individualized coaching for a few key physicians and their leaders.
• Retained consultants/coaches for one year to provide coaching and facilitation to 10 venue teams.
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Culture Interventions • Established monthly OR/IR “Culture Meetings” • Added “brief/debriefs” for all procedural cases
• Rebuilt the OR staffing model and added a nurse educator to improve competencies
• Created an OR physician mentor/trainee program • Utilized role playing to improve interactions
• Worked with the Clinical Simulation Center to improve skills during high stress situations
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Culture Interventions • Incorporated Positive Organizational Scholarship (POS) into our thinking and agenda planning
• Provided skill building through newly created CVC Learning Center adding classes in:





Managing Conflict Crucial Conversations Positive Organizational Scholarship
Personal Accountability
Giving Feedback
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Culture Interventions • Provided culture updates in CVC Enews, then evolved to CVC Heroes
• “Passion for Excellence” (Service Excellence) course orients new CVC employees to the expectations of sustaining a positive culture
• Created a program for safe interactive moments called T.E.M.P.O.  (Together Everyone Molds Patient Outcomes)
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T.E.M.P.O.
• Needed a way for everyone to speak up and feel safe doing so… Safe Interactive Moments
• Created a signaling “word” via naming contest involving all staff
T.E.M.P.O.
(Together Everyone Molds Patient Outcomes)
Copyright 2009 The Regents of the University of Michigan, Ann Arbor, MI 48109
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When to use T.E.M.P.O Appropriate use of T.E.M.P.O.:
• When you witness or experience disrespectful communication or behavior
• When you see practice outside accepted standards (i.e., hand washing)
• Stressful situations that are escalating
T.E.M.P.O. should not replace or substitute for direct
communication or dialogue when appropriate
Intended to be used when it may not be appropriate to engage in
Copyright 2009 The Regents of the University of Michigan, Ann Arbor, MI 48109
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dialogue at that moment
Safe Interactive Moments Purpose of the T.E.M.P.O. (Together Everyone Molds Patient Outcomes) initiative is to provide Faculty and Staff with a standard approach when acknowledging & responding to difficult or escalating interactions or unsafe practices that will: Be Safe
Encourage “Speaking Up”
Be Effective
Promote Respect
Copyright 2009 The Regents of the University of Michigan, Ann Arbor, MI 48109
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How to Use T.E.M.P.O BE CLEAR
BE DIRECT
BE RESPECTFUL
Use with a neutral tone.
*Use of the word should never be accompanied by non‐verbal tones that include sarcasm, belittling, threats or anger.
Copyright 2009 The Regents of the University of Michigan, Ann Arbor, MI 48109
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Recommended Response
When someone uses the word T.E.M.P.O. in your presence, say:
“Thank You”
• Stop, breathe
• Give yourself time to respond, not react
• Acknowledge the speaker and say “Thank You”
• If needed, ask for clarification
Copyright 2009 The Regents of the University of Michigan, Ann Arbor, MI 48109
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Results •
•
•
•
Dramatically reduced incidents of disruptive behavior
Wait list to join “most difficult” OR team
Reports from units that culture has improved Greater collaboration across disciplines:
• Created patient hand‐off tool between OR and ICU
• Developed new quality reporting tool
• AHRQ proposal for simulation studies
• Created several multidisciplinary initiatives and programs
• Currently exploring vertical integration within the building
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AHRQ Safety Culture Survey
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AHRQ Safety Culture Survey
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Satisfaction
Previous Current
Satisfaction
Target
Best
Hospitals
Top 10%
89.0
2012
2013
4C
93.2
92.3
93.0
7C
92.7
93.1
93.0
89.0
CVC5
94.2
95.3
93.0
89.0
Cath Lab
95.0
95.7
93.0
*
EP Lab
93.8
96.5
93.0
*
Patient
92.5
96.4
93.0
*
Staff
Outpatient (CVC clinics)
64.3
3.91
4.15
*
Physician
80.1
79.4
80.0
*
Referring Physician (External)
75.4
81.1
90.0
*
Tier I > 4.15
Tier II between 3.80 and 4.15
Tier III < 3.80
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CVC 2011 Culture Survey Questions
1.
