Session Information:

The experts have left the building, now what? A journey of transformation and continuous improvement

• Maintaining the attention, accountability and rigor for improvement after the consultants and subject matter experts are gone

• Development of control and sustainability plans

• Developing facilitation, project management, and performance improvement resources within the organization to continue improvement

• Building a governing structure to oversee improvement projects

Session Transcript:

Your presenter today is erin pelletier and she's from care new england she is the director of operational excellence everybody in the right place because i know i heard some buzz on the floor about you wanting to get into the session so it's really really great she's already talking today about not you experts but the experts that did leave peru left the building during the transformation and continuous improvement and aaron is really gone you know i mean although.

I'm substituting for your the moderator that was supposed to be here i have had time to read and i just get so impressed because i'm just like in a room of brilliance it's humbling it really is humbling when you all get together but what she's going to talk about today is really maintaining the attention and accountability um in rigor for improvement in healthcare.

What they've been able to accomplish development of control and sustainability plans which i'm very interested in hearing about and developing facilitation and project management and performance improvement the resources that are within the organization you know she's been in the uh role you know for about six years and let me tell you i'm just gonna kind of not really read this by verbatim but it's really pretty phenomenal what's been accomplished in this organization under aaron's lead.

So again she's at care england second largest health care system in rhode island and she's director of operational excellence no easy feat and she's led multiple transformation projects and they've yielded a savings of over 100 million dollars and i think that's that's pretty impressive i mean i think
you guys have a tough tough tough industry to be able to pull out that kind of savings um you know as system-wide performance improvement activity.

She's really there to drive the transformation and what i really think that caught me with aaron is her balance and i think she brings this balance into the organization which is you know you guys are in a probably the most stressful business there is healthcare and really i don't know how you do it how you actually keep the balance of your responsibility toward patient toward employee
toward community and your sanity.

I do think it's a lot but i think that aaron does it because she also enjoys the other side of life outdoor cooking gardening hiking and i do believe that what i've seen in other kind of high stress environments with that balance between getting out in nature and seeing what's there and then  being able to come into a facility as you do and make this kind of transformation is I think it's really spectacular so i'd like to welcome aaron and please do so.

Thank you thank you so much dan and thank you all for joining me this morning um so as you said i'm from cairo england and so here is that all right so here are just a couple of highlights of what we're going to go. over today so we want to just touch on the accountability and rigor for improvement the governance structure that we've built and put in place how we put control sustainability plans in place and developing the facilitation and project management capacity of our own internal resources.

So a little bit about our company it's the second largest health system in rhode island we've got three hospitals one is a med surg a woman in infants is a woman specialty hospital butler hospital's behavioral health we have a bna the providence center is ambulatory behavioral health services with over 50 different programs and services for the rhode island population we have a medical group and an aco altogether we have about 8 000 employees and 1300 active medical staff.

We Have an annual revenue of about 1 billion dollars and we are clinically affiliated with brown university and so if anyone else is from new england you've probably also heard where in the process being acquired by partners healthcare so it's a little extra little fun for us so um we've been on improvement and transformation journeys for i'd say about seven years i heard a couple of our colleagues in here talking about the baldrige journey we started out on a baldridge journey about five six years ago we submitted three applications lots of learning but for us it wasn't about getting the award or really trying the award we were using the blueprint for our transformation as we said i have the three different hospitals. 

We were really a federation of independent hospitals before we started the baldrige journey there was no shared services there was no shared processes it was just everyone operating on their own
so we used the baldrige to pull us together we developed the shared services with legal and i.t and revenue cycle and pulling things together and using that as a framework so um towards you that we called that that was branded as our transforming together t2 initiative.

So in 2013 we started entering a financial crisis um about halfway through our fiscal year we were on track to lose well we'd already lost 27 million dollars we're on track to lose about 63 million dollars that wasn't gonna cut it so we hired from another consulting firm to come in and help us with transforming together t3.

So this consulting firm came in they did an entire  analysis of our organization gave us about 500 pages worth of opportunities and we took that playbook they gave us some bench strength and we just got to it we had 13 different projects looking at span control labor revenue cycle research supply chain and so through that t3.

