AACH Winter Course 2015 Making Room for Process in Relationship-centered Care Kathy McGrail MD, Rochester Regional Health System Krista Hirschmann PhD, Lehigh Valley Health Network Agenda Time • • • • • • • • 10 min 5 min 5-7 min 10 min 5 min 10 min 25 min 10 min Topic • • • • • • • • Review of goals Distribute roles Why cycle time 8 Wastes Relational co-ordination mini-didactic Debrief RCC survey results Brainstorming and multi-voting Debrief and Close Our Objectives & Yours • Describe the impact of process on relationships in primary care • Explain how standard roles and process are essential to team based care • Apply cone in the box principles during an interactive case scenario • List two ways you can promote attention to process in your clinical setting as an avenue to relationship-centered care Quadruple Aim Decrease per capita cost Improve Patient Experience Improve Work Life of Healthcare Workers Improve Health of Populations Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider, Ann Fam Med. 12: 573-76, 2014 A Framework for the Quadruple Aim http://rcrc.brandeis.edu/about-rc/model.html Structural Interventions Shared accountability Shared costs & rewards Selection & training Conflict resolution Meetings & Huddles Boundary spanners Shared protocols Shared info systems Spatial design RELATIONAL COORDINATION Relational Coordination Shared goals Shared knowledge Mutual respect Frequent Timely Accurate Problem-solving communication Work Process Interventions Goal and Role clarification Process mapping Structured problem solving Performance Outcomes Quality Efficiency Patient engagement Worker well being Relational Interventions Create psychological safety Relational diagnosis Coaching & Role Modeling Jody Hoffer-Gittell , Edgar Schein, Amy Edmundson Nature of the Challenge Technical Challenge Adaptive Challenge • Problem is well defined • Solution is known and can be found • Implementation is clear • You can always go to the genius bar • Challenge is complex • To solve requires transforming long-standing and deeply held assumptions and values • Involves feelings of loss, sacrifice • Solution requires learning and a new way of thinking, new relationships • Those with problem must be those who develop solutions R Heifetz, A Grashow, M Linsky. Adaptive Leadership, 2009 Why Cycle Time? Patient Satisfaction YTD Dec 2014 120 100 80 60 40 20 0 explai ns Burki 87 98 Huselton 91.5 97.2 McGrail 92.7 98.2 Myers 90.7 96.1 Meyer 80 100 overall listens 96.3 97.2 98.2 96.1 100 instru cts 96.1 98.5 96.1 93.2 90.9 knows 88.9 97.2 98.2 97.4 73.3 respec ts 98.1 98.6 100 94.7 93.8 time 92.6 97.2 96.4 96.1 100 reccm nd 88.9 97.2 98.2 93.3 93.3 access 76.6 76.6 67.5 71.6 78.8 Patients perception of “knows my history” seems to drive overall score; it would be good to understand what that means to patients; national percentile rank: 50%tile = raw score of 92 Overall Office Satisfaction Trends 120 100 80 60 40 20 0 Seen within Rec 15 min office of appt Mar-14 100 95.7 Jun-14 54 98 Dec-14 51.6 94.2 Test Access results 75.2 72.7 70.3 100 94 92.9 Office Clerks Clerks staff treat w Nurses helpful quality respect 95.7 96.1 94.9 94 93.8 98 96 92.6 Defects Medications/ immunizations errors, missed screening opportunities/abnormal results Overproduction Doing more than is asked, needed, or really possible in a visit Waiting Lines, staff waiting for patients, patients waiting on phone or waiting for staff; MDs for POC testing Non-used Talent staff waiting for patients, patients Top •ofLines, license issues, moving secretarial tasks to waiting phone or waiting for staff support staff;on forms processing Transportation Pick up of lab specs, movement of paper through office Inventory Stocking of rooms, supplies outdate before used Motion Extra/over processing Too much back and forth, walking to find/get reports, AVS etc Multiple people doing same tasks or parts of tasks 8 W A S T E S Current Process Nurse visit Check in 5-10 mins 3-12 mins Waiting Room Check out Provider visit 7-14 mins 3-27 mins 13-25 mins 0-? mins 0 - ? mins Exam Room • Total process time overall: 35 - 83 mins • Value added process time: 25 – 49 mins • Wait Time: 10 – 34 mins Resource for process map & workflow diagram P Scholtes, B Joiner, B Streibel. The Team Handbook Chp 4 Front Desk MD Office Exam room AVS printer Exam room Exam Room Workflow Diagram Nurses station Rx Printer/ scale Secretaries This is the activity pattern for 1 patient who needed spirometry during the visit Patient Nurse MD Waiting Room Relational Coordination (How we would normally engage you) 1. What is Relational Coordination? • Communicating and relating for the purpose of task integration 2. What is the Relational Coordination Survey? • Seven question instrument based on Frequent Communication Shared Goals Timely Communication Shared Knowledge Accurate Communication Mutual Respect Problem-Solving Communication • Survey participants re a particular work process • Communication and relationships with other participants in that work process Role Groups Survey Questions 1. How frequently do people in each of these groups communicate with you about addressing patient wait time in the office? 