Session Information:

US Department of Veteran Affairs: Creating, Executing and Sustaining a High Reliability Organization in Health Care

• Setting the conditions and tone for creating a psychological safety environment thru continuous process improvement
• Calculating the “preventing adverse outcomes” value of continuous process improvements, which, therefore, measures true high reliability within a healthcare organization.
• Demonstrating the evidence of and measurement for “just culture.”
• Providing justification and validation of the alignment with and progress towards achieving Mission Control goals.
• Assisting with the identification of potential hazards for proactive risk mitigation.
• Informing cost analyses to demonstrate the “return on investment” from the process improvements.
• Identifying best practices to further Truman and VHA as a “learning organization.”
• Performing trend analysis to search for themes, patterns and inform decision making.

Session Transcript:

Everyone who is a registered participant so thank you for being here thank you for being part of this ecosystem of great people and great ideas that can connect to accelerate improvements to accelerate innovations all over the world, without further ado let me bring our keynote speakers to start us in a great you know with a great presentation about department of veteran affairs creating executing and sustaining a high reliability organization in healthcare.

So we have Jennifer Ford and Tim Anderson with us so I'm gonna do a quick bio on them this this these are veterans of improvement and innovation and it's a real privilege to have to have them with us. First I have Jennifer with us she is the director of product effectiveness and veterans health administration she possesses nearly two decades of health care experience and expertise ms. ford works to implement strategic direction and evidence-based assessments in order to maximize the intended value of the healthcare outcomes she leads the team responsible for measuring the benefits of the vha's investments to ensure optimal clinical outcomes and operational productivity Jennifer specializes in high reliability organizations health care access learning organizations and health id programs and products. She's a published author and frequent speaker and national and international conferences in addition to her work at vha. she's a professor at George Washington university where she has been teaching for over six years Jennifer, what a pleasure to have you with us.

Tim and the team led a facility-wide high reliability project from 2016 to 2019 at the Truman vamc this project including conducted ctt to over 40 clinical and non-clinical units and over 1500 employees receiving ctt the hro project including developing and implementing 75 department-level continuous process improvement boards this hro efforts contribute to truman va being the number one overall among all 154 va medical centers for three consecutive years. He was selected as the vis-15 chief high reliability officer for vha heartland network in july of 2019. He now serves as a vha hro steering community participant and has participated in several steering committee work groups including metrics internal assessments and as a faculty of the vha hro team welcome it's a real honor for me to have this caliber of transformation leaders with us and we're very much looking forward to your presentation.

Thank you Jose and welcome BTOES attendees from all over the world as Jose mentioned my name is Jennifer four and I along with my colleague Tim Anderson will be speaking to you about creating executing and sustaining a high reliability organization in healthcare. I know that you have many priorities and so we are very grateful that you chose to spend the time with us this morning or in the afternoon depending on where you are in the world. I know that you but first I want to take a quick look at what is a high reliability organization and what does it mean to create and execute one let's start with breaking down the term reliability.

It's the quality of being trustworthy and performing consistently well it also is the results of a measurement a calculation or a specification that we depend on to be accurate so most of us drive a car right we depend on the fact that the brakes will work when we apply them we have flown from city to city in an airplane we expect that when we fly we get to you'll be at the destination safely but if any of these expectations don't hold true the results can be fatal seems like common sense you're like Jennifer, why are you telling me this and why are you wasting my time for the next 45 minutes telling me about reliability but what if there's a breakdown in communications in a multi-layered high hazard complex environment to illustrate this what I'm going to do is take you back to January 28 1986 it was a very unusually cold morning in Florida at the Kennedy space center as the whole world was about to watch an historical event please rotate let's go down to the Kennedy space center and take a look at challenger sitting on the pad nine eight seven six.

