Creating the Burning Platform for Change - Trinity Health

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Case studies of Trinity Health,
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Breakthrough Business Management in Health Care
n Creating the burning platform for change
n Designing economic incentives
n Coordinating evidence-based care
n Tracking performance in real time
n Integrating supply chain functions
Fall/Winter 2009 Report

S e c t i o n 1
6 LEADERSHIP | Fall/Winter 2009

Creating the
Burning
Platform
for Change
Forward-thinking healthcare leaders are not waiting for
legislation to dictate how to transform health care. They have
a vision of the future—and they are already headed toward it.
There are many ways for healthcare organizations
to move toward higher quality and greater
coordination and efficiency in patient care. But
all paths start from the same point: a leadership team
that effectively identifies and communicates the need to
radically restructure the way in which healthcare services
are delivered.
That transformation requires leaders to bring all
constituencies—the governing board, physicians,
clinical managers, employees, vendors, patients, and
the community at large—on board with a new vision
for the organization.
Finding the Right Platform
Setting an example in proactive leadership, executives at
Michigan-based Trinity Health launched a major technology
investment and change initiative nine years ago. When
they foresaw the current financial crisis—in trends such as
sharply reduced patient volumes and rising bad debt—
they moved quickly to build on their earlier preparations.
By the time the stock market collapsed in September 2008,
Trinity Health president and CEO Joseph R. Swedish was
ready to launch a series of initiatives to fundamentally
reinvent the system’s business, which includes 45 hospitals
and 379 ambulatory facilities in seven states.
“To take the organization to the next level, it was
necessary to more aggressively unify and standardize
our processes of care delivery, service, and support so as
to reduce variation and accelerate gains,” says Swedish.
The program, called “Sustaining the Ministry,”
started with immediate steps, including capital
spending reductions, to offset a multimillion dollar
budget gap resulting from the unprecedented challenges
of the recession. Beyond that, however, the program
is guiding Trinity Health as it redefines the model of
care. “This is really our effort to accelerate change in
the organization,” says Kedrick D. Adkins, president
of integrated services at the not-for-profit Catholic
health system.
By “change,” Adkins means a radical departure.
Trinity Health aims to transform itself from a traditional,
hospital-centric organization that focuses primarily on
acute care to a care delivery organization that delivers
the full spectrum of care—ambulatory care, critical
care, chronic disease care, long-term care, home care,
retail-oriented care—in a coordinated, efficient manner.
The vision reflects a healthcare ideal in which
providers work together across care sites to deliver the
highest-quality care in the most appropriate setting
and in the most efficient manner.
hfma.org/leadership | LEADERSHIP 7

The vision also makes good business sense as
hospital-centric organizations watch inpatient volumes
decline and outpatient numbers rise. Revenue from
ambulatory care and physician practices now represent
almost 50 percent of Trinity Health’s business.
Fortuitously, Trinity Health’s
$400 million investment nine
years ago has proved crucial
toward achieving the system’s
new vision. The majority of the
dollars went toward building
an electronic health record
(EHR), complete with computerized
physician order entry,
which is now up and running
at 22 system hospitals.
Physicians can now access
medical records and place
orders from the hospital, their
homes, their offices, or
anywhere. Nurses are spending
8 percent more time with
patients, as opposed to
documenting in paper records. Most important, patient
safety has improved: Computer-generated alerts flag
about 14,000 potential adverse drug events each year.
The EHR rollout coincided with a clinical improvement
effort aimed at adopting evidence-based care
protocols. Long before the federal government passed
legislation on comparative effectiveness research, Trinity
Health physicians were weighing the benefits and costs
of various treatment approaches.
Today, the health system has
172 standard order sets in place
and more than 2,500 standard
The vision reflects a
drugs in the formulary.
healthcare ideal in which
Patients receive the greatest
benefit from standardized,
providers work together
evidenced-based care: Trinity
Health saw a 21 percent
across care sites to deliver
reduction in severity-adjusted
mortality (or 2,612 fewer
the highest-quality care in the
deaths) in 2007. Also, the health
most appropriate setting and system performs better than the
national average on 97 percent
in the most efficient manner. of core clinical indicators.
“As the government and
private payers move toward
payment that rewards outcomes
and care coordination rather than volume, Trinity
Health can leverage a full array of EHR and clinical
support tools to align with physicians and create better,
Managing Change
There is no one-size-fits-all formula for managing change.
Below are some key points.
Determine the context for change. This step requires
information gathering and analysis. What is the imperative
for change? Who are all the groups that need to be involved?
What are the potential impediments to change?
Build support for change. Early in the change process,
core believers need to involve a larger group of “initial
participators” who will participate in the initiative out of
loyalty to the organization.
Develop a motivating vision. Such a vision enables people to
imagine new possibilities for the organization and for
themselves as members of the organization.
Articulate clear, specific, and realistic goals and strategies.
Specific goals and strategies guide people as they undertake
the steps necessary to make the vision a reality.
Communicate. Use all available methods of communication
to get across the need for change, the vision, and the
change process.
Identify barriers to change and develop strategies to
overcome them. Problems that are ignored and allowed to
fester can breed resentment, distrust, and uncertainty.
Look for the early win. By making the most out of small,
early successes, managers can establish the credibility of
the change initiative.
Recognize participants for their efforts. Possible
rewards include promotions, bonuses, praise, and notes
of recognition.
Source: Adapted from Organizational Change: Primer, Department of Veterans Affairs, Health Services Research and Development, 2000. For the full report,
visit www.hsrd.research.va.gov/publications/primer/.
8 LEADERSHIP | Fall/Winter 2009

