Each Person. Every Moment. Better Never Stops.

On the Road with Virginia Mason Health System – November 2014

by Michelle Garrison and Jason A. Wolf, Ph.D.

A Powerful Strategic Focus
Our latest On the Road took us to an unusually sunny Seattle to visit with Virginia Mason Health System and explore the comprehensive effort they have taken on to transform their organization into a leader in patient experience improvement. We purposefully use the word improvement as the team at Virginia Mason reinforced throughout our visit, what is found at the heart of their efforts – “better never stops.”

Through a comprehensive strategic plan, a structured improvement methodology – the Virginia Mason Production System – and a commitment across all levels of the organization, Virginia Mason is focused on pursuing the perfect patient experience. For them, the perfect patient experience is achieved when patients experience high quality, and safe appropriate care combined with extraordinary service. For this to happen, they believe that they must remove the unnecessary elements from patient encounters including wait-times, non-evidenced based care and added cost.

Susan Haufe, Administrative Director, Patient Relations and Service, (pictured right) will be the first to admit that this journey has not been an easy one. When she started, the Patient Relations and Service team was a three person “complaint department.” Now the team has 14 staff members.Transformation has required a cultural change within the organization. She recalls how when she first started no one walked patients to their destination. It took time and training, but now things are quite different.

It is clear that the patient is a priority and in fact patients frame everything that they do. This is reflected in their strategic plan (pictured below). At the very top of the pyramid is the patient. The pyramid is included at every meeting, and the image is seen consistently throughout the organization. Having the patient clearly located at the top of their plan reinforces their importance for the organization.

The patient experience effort at Virginia Mason has been focused and intentional, first taking formal shape in 2008 when identified as an organizational goal. It was supported in that and subsequent years through not just a declaration of importance, but through investment in people, processes and resources to educate, reinforce and engage people in the importance of experience excellence.

Moving into 2015, they are embarking on a new phase of their journey and the next steps of expanding their experience effort. As they continue onto the next phase of their journey, there are several key areas of focus they are addressing. They have developed a strategic service plan that has an underlying goal of creating an extraordinary patient experience. Included in this strategic plan are the integration of quality and service where the patient experience is integrated into organizational strategies; a partnership with patients and families with a focus on active patient and family participation in process improvement to transform care delivery; and a need to engage, develop and activate people where they select people for service, develop their skills and enhance accountability with their people.

These elements reinforce the powerful simplicity and paradoxical complexity of experience improvement and focus on all those elements we deem to be central to patient experience success. To underline this strategic focus, Virginia Mason also introduced a new branding effort built on the powerful slogan, “Each Person, Every Moment, Better Never Stops.”

Power of Executive Sponsorship and Board Support
What Virginia Mason also exemplifies is the true importance of every person from the front lines to the executive office and beyond. In fact, they were one of the only On the Road visits that engaged a board member (and experience champion) in our discussion. This is a unique aspect of Virginia Mason’s Patient Relations and Service Team. They purposefully and actively engage champions from senior leadership that function as executive sponsors of patient experience in the organization. Pairing a physician leader, Dr. Donna Smith, Medical Director, Clinic, with an administrative leader, Katerie Chapman, Vice President, Perioperative and Support Services, in a leadership dyad, they have created a team that is able to see both sides of the equation and work together to focus on process improvements and improving the patient experience.

As Virginia Mason traveled their experience journey, a transition occurred where patient experience once seen as something “over there” became purposefully integrated into the work. In the early stages, like many organizations, Virginia Mason struggled with a focus on and commitment to these efforts, with the team working hard to show ROI and validate the needs, but now with a solid focus and strategic alignment things have started to change.

In aligning executive champions passionate about the work, they worked hard to “make the patient experience about us,” said Dr. Smith, meaning it had to include ALL voices, not just those accountable for outcomes. As champions, each individual had a role to elevate the conversation and reinforce the critical nature of the work. It took time and persistence, but the organization followed willingly. Some of the influence was also driven from the very workings of the Virginia Mason Production System (VMPS) itself, which reinforces that the customer defines value. “If that is the case, then we need to ensure we are focusing on our customers need to ensure we are providing that value,” added Dr. Smith.