Initiative we saved 75 million of recurring costs and then another 30-ish million of one-time pickups very successful still at the end of that we were losing 20 million dollars a year not enough at that time we had a hospital in our system. It was a distressed hospital um the census was very low and we have days of 23 as our average daily centers or the other health systems you know you can't operate in a hospital like that absolutely not.

So we hired another consulting firm to come in and take a look at the options you know what can we do can we turn it into an er freestanding er what can we do with this huge property really old so they worked with us and we did end up closing that hospital very politically driven very difficult project still we are not on our footing with that hospital closed so we developed our own internal action plans we've seen what the consultants.

Have done we've seen what we can do we knew some additional opportunities that still existed so we developed action plans and we needed help to execute them so we had another consulting firm to come in and uh it was great and they just really came in and drove us they helped us stand up some uh a governance structure to really execute.

And hold people accountable and so through that we saved 30 million dollars with those action plans so now we're about breaking even where we're in pretty good financial footing again and said enough is enough the staff they're just hunkered down they're burned out they're tired and said we can't do this again so we said and we made a conscious decision that we are going to build up capacity and we're going to do this in-house we've learned a lot from all of our different engagements we learned what worked.

We learned what didn't work and so now we're going to turn this upside down and do it in house all the while we've got an fy 19. 26 million dollars with action plans in flight right now so um i can't tell you which consulting firms i'm sure you. recognize these names and we've used seven up on this slide.

So here we have the traditional seventh in seven years so um we're ready to do it now so unless we have the traditional model this is where we were um it's very top-down it's a lot of one-time improvements. we there's not a lot of energy from the organization the staff don't feel as engaged they're not part of it they're not developing the improvements they're just enforced upon them and so with this conscious decision we're flipping it upside down we are empowering the frontline staff we're giving them the training and the tools to be able to to improve their work.

They see it every day they know where a lot of the flaws are we're training them to see those flaws and remove them so they are empowered we're striving for continuous improvement we are very publicly talking about our financial situation it's a little easier now we're talking.

Break even um and so that's really how we're flipping it upside down so for us the requirements for success is you have to have an imperative for change our financial situation was our imperative it was very public it was all across the media so everybody knew it and felt it we needed to our our true norths if you will are driving quality access and service.

So all of our initiatives align to those three our ceo feels it he he has a strategic vision and he communicates very very openly he's out there in town halls we've got newsletters he's does luncheons he's constantly out with the staff and furthermore he has a way of modeling this behavior so people can see in the decisions that he makes.

We can see that we have to tighten our belts we have to continue to improve so when he prioritizes we prioritize projects he's modeling that behavior and that is so so important for our success um so we're managing that one of the challenges that i heard a few other people talk about is how do you manage the day-to-day business while working on these projects so as you know it's a lot of work i mean it's a full-time job of nursing in the pre-admit testing in the pacu and all of those areas it's a full-time job.

How do you add a project on top of that so it's a tough balance to be able to as leaders that we have to give them the time and space to work on those projects and improve and to sustain you really have to ingrain in the culture we always say that we're weaving this into the fabric of who we are it's becoming part of our culture there's continuous improvement so uh here's our structure for accountability we call this the oic the operations improvement council this is a team of uh leaders it's a different uh meets every tuesday morning for one hour and it has a rotating agenda.

So the first meeting of the month is action plans each business leader has to present an update on their action plans that are off track and they're very detailed we do not accept any tbd's we don't accept any on goings we want to hear the distinct steps that you are doing you can't say working on it you can't say monitoring those words are not allowed then the second meeting of the month is pipeline this is where the new ideas come in business plans are presented we have a nice robust strategic financial planning department so they help us value all of our plans uh looking at the market analysis.

Those are all presented at the pipeline meeting so we're constantly fueling the new ideas the shared impact meeting this is for the plans that impact more than one operating unit so this is where a lot of the revenue cycle.

Improvements uh charge capture improvements we're looking at our leave of absences across the organization so those things that one impact one plan will impact multiple different operating units and hospitals we look at them at that meeting and finally the dashboard meeting this is because you can never take your eye off the ball this is where we look at the sustainment of all the other projects that have been closed down.