more efficient systems of care,” says Terry O’Rourke, MD,
chief clinical officer.
Despite how far Trinity Health has come, it still has a
lot of work to do before it can call itself a “care delivery
organization.” Most of the progress to date has been done
on the inpatient side. Now the health system is extending
its EHR and clinical improvement efforts to ambulatory
clinics and outpatient services. The work includes
implementing standard EHRs and related technologies
for more than 1,000 employed physicians.
“EHR capabilities already support care delivery in
our hospital-based outpatient service settings, and we
are in the process of finalizing a strategy and approach
for ambulatory clinics,” said CIO Paul Browne. “These
will be areas of intense focus for the next several years.”
Trinity Health is also reaching out to physicians to gain
their support and cooperation in improving quality and
efficiency across care sites. The health system is studying
various alignment models, including physician employment
and clinical service line comanagement agreements.
Communicating the Vision
Seattle-based Virginia Mason Medical Center’s view of
the future can be summed up in the organization’s
motivational vision: “To be the Quality Leader and
transform health care.” Virginia Mason leaders seek to
have zero defects in the quality and safety of care
delivered to patients, and they intend to lead all healthcare
providers to share their vision.
To move toward this goal, Virginia Mason—a
336-bed hospital and a network of clinics across western
Washington—uses the Virginia Mason Production
System, which is adapted from the famed Toyota
Production System. Virginia Mason seeks continuous
improvement to eliminate defects and waste. The idea is
that, by creating processes that eradicate rework and
inefficiency, the health system frees up staff time and
financial resources to focus on patients.
To date, the positive effects on quality and costs are
inspirational. Here are a few examples: Patient falls have
decreased from 3.42 per 1,000 patient days to 2.92 falls
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hfma.org/leadership | LEADERSHIP 9

in a single year. Inventory costs have decreased by more
than $1 million through the use of supply standardization.
The amount of time it takes patients to receive lab results
has been reduced by more than 85 percent. Plus, the
health system has saved $11 million in planned capital
investment by using space more efficiently.
Having undertaken more than 660 continuous
improvement activities in the past seven years, Virginia
Mason staff members know the system’s vision and
strategy for achieving it. “We have a very well developed
strategic plan that all 5,000 of our employees could
explain to you,” says Suzanne Anderson, senior vice
president, CFO, and CIO. “Having everyone understand
what we are aiming for and having the Virginia Mason
Production System as our tool to get there is what
allows us to achieve the results that we are aiming for.”
A triangle graphic is used to reinforce the health
system’s strategic plan at every turn (see the exhibit
on this page). The graphic spells out Virginia Mason’s
vision, mission, values, key strategies, and foundational
elements.
“As we do our work, we start meetings with this
graphic so people understand that whatever we are
working on at that moment ties to our strategic
plan and what we are trying to accomplish,”
says Anderson.
For example, a current initiative aimed
at improving the discharge process in the
emergency department (ED) addresses
Virginia Mason’s “service” strategy,
which seeks to “create an extraordinary
patient experience.”
Virginia Mason leaders use
this simple graphic to
continually communicate
and sum up the health
system’s vision and
strategic plan.
Strong
Economics
People
We attract
and develop
the best team
Patient
Vision
To be the Quality Leader
and transform health care
Mission
To improve the health and
well-being of the patients we serve
Values
Teamwork | Integrity | Excellence | Service
Virginia Mason Team Medicine ® Foundational Elements
Responsible
Governance
We relentlessly
pursue the
highest quality
outcomes of care
Integrated
Information
Systems
Source: Virginia Mason Medical Center. Reprinted with permission.
Strategies
Quality Service Innovation
We create an
extraordinary
patient experience
Education
Virginia Mason Production System
The initiative also ties into one of the plan’s foundational
elements—strong economics—since a more efficient
discharge process would help increase patient throughout.
Further, it ties to the “people” component of the
strategic plan because a less crowded ED reduces the
frustration that staff members experience when they
work in a harried ED.
“Elements of this initiative tie into each one of the
pieces of our strategic plan,” says Anderson. “If you
have staff people involved in the work, it is important
for them to understand the bigger picture.”
Catching the Momentum
The leaders of Trinity Health see the current healthcare
landscape in historic terms—and they are using this
momentum to stoke a transformative change process.
“We say our business model is experiencing a
tectonic shift,” says Adkins, pointing out that delivering
hospital-centric health care is no longer sufficient to
fulfill Trinity Health’s mission. “We have to realign our
business, change many of our processes, and reposition
ourselves to reflect how we see healthcare transformation.”
But it’s also important to get it right, says Andrea
Walsh, executive vice president of HealthPartners,
the integrated healthcare system in Minneapolis.
One of the biggest leadership challenges in
health care is balancing the need for urgent
change with a well thought-out strategy.
“We need to figure out that right balance
of taking the time to do it right with
the recognition that we do not have
a lot of time.” n
We foster a
culture of learning
and innovation
Research
Virginia Mason
Foundation
10 LEADERSHIP | Fall/Winter 2009
Republished with permission from the Fall/Winter 2009 Leadership Special Report, copyright 2009, HFMA Learning Solutions, Inc., www.hfma.org/leadership