Both Dr. Smith and Katerie also spoke to the value of executive champions and how they have been able to help. They have been in a position to elevate the conversation, to ensure resources, raise awareness and even weigh in on critical budget issues that could help (or limit) the experience effort. Katerie offered, “That by integrating our effort into the work of the organization, it is now part of our fundamental growth strategy.” No longer one of many potential focal points, she continued, “the benefit of having the right people at the table is that there are no more isolated patient experience conversations.”

This was reinforced further by the clear awareness and engagement of Virginia Mason’s board as the idea of having the right people at the table is carried over to the executive board meetings, and some of those right people are patients. A patient or family member attends every Board of Directors meeting and shares their story, making sure the patient voice is present. Lonnie Edelheit, Virginia Mason Health System board member, says that the sharing of patient stories is beneficial for the board members. “When patients come and share their stories, it can be electrifying.”

He recalled one such story that actually came from a Virginia Mason employee who attended a board meeting so she could share her own experience as a patient. She shared how she had been too intimidated by her physician to ask him what she saw as a critical question. She had not seen him wash his hands, but she was afraid to ask him about it because of the reaction she might receive. Through the sharing of these stories, the board members are able to maintain a connection with the patients and align with the strategic service plan area of partnering with patients and families.

In addition, Lonnie reinforced that the board can (and should) play a critical role in ensuring experience success, offering, “We have an accountability to the organization and the community to ensure the best experience.” This reinforces the powerful nature of governance and the impact it can and should have on experience excellence.

Designing with Instead of Designing for the Patient
In expanding the conversation on having all voices at the table, in addition to bringing in patients to share their stories, Virginia Mason welcomes their patient-family members as equal partners in the work they are doing. Through the Patient-Family Partner Program, they are finding new ways beyond the typical Patient and Family Advisory Council to engage with their patient-family members. There are many ways to be involved in the program from improvement workshops to serving on focus groups and panels to volunteering in the hospital.

Working with their survey provider, they added a question to their patient surveys that asks patients if they would like to be involved with the hospital. If a patient checks this box, they are contacted to see in what areas that would like to volunteer. Physicians also have cards that they can hand out to their patients with more information about the program.

Through the Patient-Family Partner Program, Virginia Mason has created a comprehensive process for engaging with patients and family members. There is a recognition, though, that not every patient is ready to serve in the program. To address this, they have created a checklist that helps patients and family members recognize if they are ready and prepared to be a Patient-Family Partner. If there are statements on the checklist that a patient or family member might not agree with, they are encouraged to work on these items before becoming part of the program.

This checklist consists of 11 statements. Some examples include:

• I am willing to talk about the positive and negative care experiences I had as a patient or family member of a patient.
• If I had any negative experiences, I am coping well and I am ready to respectfully share my ideas about how things could have gone differently.
• I am ready to speak up and share suggestions and potential solutions to help improve hospital care for other patients and family members.
• I have time in my schedule to be a partner. Usually partners spend at least 1 hour a month and not more than 4 hours per month. You may volunteer to be on a specific workshop; in that case it may be several days up to a full week.
• My motivation is to help future patients and families.

In addition to the checklist, patient-family members complete a detailed questionnaire as well as go through an interview process. Ann Hagensen, RN, Patient Relations Project Manager, reviews the questionnaires and administers the interviews. Through these interviews, she finds out what matters most to the patient. She shared, “It is important to realize that patients want to work and to contribute, not just tell their story and leave.”

Creating Remarkable Experiences for Patients
One cannot talk about the work of Virginia Mason without acknowledging the presence and impact of the Virginia Mason Production System (VMPS). We must also note up front that volumes have been written to address and explore VPMS alone, and we will not do that here. Rather we will share how it has impacted the experience efforts.

As an integral part of the operations of Virginia Mason, VMPS was alluded to or mentioned in almost all our conversations during our visit. So of course the question is: “What is the Virginia Mason Production System?” At its core, it is a management method that seeks to continually improve how work is done so there are zero defects in the final product. 

This management method allows Virginia Mason to identify and eliminate waste and inefficiency in many of their healthcare experience processes while allowing for staff to deliver high quality and safe patient care. As a result, it also provides staff members with more free time to spend talking with, listening to and caring for patients. VMPS is a daily part of the work at Virginia Mason and is central to the success they have seen as an organization.

