HealthPartners Medical Group and Clinics
Bloomington, Minnesota, USA
In the second of three interviews with CEOs regarding their first-hand experience in transforming health care in their organization, we talked to Mary Brainerd, CEO, HealthPartners Medical Group and Clinics in Bloomington, Minnesota. HealthPartners is a participant in IHI’s Pursuing Perfection program, and Mary has been instrumental in its transformation.
IHI: What made you decide to embark on transforming HealthPartners?
MB: A couple of things caused several people in our leadership team to think that transformation was the right thing. The Institute of Medicine (IOM) reports were one motivator, as we all saw the reality of the situation reflected in the comments that were made and the examples that were given. And personally, I had a serious health problem and knew from that experience what the care delivery experience can feel like to someone with a serious health problem
The challenges we have with effective staff and patient communication, handoffs between specialists, and implementing best practices became increasingly clear to me. It was very apparent that patients end up reintroducing themselves to the health care system and their caregivers far more than they should. I could see personally how the experience felt and realized the opportunity that we had, given all our capabilities in care delivery, to make some really significant breakthroughs.
IHI: Where did you start?
MB: HealthPartners has a culture of continuous quality improvement that goes back a long time. We had a couple of major projects planned and about to begin, and already had begun work to see if we could achieve some outstanding results for people with chronic illnesses, starting with diabetes. So it was changing our mindset to say, “How can I support this work and use it as a basis for breakthroughs in transforming care?” The work we had on the horizon for advanced access felt like an opportunity to test our potential with system-wide change. And at that point, it became clear that we needed some infrastructure and cultural change as well.
One major infrastructure change needed to be wide-scale implementation of the electronic medical record. It is pretty clear that you are not going to affect the need for people to reintroduce themselves until you have access to information that is far beyond how fast we can move a paper medical record around. We also began making the case for approaches that put the patient experience at the heart of our work. That was the next area of focus.
IHI: How did you begin to change the culture to support transformation?
MB: We deliberately changed our governance structure by changing the focus of one of our board committees to transformation. It is important because, absent that, it is too easy for work like this to become a “project,” — or worse yet, someone’s “pet project.” In our case, it has become a part of the work that our Board thinks is necessary for our future success.
IHI: What is the charter of this board committee?
MB: The Care & Health Transformation Committee is charged with establishing the goals for care and health transformation. They clarify the aims and help us set our sights high. They help develop measures and a common language for this work. To hold a whole organization accountable for results, the board really needs to know and have a role in determining how we are making the changes.
IHI: How are you working to change the culture elsewhere in the organization?
MB: We had been communicating more to staff about the organizational aspirations, but heard back that they did not understand it. They understood the words, but wanted to know how the organization would be different and how they would know if we were accomplishing the goals.
We used theater to address these concerns by commissioning a play from Mixed Blood Theatre Company. In the play, Fire in the Bones, there is a “before” and “after” theme about what health care is and what it could be. The staff did prework before the play, and after each performance we had an open discussion. It was a way we could create dialog and a common experience for our more than 9,000 employees.
This strategy turned out to be a riskier move than I thought! We received a lot of feedback. The good news was that people really felt the “after” scenario connected with the reason they went into health care in the first place. They said things like, “This is the kind of work I wanted to do,” “This is what makes health care exciting,” and, “This is what my real motivator has always been.”
On the other hand, we also heard, “We feel like management and the organizational leadership make decisions without understanding the work we are doing,” and, “We feel like we don’t have enough involvement in changing the work ourselves.” We saw opportunities for change not only from a patient perspective, but also from staff’s perspective.
We also performed the play for some community roundtables, comprised of consumer advocates and representatives of minority communities. We were concerned that the play might be too melodramatic, or not illustrative of reality. In one performance, however, a young man of Southeast Asian descent stood up and said that the play depicted exactly how he had reacted to his own health care situation. He had pulled away from it even though he had just been diagnosed with cancer.
Overall, the play was provocative, so we had real rigorous, emotional discussion afterward, which was not at all easy for us as leadership to hear. But clearly, it was necessary, and we are grateful for the feedback because it will allow us to make sustainable changes.
IHI: What are the biggest barriers and what are you doing first?
MB: We are trying to talk about the real issues, and what we have found is that people sometimes assume that their leaders are primarily concerned with operational efficiency and financial results. We realized that we need to be much more present with our staff than we have been in the past. The voices of our patients and consumers are not very clear, so we make decisions that often do not work well for our front-line staff, our patients, or our members. We have been moved to say that if we want to be patient-centered (and that is what the play is all about), we need to incorporate the voices of our patients in the design work that we are doing, in making decisions, and in shaping the discussion.
We have two clinics that are doing complete care redesign for primary care, all the way from before someone comes into the visit to after they leave and go home. In these cases, there are patients involved in the design along with the care team. The receptionist, the care team, and the patients are redesigning the care together.
We use video to capture patients’ perspectives and share it much more widely in the organization so that we get the voices of the patients telling their own stories. We have a very engaged Patient Council with a strong perspective that is brought to many of our plans and decisions. We find that having patients involved in the planning and decision-making changes the discussion.
IHI: Have you seen any changes so far?
MB: We have seen more of our employees feeling empowered to make changes on their own that might improve things for patients. In our oncology program, a doctor and a nurse thought that there might be a better way to prepare for visits, so they did what IHI calls “small tests of change.” We see more of that happening without someone saying, “You need to do this,” from a management perspective.
IHI: How are you being more present with employees?
MB: In a couple of ways. We continue to do extensive small group forums directly with employees. They are not related to the play anymore, but to the work, our aspirations, and to how they can have a stronger voice in the decision making of the organization.
We also created an Intranet forum that is used actively. The discussions are no longer about the play but about recognizing people who are doing creative things, raising concerns about roadblocks people see in their work, and suggesting how we can remove them. People express their opinions about corporate changes as well.
IHI: Who responds to the Intranet forum?
MB: I read all of the questions. I get help with some answers, and some I respond to myself. Now the volume is so high, I receive a great deal of help!
IHI: What are your next steps?
MB: To be clear about results. I think we have been pretty clear about the aspirations, but we need to hold people accountable for, and have a system capable of, achieving results. We also are focused on the business case. As Jim Reinertsen says, and it is so important, “As long as somebody thinks there is quality and the ‘rest of the business,’ we will never have sustained change.” So, we are looking at how to effectively make the case for these strategies at the core of our business. We have started by changing our annual planning process so that everyone focuses his/her annual plan on the IOM’s six aims. We stressed in last fall’s planning process that “everything you do must relate to the six aims,” and we will focus on this again in this year’s planning process. Performance measurements will be against those aims. Those measurements are the most challenging for us right now.
IHI: What is your advice for other CEOs?
MB: Building quality improvement work into the leadership and governance structure so that it is not a project will be absolutely essential for sustainable change and transformation. I cannot say that strongly enough.
For more information about organizational transformation, read Jim Reinertsen’s paper entitled, A Theory of Leadership for the Transformation for Health Care Organizations.
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