We have main engine start four three two one and liftoff liftoff of the 25th space shuttle mission and it has cleared the tower three engines running normally three good fuel cells three good apu's velocity 2257 feet per second altitude 4.3 nautical miles downrange distance three nautical miles so the 25th space shuttle mission is now on the way after more delays than NASA cares to count this morning they looked as though they were not going to be able to get off one minute 15 seconds velocity 2900 feet per second altitude nine nautical miles downrange distance seven dog looks like a couple of the solid rocket boosters uh blew away from the side of the shuttle in an explosion. Flight controllers here looking very carefully at the situation obviously a major malfunction.

We're waiting where they're holding their breath, obviously a major malfunction the catastrophe you just witnessed was the space shuttle challenger many of us were in school sitting at the edge of our seats watching this and it was historical because of the first time a teacher one of our own was going to go up into space exploration 72 seconds sorry 73 seconds into the journey seven souls had expired so what went wrong after many delays it was determined that the o-rings were faulty in cold climates but was that the real problem actually it wasn't the real problem was 12 hours before that flight was to take off NASA engineers emphatically told NASA management not to take off that the o-rings would not hold in the cold climates obviously there was a commission to look at the root cause analysis of this disaster and was ultimately determined that the Syria there was a serious flaw in the decision-making process leading up to the launch the translation to this is this disaster could have been avoided so next time you get one of those recalls on your car or you're sitting on the you might want to take your car in right away or you're sitting on a tarmac and you're frustrated that the plane's not taking off maybe you want to kind of take a step back.

What we have learned by studying literature about high reliability organizations is they all have these five major principles and characteristics they are preoccupied with failure what this means is that everybody in the organization is a problem solver they look for cracks in the foundation and look to fix those cracks in the foundation there's absolutely no turning a blind eye and they're only drawn to improving the organization's ability to thrive next is reluctance to simplify don't cut corners check and recheck your list get down to the root of the matter sensitivity to operations operations happen every second of the day and a leader cannot be at every place at the same time watching over everybody that's working therefore we must rely on our front line staff to tell us what's going well and what could be improved they are the ones who can educate us and make us more highly reliable but don't ignore them ever they are some of the organization's greatest assets a commitment to resilience understanding and exposing weaknesses and where you might be wrong is very difficult to do but if you have the guts to uncover some of these weaknesses and make it transparent to the organization your ability to reduce risks and safety events exponentially increases and finally deference to expertise well.

If NASA's management had only listened to the experts so what does this mean to healthcare everything healthcare too operates in a multi-layered high hazard complex environment as a matter of fact jose mentioned the order of magnitude of the department of veterans affairs let me just sort of reiterate what our transformation and our modernization efforts look like in terms of size we're 172 hospitals across the united states with about 900 outpatient clinics we have 320000 employees and we spend tens of billions of dollars tens of billions of dollars over the next we will be spending that over the next 10 years in transforming and modernizing just imagine trying to get 320000 employees to transform in healthcare a breakdown in communication though can literally mean the difference between life or death and in fact preventable preventable medical errors.

Medical errors is actually our third largest cause of death again preventable misdiagnoses surgical errors and medication errors, are usually the most preventable errors and the most prominent how many times have you gone to a doctor and you say to your and your doctor says hey if we don't call you everything is fine now imagine that you had a cancer diagnosis and it got misplaced and you were never called not only is this devastating but it actually happens more frequently than not my advice to you always double check your diagnoses and be very proactive with your health care surgical errors also haunt the industry imagine waking up from surgery and only to find out that the shoulder your healthy shoulder was was the one that was operated on and now you have chronic pain in that one and have to go back into surgery to actually fix the shoulder that needed to be fixed in the first place and finally medication errors adverse drug events happen all the time medication reconciliation is a constant issue drug interactions and missed allergic reactions are unfortunately common place again what do these errors have in common preventable the necessity to operationalize a high reliability organization and healthcare is clear and evident, but where do we begin how do I do this.