2.
We work together as a team.
Staff and faculty treat each other with mutual respect even when there are differences in opinion.
3. We support a culture of open communication to ensure patient safety.
4. It is relatively easy to resolve interpersonal conflicts and disagreements.
5. Leaders role model the behaviors of a desired culture.
6. Disrespectful behavior is managed appropriately and timely.
7. I am aware of the TEMPO program. 8. Education about safe interactive moments (TEMPO) has made a positive difference.
9. I feel empowered to speak up.
10. I have seen improvement in my work place culture since 2007.
11. Overall our workplace culture is (scale 1‐7) “toxic” (1) – ideal (7).
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Indicates improvement from 2007 to 2011 (8 of 8 questions)
Underlined = statistically significant improvement (4 of 8 questions)
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CVC Responses by Venue
Response rate = 381 / 925 = 41.2%
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Scale: 1 = Low and 7 = High
CVC All Responses
Greater than 2 years n = 303; Two years or less n = 78
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Scale: 1 = Low and 7 = High
CVICU Responses
Greater than 2 years n = 51 Two years or less n = 14
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Scale: 1 = Low and 7 = High
CVC OR Responses
Greater than 2 years n = 44 Two years or less n = 11
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Scale: 1 = Low and 7 = High
CVC IR Responses
Greater than 2 years n = 9 Two years or less n = 1
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Chief Brief
Dr. Darrell Campbell, Jr. MD, FACS, Chief Medical Officer
Friends,
On Monday, December 12, 2011, one of our surgeons violated the very culture that team
training is meant to create: when asked to be personally present for the time-out, he verbally lashed out at the
nurse in an abusive, profane and very public way. Fortunately, I learned of it within hours of the event. The
incident has been investigated. Though the surgeon is remorseful now, the event and other behaviors remain
under review. There will be serious consequences from his intemperate behavior. Some of those consequences
may be visible and some kept more discreet. I wanted all of you to know however, that this
behavior is
unacceptable. As is true for other hospitals around the country, we are all aware that such behavior has
been tolerated for too long in our hospital. Those days are gone. Abusiveness and disrespect
will not be tolerated. As offensive as this physician’s behavior was to those directly affected, the
implications of it are much broader than feelings of intimidation and anxiety for those forced to endure it. Patients
are safer in an environment of mutual respect, an environment in which every member of the operating room
team is valued and encouraged to speak up, and expected to hold the line on safe practices we adopt without
fear of being humiliated or abused. All team members are entitled to a workplace in which they find joy and
meaning in the very important work they do. We are determined to establish such a climate and we will zealously
guard such a culture. Behavior like this doesn’t just offend those who had to experience it – it places our entire
mission at risk. We won’t allow that to happen.
I am sorry this happened. I applaud those who brought it to my attention. As we move forward, we may
experience other instances of behavior inconsistent with our goals and if so, we will address them directly and
firmly. We are all in this together. The surgeon involved will undoubtedly be a better doctor for our intervention
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and we will collectively be stronger for the experience.
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A Model for Creating Hope and Gaining Trust
Leaders Truly Listen
Create Hope and Trust
Managers Share Reality
Validate Concerns
ACT
Develop Strategies
Address Root Causes
Model designed by
Shon Dwyer, RN,
CAO, UM Surgical Services
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Ongoing Efforts • Issues are taken seriously and responded to quickly
• Recruitment and retention decisions based on organizational “fit” for faculty and staff
• Requests to share improvements with other institutions, departments, and venues
• Presented program nationally
• Launched new “Walk in My Shoes” Program
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Moving Forward: World Class Culture
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Questions?
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Contact Information
Linda Larin, FACCA, FACHE, MBA
Chief Administrative Officer
University of Michigan Cardiovascular Center
llarin@umich.edu
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