Are we still on track if not they similarly have to present an action plan with distinct steps to get back on track so this really works for us it doesn't work for every organization but we seem to have we can keep our eye on all the different action plans all the different areas and facets of our business and our improvement plan.

So that's weekly we have those meetings where everybody comes together i also meet with each hospital or each operating unit weekly we sit down we go through the action plan it's a very detailed meeting we talk about the barriers it's a lower level deeper dive into each of the action plans at this meeting it's interdisciplinary everybody's there.

So we have the cmo we've got nursing we've got all the different disciplines at this meeting and by pharmacies representative is an action plan that impacts them our life cycle so we have monthly operating reviews and really anybody can bring an action plan idea forward we just ask the questions how can we better serve our population how can we better bill or get paid for the services that we do where can we better manage our costs any of those ideas can come forward to those weekly action plan meetings at the operating units it gets we do a feasibility analysis we quantify it is there real value here is it going to be is the juice worth the squeeze type questions so we go through that um if the operating unit endorses it then it goes into the formal process it gets presented at the pipeline meeting.

All the leaders across the organization get to see their plans see what the impacts would be hr and marketing have a better understanding of what it is that we're working on it can see what will they need to do to support this action plan.

It goes through a phase of implementation and then it goes to the dashboard where we realize monitor and control so that's our life cycle here is just some ideas that we have been. working on so category a plans are things that we're working on that are in the budget we pre-planned for them we know what it's worth we put them built them into the budget for the year category b plans are things that come up throughout the year they're not built into the budget but there's still real opportunities that we're working on and category c are pipeline.

They're not they haven't started yet they're in the pipeline we're still working on quantifying them they're coming forward so you can see we have broken down into different categories of growth the revenue cycle labor and then non-labor here's a sample of our excel dashboard that we use um what we do is it's broken out we if there's a different facility that we're.

Tracking the period by which the results are being reported for the year-to-date result the threshold is the minimum level that we will accept and the target or the goal is what we are building into the budget to realize we have a status indicator tells you if it's measured monthly or year-to-date desired direction.

Some things we want to go up some things we obviously want to go down and then we can see a monthly trend after that so in order to keep this new program alive for us our opex program we are we developed a training curriculum it's nine hours it's three weeks in a row so it's friday it's about three half three hours in the afternoon on fridays.

We develop the content in-house we have five lean practitioners throughout the organization and they all cycle through and help teach the program that actually has been really well received by the organization at first we were planning to just have one core facilitator and the feedback was actually the the organization likes the varied disciplines coming through and teaching the curriculum.

So we have targeted the managers and directors first we want them to be able to understand the lean improvement process and be able to support their employees as that starts to get rolled out at the same time we have three core lean projects that we're working on one is looking at the entire life cycle or value stream of our operating rooms from start to finish so as people go through this lean program they get pulled into that program.

Into those projects and can help whether it's the documentation or with observations and going to the gamba um so they're helping support that project and get some real-life experience they can bring it back to the departments. 

So here you can see a little bit of our turnaround so in 2017. we did end up losing 47 million dollars and then you can see throughout fy18. Where it really started to take hold um for financial reasons the obligated group is everything without memorial hospital.

Which is what we closed so we still have it on the books obviously because they're still spend down the operations when it was opened so without memorial we did um we did have a positive operating margin six million dollars so that's our to story thank you uh do we have any questions yes so i can empathize with you but uh stephen knows how to pistol myers.

I can empathize with you by going through um consulting groups and it always amazes me how managing always feels like consulting groups groups are much more than your in-house experts and or you're bringing in yet another group so we're on four over the last uh how come none of those consulting groups came up with your solution.

Well so it evolved with each different group they had a different asset that they brought to it and so our solution pulled the best of each of the different question experiences so how did you go about selecting which consultants to work with and what were the different assets that you can brought along so uh our board and ceo did the selection of the consulting group so in some cases.

You have the right people making the choice for you yeah yeah i'm sorry so some of it was based on prior experiences rhode island's a small state so how did you convince your c-suite to provide the team with protected time so they can do the daily management of their kpis and also improvement efforts as well.