We hope to provide some of those answers to you today so how to create execute and sustain an hro is also a multi-layered complex task and it happens over time well we at the va have a gem called Truman medical center in Columbia Missouri it has over 1700 employees and all have adopted the principles of high reliability in terms of leadership commitment a culture of safety which also we refer to as just culture you'll be hearing that term from us and continues process improvement ten years ago they set out to create the hospital of the future a high reliable facility where our veterans can can access services in a timely manner be safe and also experience an exceptional and consistent visit every time they step foot in the door but it even gets better our employees get to get those same advantages they gain access to a safe workplace they're able to and encouraged and rewarded to speak up so transparency occurs and you gain a high level of employee satisfaction as a result.

So now my colleague Tim Anderson will explain how the condition and tone was set at Truman so that the foundations of leadership commitment and a culture of safety or just culture and our structure here was created, Tim. thank you Jennifer as you see in this slide we chose leadership commitment as the bricks for the foundation of our high reliability journey which is now being replicated across all of vha this included both clinical and administrative leadership commitment i think frequently when you try to operationalize hro you look at the clinical piece only but it will frustrate your clinicians if you're not looking at the business operations logistics prosthetics the it and the other non-clinical support services so we made a mindful effort look at capability and reliability within the non-clinical and administrative areas and we committed to a long-term process like jennifer mentioned.

We had a three-year project but it started 10 years 10 years ago in 2010 when we started applying aldridge leaders across the journey had to be educated and had to have a certain skill set in order to be on this journey and this was hardwired into their executive career contracts their performance was dependent on their knowledge and ability to be a part of this journey and although we had challenges moving to a zero harm goal i think most of the leaders who stayed on for the journey very much embraced this and it started with if the leadership commitment was the bricks the culture of safety would more hold this together the second piece of the yeah three pillars and we had a shared foundational definition and we operationalized that with a just culture decision support tool based on david mark's work and this created the culture of safety by hardwiring a decision process on how we would respond to all deviations patient safety incident reporting in our employee relations labor relations we had a strong union presence and probably the greatest shared environment.

Where we had non-negotiable respect for people was an event a legacy event in 2013 on the locked behavioral health unit where an acutely psychotic schizophrenic patient admitted onto a general psychiatry locked ward and he was hearing voices and at the time there were not a whole lot of resources for elderly veterans who have dementia and no other mental health needs so there was a 78 year old world war ii veteran on the unit with dementia unable to care for himself looking for placement the social work was working actively to place the fellow and the 38 year old who was admitted around midnight continued to hear voices through the night and the next afternoon he beat to death the 78 year old demented fellow thinking he was uh possessed demonically by spirits and this was in the hallway for all the veteran patients and the staff to see they were unable to pull him off.

He was a large former marine and in the after action root cause analysis there was a number of systematic changes to the processes on that unit including eight hundred thousand dollar remodel that included direct lines of site for the staff to see patients at all times and cameras and integrated computer docking stations that were designed in a manner that could not be taken apart are used to harm anyone but probably more importantly was an aggression assessment scale that the chief and i chief of staff and I developed where every patient that was admitted to the unit had an aggression scale rating and their treatment plan was based on that aggression scale and while this root cause analysis was being conducted the network director of our healthcare system in the Midwest was receiving pressure from the department of veterans affairs in Washington dc to have some disciplinary action towards the treatment team, specifically the attending physician or the head nurse of the unit including termination and the network director at the time.

Who's still the network director he said absolutely not there were way too many system issues that were identified in this recuse analysis that was also verified when the office of inspector general investigated the event and they found no reason for any kind of disciplinary measures that it was a system issue so this 2013 event it became legacy that was reflected in 2017 to 2019 in the all-employee survey results that Jose talked about where Truman va was number one overall for workforce satisfaction and I think that was the mortar that solidified the culture of safety and psychological safety at the Truman va all this is predicated on a systematic messaging that the CEO and myself did to message how this is going to change how we operate this is going to become the fabric of our operations and we based it on some of the ted talks from Simon sermonic on how people want to be communicated.