VMPS is managed by an internal cadre of consultants and coaches who engage in key initiatives directed at improvement process and outcomes. The Kaizen Promotion Office sits as the control center for this vast and impactful work. It also serves as the location for weekly huddles in which key executives, leaders and staff come together to address key areas of focus, organizational value streams and track metrics for improvement.

The evolution of VMPS is significant, as the organization has found a clear process by which to adapt a non-healthcare model with great success to the highly dynamic healthcare environment. As we look at the VMPS work from the perspective of experience, what is clear is the organization’s efforts to move outside the primary “process box” to think about all the players involved in the dynamic of delivery. Central to this is the inclusion of patient and family voice. One of the primary means for enabling this has been through the addition of Experience Based Design efforts in driving improvements.

Virginia Mason introduced Experience-Based Design (EBD) training tools in 2009. At the beginning, there was a concern that with the introduction of EBD the organization would lose its focus on the LEAN process central to VMPS. Instead they found that it filled a gap, allowing for the patient (as well as the staff’s) story to be included and providing a method to address the role that emotions play in patient care. Today, they are faced with the challenge of keeping up with the increasing level of interest and demand for training on applying EBD throughout the organization.

Reinforcing the Importance of Staff
At the core of the work of Virginia Mason and their commitment to be a quality and experience leader is the organization’s strategic focus on its people. As important as patients and family are in everything they do, Virginia Mason, as evidenced by their strategic service plan to engage, develop and activate people, has not forgotten to focus on their staff as well. At the end of the day, we had a chance to sit down with several front-line operational and clinical leaders from throughout the organization and share a conversation with them, learning more about the roles they play and the impact they have on experience.

A critical insight shared by one leader was the recognition and acknowledgement that while the job they do every day is not unique or new to them or their staff; it is unique and new for the patient who may never have been through this experience. When you use this lens through which to see your work, it begins to shift how you engage with those on the receiving end of care.

When asked the question, “What makes Virginia Mason different?” the responses all revolved around two common themes: one, that the role of innovation and improvement has created a common language and process for ensuring people are doing the right thing every day and, as Alana Pumphrey, Manager, Cardiology Clinic, shared, “At Virginia Mason, it is clear that both the patients and the staff are valued.”

This discussion of the value of staff ended our day as it started. Susan Haufe, our host laid out the overall roadmap for experience improvement over the last eight years and shared a common theme among the efforts that resonated at all points during our visit – that people were at the center of this work and, in fact, “respect for people” was not just a nice phrase, but a central framework grounded in foundational and expected behaviors. Susan shared, “Each person” isn’t just something we say. It’s everything we do, every day.

A living example of these values came through from our host and tour guide Jennifer Bradley, Director, Patient Relations and Service, (pictured here with two volunteers) who shared with us that she chose to come to Virginia Mason because of the people she encountered here. But not only did Jennifer show us the work of many others, she exemplified the attitude of the staff we met with throughout the day. Her past experience working at a children’s hospital has provided her with a unique perspective on how to connect with the patients and families she meets. One example she offered is how she hands out a stuffed animal toy to patients who don’t have family visiting. She will leave the toy with them saying, “I can’t be here, but my friend can.” Doing this allows her to make connections with patients. As she says, “It is those connections that make all the difference.” It is also the small moments such as this that can carry a lot of meaning for patients and families. Because of this, Virginia Mason’s focuses on listening carefully to each person, engaging with them in language they can understand and delivering expert care that is worthy of their trust. It is clear as well that they have made working together as a unified team to meet the healthcare needs of their patients a priority.

Virginia Mason’s strategy, built for and focusing on their people, has led to a number of exciting learning innovations, perhaps one no more unique than the establishment of a Patient Experience Fellowship program. A six-month education program, the fellowship is designed for Select bedside caregivers, RNs and PCTs (Patient Care Technicians) bedside caregivers and nurses to develop their knowledge and skills as well as expand the network of organization champions guiding experience efforts. Currently 36 staff members are participating in the inaugural cohort. The program is comprised of four full day sessions, educational offerings and mentoring over six months which consists of communication skill building, change management and leadership development.

Fé Ermitaño, RN, Patient Experience Project Manager, who leads the program shared that the response to the program from the participants has been powerfully affirming and they feel that they are on a transformational journey. However, one of the biggest challenges has been seen in the project work, as they want to immediately try to solve big problems. Instead she advises them to focus on smaller deliverables because “through small powerful acts, they can be an everyday leader.”

