Feb 27, 2015

Announcer: These are the conversations happening inside health care that are going to transform health care. The Health Care Insider is on The Scope.

Wendy: I'm Wendy Chapman, I'm the Chair of Biomedical Informatics at the University of Utah. And we have a special guest today from Pittsburgh, Pennsylvania. That's Dr. Tania Lyon, and Tania has spent the last six years leading a large community hospital in Pittsburgh through a lean transformation. She's their first Director of Organizational Performance Improvement and we're looking forward to hearing from her about how you change culture in health care to improve our care of patients. So, Tania, what's been your experience? You have a background in sociology, and you found your way to the health care industry. How did that happen?

Dr. Lyon: There are any number of issues that involve how organizations and people interact with each other that kind of comes out of sociology, so I think I've always had this fascination with how do you make organizations work for people rather than the other way around. And, certainly, we have a health care industry that does not work very well for people. It's not necessarily been designed around the patient, it's often designed around the convenience of physicians, or it's designed around the way our payment system is set up. And I think what's been happening in the last 10 years is a major shift towards trying to re-orient the way that we deliver health care to make it patient and family centered.
So, a little bit of the story that led me to what I'm doing now is I work for a community hospital in the suburbs of Pittsburgh, Pennsylvania. We have remarkable stability. We just celebrated our 60th anniversary this year, but we're only on our third CEO, which is fairly remarkable in health care, you often have high turnover in senior management for hospitals and insurance companies and things like that. Eight or nine years ago, the new CEO, our third, came on board and kind of inherited a good enough hospital. It was good, we were winning awards, it had good standing in the community, but there was not a culture of change. It was a culture of we just keep doing it because this is the way we've always done it.

Wendy: Tania, can you tell us how you helped your organization turn around your emergency department from being one of the worst to being one of the best?

Dr. Lyon: We had to change the way people thought about their work. We had to show them the value of changing the way they did things. So what I did was I brought in this philosophy called "lean", which is really, it came from Toyota. Toyota is probably the best documented, best example of a lean organization. Another way of describing that would be a continually learning organization. Someone who has an organization that has learned how to make mistakes, but acknowledge them and learn from them, so that you're constantly improving.
So, one of the important elements of that is to not make decisions in a conference room or in a board room, but to have a much deeper understanding of what things are actually like on the ground. You go to where the work is being done. So, instead of just saying "Hey, the literature says that we should be doing this, so everybody from now on, do it this way," we pulled in people from every aspect of that intake process. So, we had registrars, we had techs, we had nurses, we had day shift and night shift represented, we had management, we put everybody in a room and we asked them to help map out this intake process. How could we make that work every time, every patient? And we let them design a new way of doing it that was grounded in what they knew they were going to experience every day. And we picked a time to test it.
So, that's a big way to approach change in a organization is, rather than announce "We need to do it a different way, and here's the way we're going to do it from now on," is to frame it as an experiment. Let's just test this, okay? We're going to be scientific about this, so what we want, we want you to try this with us for a specific amount of time, we're going to get your feedback. Then we can decide if this is something we want to go. Much less threatening. People are more willing to experiment if they know that they're going to be asked their opinion on it.

So we picked a 24-hour period to try this new method, this new intake process, that had been designed by the people who do the work. And at the end of the 24 hours, the idea was we'll discontinue it, we'll kind of evaluate it, and we'll see what we need to change and we'll go back and try again. At the end of the 24 hours, nobody wanted to go back to the old way, and so we just kept it going from there, and tweaked it as we learned. We kept meeting regularly and made a lot of ongoing improvements to it, and our turnaround story is really quite remarkable.

We started out in the 14th percentile nationwide for emergency department our size in overall patient satisfaction. That's pretty low. If you remember your SATs, you don't want to be down there, in the bottom percentiles. We were first percentile locally. We were the single worst emergency department in the region. People were driving past our hospital to go to other emergency rooms because we had such a bad reputation. And in just 18 months, we were in the 95th percentile, which was our wildest dream, and a quarter later, we were in the 99th percentile. And we've held that for about five years now. So there's consistency as well, it wasn't just a big bang, but we really were able to change the culture and hold it there.
There is a lot of pride. We lost people. That's an important part of culture change, is that there were individuals who really did not like that we were going in that direction or that we were asking people to shake things up and start looking at things differently. They were comfortable in the way things had been, and they left. Either they self selected out or they were invited to leave, and I think that's a necessary part of major culture change in any organization.

But the results cannot be argued with, and now you find that people are smiling when you they go down to the ED. Often, if you walk through our emergency room, things are kind of very quiet and you might make a comment and say "Oh, so we're not very busy today," and staff will look at you're crazy "Are you kidding? Every room is full." But we've really ironed things out and made a much more stable process that everyone had a chance to buy into and try and recognize its value. And that was kind of our starter miracle story that showed people we can change the way we deliver care, cultures can change, our department culture changed there, and so from there we started spreading it to the rest of the hospital.

Wendy: That's an amazing story. So, summarize for us, what do you think were the important elements that made that succeed?

Dr. Lyon: There were several things. One was it was definitely an organizational effort. It wasn't just that the ED has bad scores so the ED needs to fix its problems. What the senior management team understood was that the ED is not living in a vacuum. One of the big problems with getting patients out of an ED is finding beds for them in the hospital. So we actually had to look at it as a full continuum of care. Like, why are people still in our beds when they don't need to be? Can we do a better job of reducing the unnecessary delays that keep people in hospital beds longer than they need to be? And so, we were looking at it from that perspective as well, it was basically a throughput initiative rather than an ED initiative.
So, seeing it globally was important, and having the senior management team involved and interested and watching the data. Often, my boss, our Chief Operating Officer, he could pull up on his smartphone the status of the ED and could see at a glance how many people were in the waiting room, whether someone had been there for over two hours. He could pick up the phone at 3:00 in the morning and say "Hey, so why is so-and-so still here?" And it was that kind of attention that really made people realize this is important, we need to change.

So, the leadership component is really critical, looking at the big picture was really critical, and then I think that piece where you ask the staff who do the work to help redesign that work is critical, rather than telling them how they need to change their work.

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