We started with the what additionally that would be we are hospital the how being we're specialized experts in a wide variety of care including prosthetics research and mental health and then the behavior come get care from us and we would change that that why message too we exist to care for American heroes and provide safe care that really changes it from being a hospital to we're providing care for heroes there's a high quality health care here that makes a difference in our heroes lives how was specialized care in a wide range of health care services and we transform veterans lives by going above and beyond everyday healthcare and finally we're a world-class hospital come and see it for yourself so this messaging became hardwired into everything we messaged for reliability the team commitment for the executive leaders really transformed what their daily calendar looks like about halfway into the journey.

It was not unusual for the CEO of the hospital to have 40 hours out of the month for high reliability activities it would attend high reliability training clinical team training which is the va's version of team steps just culture training it was recognized lean leader went through yellow belt green belt and black belt training he or the other executive leaders would provide introductions to all high reliability activities including lean training clinical team training patient safety forums walk arounds and his calendar and his executive calendars became filled up with high reliability activities including visiting those 75 visual management boards for continuous process improvement so that it his thought was as was mine leaders who are not visible aren't leading and they didn't attend the rounds and they didn't attend the boards as subject matter experts it was just to show the visible support and help identify barriers to continuous process improvement becoming a learning organization, one of the bellwether moments in that clinical team training was we had a general surgeon he was a respected surgeon he was respected at the university of va frequently he was teaching the medical residents and and the medical students on surgical equipment.

I had observed him a number of times in the operating room and he would literally take apart a piece of machinery what's going on with it he went through the clinical team training he developed a debriefing at the end of every case and about six months later I went back after his training to absorb some of his cases and he had an endoscopy tower that did not have a vacuum attached to it so there would be a bit of smoke when the cauterization took place and he felt like that smoke was toxic to the team and potentially to the veteran patient so instead of putting in a safety report and a request to get this vacuum he got on the phone right away and called biomedical engineering and he had the biomedical engineering staff bring over that vacuum attach it to the tower and eliminate that risk right at the or table before the veteran even left the operating room and I felt like that was a bellwether moment in changing the front line physician's approach to high reliability next.

We're going to have Jennifer talk about some of the details that allowed the psychological safety and the leadership to make continuous process improvement really the sustaining piece consistent gaining peace for the house on which the foundation was built for the culture of safety and the leadership commitment thank you Tim.

So everyone you've heard terms such as hardwiring and psychological safety um these terms these terms and the activities just described all lead to what we call a shared mental model so remember when you were a kid and you were sitting in a room one of the games you played was the telephone game and you would whisper a phrase to your partner or your friend next to you and they would whisper to the next person so on and so forth and at the end of the telephone game the message that was revealed was completely skewed and muddled from what it was originally um set so what we when we apply these hr principles and the components that we just learned about what we look to do is minimize that issue of the telephone game and quite frankly create.

This shared mental model where we're all interpreting the messages uh the same or similarly so operation obviously operationalizing this effort is just absolutely not an easy task especially when we are seeking evidence-based information to make decisions but we have made with this case study major breakthroughs in the va but what's even more exciting is that this foundation has led to a phenomenal change in the organization with unprecedented results.

So the conclusion here is that just culture leads to leads to consistent deliberate not random continuous process improvements which includes the entire organization not just certain parts of the organization and it all starts with a simple visual communication board a whiteboard if you will a gathering place to communicate the simplicity of this board is brilliant the impact of this board is unimaginable 73 73 of these boards were distributed and implemented across the Truman va to every clinical and non-clinical unit as you can see the boards are divided into the plan do act results process and also some and also just do it so the board is placed at each unit and is a constant reminder that there's ideas.