I think it really is with the imperative for change we feel it all the way top down that we need to do this but at the same time they're within quick and early wins they are seeing the excitement and the momentum and i just gotta say it's a completely different organization culturally than it was six years ago i still feel empowered and they're proud and they're happy and you can see it and the best thing is when you know someone just hey i heard that you did over there can you come in and can you do that to my apartment there's no there's no secret sauce they led the change they knew where the issues were and they made the improvements.

They piloted it and they did their psas yeah that really is so as far as protected time the managers see it and they feel it and they they that's the decision the staffing the way that they can staff their department that's great because i know our organization is very particular not to keep in their budget in the labor closets you know as certain yes right right yeah so what we did in our hospital is um to be able to allow frontline staff to have that time they clock out of their unit and clock into my department.

So i take on the burden and then that way it keeps their budget in line and they can back still so that that way we have coverage patients aren't suffering i mean we've got all that covered and then they just go into my budget thank you for sharing yeah you mentioned the town halls no that started about halfway through um i think that may have been one of the suggestions of one of the consulting firms that came through is really get out there and start sharing.

What's going on um so they're and they in the beginning they were not well attended and now they are so do you do the surveys or what kind of feedback do you do from your teams we do annual employee engagement surveys.

We actually just finished up the cycle and got the results back and we have the highest response rate that we've ever had in the history of the organization do they feel now that more connected with that strategy do you have kind of asked that question do you well yeah connected do you feel you belong yes so that's come up that's yeah that's tremendous yeah what were some of the opportunities that drove the highest cost savings uh i'd say revenue cycle had the most opportunities for us um so just looking at charge capture.

We have a lot we had a lot of cap rates in our er for instance it was a flat rate whether you came in for a band-aid or you came in and ended up going in for a stomach procedure it's a flat rate so we were able to with more technology granulize the charging uh regarding the ideas you know about moving into an action plan or if you talk a little bit about letting that out and doing that you have parameters around that and or how do you determine like.

It's just something the department should handle or like maybe the business doesn't want the department to do that or whatever i guess i'm looking for the parameters around you know moving something from an idea to whether it makes it onto the master list or not like what yeah so um good question we haven't turned anything down but we have looked at the quantification we've had some really great ideas and after going through the quantification process it turned out that opportunity wasn't what we originally thought it was uh so it fell a little bit lower on priority lists yesterday at least have to be prioritized yes yes they do we do that through the operations uh improvement council.

Yeah so you said that you said the training the manager and the director yes do you have also vice president in your hierarchy in your system yes so have great ideas only an action plan that the vps then would be able to sponsor making sure it actually happened to that level great question and thank you for asking that we did start with the svps so what we did is we brought them all into one single session and went through an abbreviated version of the content so they got it first and we asked for their endorsement for the program and after that only then did we make the decision to
start rolling it out as part of the training.

Each attendee has to select a project that they start working on whether it be as small as a 5s or something a little bit bigger and creating dashboards for you know a lot of them are looking at how
they assign resources in their work and value stream mapping that so they have to go through the project so between each class because it's a three-week program they have assignments of you know doing the value stream map and identifying the waste and then identifying counter measures
so they do go for that project we do we're now keeping a catalog of all those projects.

So they they endorse it but really their role is to stand back and let their staff do it support them give them the time and they can protect their time to work on their projects champion it uh and then it does come up to the operations improvement and we celebrate the success of all of these projects and all the newsletters and town halls and very publicly publicize their wins okay well thank you all so much.

About the Author

Erin Pelletier,
Director of Operational Excellence,
Care New England Health System.

Erin Pelletier is employed at Care England, the second largest health system in Rhode Island, as the Director of Operational Excellence. Here, she has led multiple transformation projects yielding savings over $100 million. As the organization continues to improve, she is installing an integrated approach to system-wide performance improvement activities designed to drive transformational change and maximize financial results.

Erin holds a Masters of Business Administration degree from the University of New Haven, B.S. degree in Mathematics with a concentration in statistics, and is a certified Project Management Professional and Six Sigma Green belt.

Erin lives in scenic Connecticut with her husband and three children. She enjoys cooking and any activity outdoors such as hiking, passing the football, or lounging on the beach.