We saw several other examples of the focus on staff. Shannon O’Keefe, Service Coach, spoke of their phone etiquette-training program. The training is for employees who spend more than 80% of their time on the phones. This included nearly 1,000 staff members. The training was so successful and widely received that others are asking to be included in the training. They recognize that many of the skills being taught in the program are applicable to not only phone interactions but fact-to-face interactions as well.

Through training programs and educational offerings, the staff at Virginia Mason are learning how to own the experience, make it amazing and wow their patients. They are empowered to handle patient issues. Essentially they have been “deputized” to be experience leaders in their own way. This allows them to elevate not only the patient experience, but the staff experience as well. In just these few examples, we have seen the integration of strategy, practice, process and commitment – words that while they may not be explicit in what Virginia Mason talks about in defining their efforts, are unmistakably present in all you see they are doing every day to impact the experience for all engaged in the organization.

Better Never Stops
In wrapping up our experience with Virginia Mason, we had the privilege to spend a few minutes talking with Gary S. Kaplan, MD, Chairman and CEO of Virginia Mason (pictured right). Our conversation reinforced the key theme running through all we experienced during our visit and reflected the focus, intention and effort we saw throughout the organization.

He started by sharing how he was very proud of the team, acknowledging that while they have accomplished a great deal, “I know we can do a lot more.” This is a common statement we hear from leaders in high performing healthcare organizations – that great or best are not places to achieve – but rather as the Virginia Mason brand reminds us: “Better never stops.”

Dr. Kaplan also underlined key messages we heard on our visit. First, the patient and family experience is everyone’s work and responsibility regardless of the role they play. This is reinforced by having visible and clear leadership champions starting at the top, including himself. He added, “If I’m not living and breathing what we believe is important, why should anyone else.”

Dr. Kaplan noted that the experience improvement effort at Virginia Mason took focused and intentional work and broad commitment, offering, “it wasn’t always the way it is here today”. In asking how they were able to move the organization forward, he added, “you have to be kind of nuts about it.” Expanding on this thought, he suggested it requires a relentless commitment to your people and processes to make and sustain improvement in these areas.

We asked Dr. Kaplan what he would share with other leaders and executives about what he learned along the way as they have traveled this improvement path, and he provided some powerful insights:

First, this needs to be senior leadership work. You cannot just pass it off to a department to do; it must be championed by leadership, but not micromanaged and then it must be owned by everyone in the organization, including the board.

Second, the CEO must do more than advocate. Instead they must reinforce it is part of “my work”, then be willing to ensure the effort is supported, resourced appropriately and given a sense of empowerment to move forward.
Third, you must have the commitment and the humility to engage the voice of patients and family members in as much as you can. He noted Virginia Mason made a conscious decision not to have a Patient and Family Advisory Council (PFAC) as the default framework for gathering input, opting instead to integrate patients and family members in all improvement and design events. The purpose is to have active and engaged voices at the points of creation, rather than reaction.

Lastly, Dr. Kaplan offered a point central to all we espouse via The Beryl Institute: “Patient Experience is all part of the whole of what we do,” he said. “We do not have a patient experience initiative, but rather it is who we are and who we aspire to be.” It is this dynamic of aspiration that acknowledges for every step on the journey to experience excellence – providing the best in quality safety and service outcomes – that there will always be a step to follow. The team at Virginia Mason was unwavering in their commitment to the idea that improvement is not something you achieve, but rather an effort that moves you forward continuously. We concur and were inspired by all we were able to experience in our short time together. Virginia Mason has made great progress towards experience excellence, in driving improvement and innovation, but perhaps their greatest “ah-ha” will remain in being relentless in their pursuit; for it is true – better never stops.

Our Appreciation
As no On the Road story can capture all an organization is taking on to impact the patient experience, we encourage you to dig deeper connect and explore further what Virginia Mason is tackling in their efforts. One great opportunity will be during Patient Experience Conference 2015, when members of the Virginia Mason team will offer a pre-conference on the impact of Experience Based Design on their overall experience efforts. The session will provide a comprehensive and powerful overview of how Virginia Mason continues to evolve their efforts to drive the best in outcomes overall.

We offer special thanks to Susan Haufe, Jennifer Bradley and the entire team at Virginia Mason for providing a full and welcoming visit and for their willingness to share the Virginia Mason story with all of our community.