That can be approved upon or that I can add ideas to this board the needs could be as complex as a surgical innovation as Tim described or as not as complex but important as wheelchair maintenance on the right hand side of the board you see these slips in various various forms what happens is somebody sees something and they simply write something on a slip and attach it to the board then people gather around the board of all levels of the unit so from you know the front line to the leadership and they discuss the ideas on the board and lend everybody's viewpoint and expertise to solving the problem what happens is group think starts to form collaboration happens naturally and the best outcomes for the unit are achieved so what my organization does Tim went ahead and implemented this amazing transformation and what I do is I try to evaluate it for effectiveness and value so as a mental poll how many of these process improvement ideas do you think were captured between this time period 2015 and 2019 so if you answer d you are correct in fact there is 3180 improvement ideas over those five years so let's take a look at the distribution of them so the boards were starting to be implemented in 2015 and by 2017 all of the boards have been implemented and the folks have been trained on how to use them so look at the increase the incredible increase in improvement ideas from 2017 to 2019.

If you think about this if there's 365 days in the year a person might work a maximum of 232 days out of the year if you take out a two-week vacation 10 holidays and maybe five six six sick leave days so if you divide that number 232 into each one of these years in 2017 that leads to two improvement ideas per day 2018 four per day and 2019 six per day and we are still counting so then we had to decide well how do you take all this data what do you how do you capture it what do you do with it so i had to come up with a database schema with tags and searchable items so that we can start to analyze the incredible amount of data that we collected and what we were looking for is to see if we could find tangible and demonstrative results and here's what we found this may or may not surprise you but there's roughly a 60 40 split in improvement ideas between operational and clinical care respectively so what does this mean to leadership.

I can see this as being able to determine where I've realized benefits and innovations and also where i might need to focus future investments we then thought well wait a minute we can't just have all of these ideas and split into clinical versus non-clinical how do we know what the impact is to the organization what's the significance so then we said okay well we're going to put some definition around this so a high impact project is something that is multi-tiered multi-layered throughout the organization medium might be an innovation that's really just in a clinic or a unit and low is something that almost just can be solved immediately.

So an idea an example of a high impact project would be the um well we realized that there was inadequate oral hygiene between some of our high-risk elderly patients they were acquiring acquired pneumonia so just by simply ordering toothbrushes and making sure that toothbrushes were in every single hospital room it was determined that not only did we help to prevent the virus but we saved forty thousand dollars per incident safe a medium impact uh idea might be something like needing a hook in the icu unit to display the iv bag during a code red many times and obviously with the code red in frantic situations the bags were in different places in different rooms consistently putting the bags on the hook consistently in every room really saved a lot of time and things that you don't have to think about in a in a high stressful situation and in terms of a low it may be something like you know.

I might need some type of supplies to do my job better some of the lows were categorized as a light bulb needs to be changed however the problem with that is that could also be a high impact because with the light bulb you might be able to be able to prevent a fall from happening okay so with these types of examples in mind the results were eye-opening when you kind of take a look at which ones fell into high medium and low categories 15 of those uh slips fell into high impact categories and 40 fell into medium so if you recall back in 2019 distribution there was 1 461 slips if you do the math that leads to 219 high impact projects and 584 medium projects per year that's one per day that's being uncovered for a high impact and two per day in medium if you recall the medium impacts aren't too shabby as a leader of an organization am I not only proud of that but the results are just measurably off the charts and our success continued.

Health care is extremely siloed many efforts have been underway to break these silos like value-based care and bundle payments but true value is derived by integrating teams which instills confidence in the organization and helps to reduce redundancies and errors the Baldrige organization promotes a framework of performance excellence they have the in their scorecard system they demand integration as one of the critical success factors through our analysis Truman was able to demonstrate 33 of their projects had a significant degree of integration a third of the projects is a great number we obviously strive to improve that number but what an excellent start and then further analysis helped us uncover the trending and themes that were emerging of the 3184 improvements they all fell into these nine top 19 excuse me categories from suicide prevention medication developments care coordination all the way to improvements and communications inventory teamwork and process changes.