2. Do they communicate with you in a timely way about addressing patient wait time in the office? 3. Do they communicate with you accurately about addressing patient wait time in the office? 4. When there is a problem with patient wait time, do people in each of these groups blame others or work with you to solve the problem? 5. Do people in each of these groups share your goals for addressing patient wait time? 6. Do people in each of these groups know about the work you do with addressing patient wait time? 7. Do people in each of these groups respect the work you do with addressing patient wait time? Your Aggregate RC Results Debrief • What’s the story or example you could tell about these numbers? • Does anything surprise you? • What do you think would be the most important dimension for the team to work on? • Is that something that you’d be willing to do? Start where you are. Use what you have. Do what you can Teddy Roosevelt Brainstorming • Used to help brainstorm and focus on the reasons why a problem is occurring • Problem: Long cycle time for patients • Let’s brainstorm root causes: • Process/Policy • Equipment/Supplies • Environment Think about what you see in your day to day • 8 Wastes work that, if done differently, could improve patient cycle time. Write down all the ideas on post-its (6 mins) Resource for brainstorming, multi-voting & nominal group technique: P Scholtes, B Joiner, B Streibel. The Team Handbook Chp 3-13 through 23 Prioritizing: Multi-voting • Cluster Post it notes in shared categories • Review, name categories • Vote • Identify priorties Next Steps • What can we start right away? • Next meeting: Future State Process Map If you want to go fast, go alone. If you want to go far, go together. African proverb Debrief Workshop • How did we set up the team meeting that could produce a change in the team dynamics and behavior? • How do you do these things within the constraints of real time limits? • How is similar or different than your home practice? • What got you excited or curious? Enhancing Facilitation with Relational Coordination Data outtakes • Assumption: This is an office with some ground of health; that assessment is based on either site visit and conversation, observation and/or review of self assessed function/teamwork • If ground of health is not present at a foundational level, don’t start with something this complex; start with something simple and an easier win; you may not even be able to start with work; you may need to start with relationship repair or basic relationship building • Without collecting new data, some data is routinely collected by healthcare organizations that can be used to form some initial impressions about the team’s ground of health: existing patient satisfaction scores, existing hedis measures (not as helpful for safety net settings), Culture of safety scores (or equivalent) • Existing scores provide information about how well the teams are doing under current circumstances, but do not necessarily give an accurate picture of their capacity to be creative, to learn, and to adapt to changing circumstances • A goal central to improvement work is to do the work , improve it while doing, and to create self sustaining, reflective, learning communities Vision Continuous Quality Improvement Multi-method Assessment Process and Reflective Adaptive Proces Improved components, improved measurement, improved patient outcomes Reflective, adaptive practices, increased capacity for learning, improved systems, richer connections & relationships, improved pt outcomes Leadership Create better run Goals organization, increased efficiency, effectiveness, predictability and control Optimize potential to co-evolve in ways that increase organizational fitness Perspective Emphasizes developing learning capacity Leverages diversity Promotes some types of diversity Frames the future by social interaction Recognizes/uses interdependence of the formal & informal organization Uses social interaction for sense-making Uses multiple methods/perspectives to enhance learning capacity and identify priorities Emphasizes what agents know today Attempts to minimize effects of diversity Strives to reduce variation Frames future by planning/ forecasting Tries to get everyone to conform to the formal organization Does not focus on social relationships Continuous Quality Improvement MAP & RAP Teams Views teams as the way to implement organizational change and solve problems Patients typically not members of team Facilitator sometimes viewed as external to the team Views teams as connected to the entire organization and a small complex adaptive system that may change the culture of the entire organization Patient is a full team member Facilitator acknowledged as part of team, not external to it Orientation Improvement cycles to enhance one process at a time Enhance relationships and information sharing around a set of interrelated processes Stroebel C, McDaniel R, Crabtree B, et al. How complexity science can inform a reflective process for improvement in primary care practice. J on Quality and Patient Safety 31(8): 438-446, 2005