Transcript Making Room for Process in Relationship-centered Care

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
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10 min
5 min
5-7 min
10 min
5 min
10 min
25 min
10 min
Topic
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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