It is no wonder that Truman went from being 75th to number one in best places to work within the va they also decreased employee burnout by 52 impressive results and of course no analysis is complete unless we do a return on investment besides the benefits we just previously went through of psychological and patient safety this organization realized a 2.8 million dollar savings in cost savings and cost avoidances through this assessment leaderships can gain tangible assets to be able to make decisions on future or to be able to make decision making decisions on future environments for a safer environment for greater patient experience and really truly continuing to become an hro so when you tally all the evidence that's been presented to you.

Today just now we can really just summarize all of this into seven distinct and highly high valuable findings number one as i just mentioned roi is is paramount funds are not unlimited and and truly demonstrating improvements while reducing costs directly speaks to proving health care value expecting just culture is only half the battle but demonstrating it and sustaining it is truly innovative instilling just culture is a dependency to a consistent and growing continuous process improvement environment environment consistent not random being the operative word how many times has your leadership set out to meet objectives only to find out the members of the organization, don't really know what how to interpret the goals of the organization what this process does is reduces that ambiguity and this method provides the justification and validation that the goals are met by documenting your successes others can learn from your strong practices and your mistakes.

We here at the va describe a learning organization being the largest energetic hospital network in the united states our learning organization strives to demonstrate the reluctance to simplify sensitivity to operations and an organization's commitment to resilience performing trending analysis is yet another insight where leaders can identify points of failure and look to avoid future safety events it also gives us an outlook on future strategies and needs of the organization you've all heard the term if I knew then what I knew now or otherwise known as Monday morning quarterbacking mitigating risk is one of the most challenging things to do in an organization an hro is constantly detecting risk early throughout all parts of the organization all levels of the organization have the ability to bring their expertise forward to avoid safety events from happening.

So I ask you wouldn't you be glad to know that your food service employee double checked the tray so that they didn't place a piece of chocolate cake on for a diabetic or how about would you would you love the fact to know that the nurse was able to stop the line and prevent the doctor from actually amputating on the wrong limb and finally in my opinion the most compelling of it all how do you calculate something that never happened how is the value of what is the value of something that was prevented it was an anomaly that the Truman organization did not have the same a talent the same challenges at the height of covet 19 as other hospitals were reporting in the country um they did not report any lack of ventilators they had their pbe supplies and they didn't have the same type of capacity shortages or was this an anomaly after all we did a quick query of the database and we found 267 instances where covid related improvement ideas have results that help to prevent those issues not an anomaly overall but to dub an old visa commercial.

I would call that priceless so becoming an hro is the journey is always continuing it's not a snapshot in time or a one-time award it's about people and people change they leave an organization and they join an organization they have different priorities in their lives that may or may not distract them in their in their work life the better the foundation and not deviating from the norm the better people can stay on track people also mature during those ex during their experiences so not only does this journey continue but it definitely becomes more interesting challenging and exciting along the way thank you for taking the time to sit with us during this presentation.

We'd be happy to answer any of your questions Jennifer and Tim what what a fascinating journey. We have here uh on the on the on on what you have to share with us it's the scale uh it's just unbelievable um incredible results congratulations and thanks for taking the time to share with us so we have some questions that have come up uh that i want to share with, you we have another seven or so minutes here when I take this time to do a live Q/A.

I have some questions myself but my questions don't matter I'm looking at the questions from the audience and what I see here is that Keith Clint scales uh has like the number one voted question so far and I'm gonna relate that to you and he mentions the veteran affairs is a huge organization how do you drive employee engagement and excitement about the idea process and who are the champions the cheerleaders who drove the change to an improvement culture that you're trying to establish Tim I don't know if you want to take that one or if you want me to take that one. I can take that and I think like I tried to describe in the opening. It really has to be the CEO has to be the director of the medical centers it can't come from Washington dc it can't come from the network office it has to come from the local director and I think some of that is predicated on their resources and capacity it could be that depending on the facility you're looking at they're not there they don't have the readiness yet to undergo that kind of change but we had 18 pilot sites were trying to replicate.

what we did at Truman and they were self-identified identified and through some objective criteria selected to be the next 18 Truman medical centers so it really has to be predicated on the culture of your facility based on the all employee survey results and your capacity to understand really there's not any reason to to begin this journey if you don't have an adequate lean staff for instance we had a master black belt with a two master's degree in engineering and health administration and he was able to teach black belt classes and we had over two dozen qualified master black belts at the end of the three years.

So they were able to coach the green belt projects and generate that excitement and then that excitement made it that employees were engaged and they felt like they owned their work processes and they owned how their workflow would go which which helped with retention and it continued and sustained that excitement when you feel like you own your work process the one thing that I'll just say is we can't stress enough the leadership commitment and it's not just committing funds it's committing their time their rounding they're getting to know people they're visible they're not in a in an office taking calls and never around in the facility that's kind of number one and um i i think again the leadership commitment is is just paramount yeah I'm curious about that leadership commitment was this an initiative that was driven very much from the top down or was an initiative that was you know you influence the top.

If you will what is the involvement of senior leaders in the organization on the initiative so their involvement that's a great question it was not a mandate it was a coaching and an assistant it was a transparency that those visual management boards that Jennifer showed you it was hardwired into their contracts they had to observe 75 of those a year so as a senior leader you would go to the board when they did their visual management board rounding and you weren't there to provide answers or solutions you were there to coach and to help identify barriers to those unit level projects so that they could work the solutions themselves which is I think often senior leaders want to go in and fix and instead of I think that's when you're going I can um describe it is it really does create a flat organization where all members of the organization.

Whether you are the housekeeper all the way to like I said the food service worker somebody in the pharmacy logistics and any clinical nobody's afraid to speak up it really does create that flat organization and to quote one of our colleagues um he he said I'm not going to stop anybody from saying anything but some of the things they say to me you know are a little bit outrageous but that's a just culture and that's what we want we don't want people to shy away and uh tell us a little bit about uh you know clearly this is a very large scale transformation you have been very successful and congratulations on that um uh and uh in what other aspects you think that the transformation that you're doing here uh is different from what most healthcare organizations are trying to do with improvements and innovations um I'll take that one.

So I think you know i kind of tried to reiterate it through the presentation several times everybody does continuous process improvement but what is the difference between an hro process improvement and individual process improvements think about an elevator think about an hro is not complete until everybody is on the floor at the same time there's many times where a continuous process improvement hey we cured cancer or something along those lines happens and the rest of the organization is falling apart and hro doesn't allow that it's one for all and all for one you're all on the same elevator floor you know on the same elevator floor as everybody else and until everybody gets on that same floor you're gonna strive to make sure everybody comes up and then once everybody's on that level they're gonna get back in the elevator and strive for the next level that really is the difference between a random one-time continuous process improvement and the entire organization focusing on continuous process improvement or the hro journey.

It sounds that you have really democratized improvement in innovation make accessible to all the organization and and you have very clear mechanisms to translate the principles into value creation action we're almost out of time so a quick question is you can give me a short answer on um this is such a big ecosystem you have so many ideas coming in just give a high level view on how you're prioritizing what you need to work on it really is limited by the capacity of the particular unit so if the unit has the capacity to work on a performance improvement project they will work on it and it's dependent on that unit's capacity right Jennifer and Tim thank you so much for sharing this incredible insights on the on such a large scale transformation healthcare in the government and the services that we're providing to to veterans.

So we're very grateful for all the improvements and innovations we have done in doing that and uh you created financial and social value at scale so thank you for for that thank you BTOES community thank you much ladies and gentlemen, that's some of the best of the best when it comes to large scale transformations.