Podcast | Evolving Daily Management with Neha Patel

Chris Backous:

Hello, and thank you for joining us for better never stops a podcast for all of us committed to transforming healthcare. We interview leaders from around the world including leaders right here in Seattle, Washington, where they’re doing the workday in and day out to sustain a culture of learning and improvement at Virginia Mason Franciscan health. In each episode, we hope to explore our philosophy of go see, ask why, and show respect. My name is Chris Backous. I’m an executive partner at the Virginia Mason Institute. My guest today is Neha Patel, a Senior Director for the Department of Medicine and Surgery at Virginia Mason Franciscan Health. Today’s conversation will focus on daily management and the activities and tools that leaders across the organization use to know run and improve their business every day. Welcome, Neha. Please tell us a little bit more about your role and background at Virginia Mason Franciscan health.

Neha Patel:

Thank you for having me, Chris. I am a Senior Director over the Department of Medicine and Department of Surgery specialties. And I co lead at the downtown Medical Center and nine regional medical centers with my partner, Vonda Miller. I’m a nurse. And I mentioned that’s not required for my role, but it helps. And I’ve worked at Virginia Mason for about 11 years now. And I’ve grown up in ambulatory leadership, and I’ve been over areas like pulmonary and Nephrology and transplant. And I also spent a couple years as a Virginia Mason production system specialist in the Kaizen production office, which was very valuable to my growth and leadership.

Chris Backous:

Great. Well, thanks so much for joining us today. Today, we’re going to really talk about not just about the basics of daily management, but really some of the activities, you’ve been involved in evolving daily management to the next level for the organization. So daily management, we both know, is one of the three elements of what we call worldclass. Management. So at the top of the organization, we have that strategic alignment, then as the organization works across the functional silos, we call that the cross functional. So really, our focus today is going to be at the front line, the daily activities, the habits, behaviors, the tools that really allow people to stay true to the intention and objectives for the year. So what do you think daily management is so helpful and so important for organizations as part of their approach to Lean management?

Neha Patel:

Yes, I think the most important part of daily management is making the daily operations visible. So the most common things we feature on our daily production boards, and I think this would work for any industry, right is your demand. In our case, it’s our number of patients or procedures, and then our capacity, right, and our ability to serve our patients. And so that is, in our case, physicians and number of team members.

Chris Backous:

You know, I think back to since both of us, had our time and KPO. I think about those conversations regarding tack time, you know, in that that big question, every leader gets asked what do you produce? And I think that’s such an important piece of daily management is we can get lost in the day. But fundamentally, what are we here to do? What do we produce? Have you found that that is an important conversation to have with your frontline leaders kind of at the beginning?

Neha Patel:

Absolutely. When preparing for this, I was thinking about the engagement and what helped us create engagement for our daily production boards. And we know you know, ultimately talked about the patient and the patient experience. And so when reviewing these huddle boards, or production boards, you know, we try to huddle around them. And we try to make visible, not just our demand to our capacity, but also any barriers and we also try to celebrate team wins. And so a lot of times, I remember when I first started linking these hurdles, we would share a patient’s story, right, the reason why we’re here what we call the “see feel change” or share a great safety catch from the day before. And I think that that actually really helped create engagement because people look forward to hearing that feel good story and what they contribute to every day health care, as well as what they did to help maybe shave Someone save someone’s life prevent a serious safety issue from occurring.

Chris Backous:

Yeah, I think it’s probably important for us to help, you know, shine the shine a little bit more clarity on when we’re talking about daily management. We’ve already talked about the boards and the huddles, it’s you know, so you have the daily huddle with the team, you have your daily production board, and then you also have your Leader Standard Work is some of the three kind of key elements of daily management, and you use the term engagement. So I think about that where leaders are, especially frontline leaders today are just feeling overwhelmed. You know, staffing levels aren’t where they would like them to be demand is the same or greater. And I could imagine, you know, bringing the concept of daily management to a new frontline leader and having them say, I’m too busy for that. I don’t have time for that. Have you had to have those conversations on the value of daily management? If and have you seen like a change in that person’s perspective? Because they embrace the standard work?

Neha Patel:

Yes. It’s interesting to think about now, after COVID, because I remember having those conversations prior to COVID. And just a reflection on why would we Why would we renew this every day. And, you know, I mentioned all the ways that we created engagement, we just asked them to try it. And we tried to create fun things and fun reasons for them to attend and be engaged. And now I think after COVID, and all our staffing challenges, I think people are really interested in the content, right? They’re interested in how we’re going to serve our patients today. So both at the local team level, and also at the manager level, where I’ve shared with you before that we have a larger production board, where we look at our metrics and how we can best share strip staff across our areas to serve our patients, people come because they want to see who needs help, how they can help or how they can get help. So I think that reason for engagement and daily management is really, from my perspective changed over the last few years.

Chris Backous:

You know, so the perspective has changed, but we’ve had to evolve daily management as well, you know, when we started, it was boards and huddle vary site, location specific, but the world’s changed you, you know, COVID changed a lot of what we did, and yet the value is still having those conversations and using information to drive decision making and problem solving hasn’t changed. So you’ve done some work recently, right to help evolve daily management so that it’s more, I guess, post COVID user friendly. Can you talk a little bit about that?

Neha Patel:

I mean, I think one of the biggest things that we did is what I just mentioned, is we started a daily huddle for all managers across our, you know, 40+ departments. And the reason we did that was because before the handles were just department specific, and staff would be shared across their department, but we did it because we knew that there were areas that were fully staffed some days and areas that were short staffed, and that there were varying numbers of physicians, you know, on any given day, and so we wanted to put it all in one place. So we created a production board, where just those high level metrics for each department are in one place, and the managers huddle around it. And what that evolved to do is we started creating definitions around stalking what was critical staffing. So we defined it as in the beginning, just red, yellow, green, and green was I can give staff yellow was I can’t give staff and this is this is the department telling you what they whether or not you can, you know, yellow is I can give staff, I can’t give staff but I don’t need any. And red is oh my goodness, I really, really need help with staffing. And so the manager started huddling every day at 8:30. And you know, there were days when, you know, we just didn’t have enough staff to support all the areas and there were days where we had extra staff. And there were a lot of days where we were really able to help each other out. And it worked out really nicely. But what ended up happening is we started needing more information, right? It was interesting to watch, I guess you would say the storming and norming of the group, right? Every clinic is different. Every specialty is different. And so we needed more information behind what was around what was behind those numbers, right? So you would see in rheumatology that they said that they were yellow, but they only had six patients during that day. And then ortho would say that they were green, and they can help someone and they had 20 patients that day. And we were trying to figure out what it all meant. Right? So then we started working towards ratios. We started saying well, why don’t you Why don’t you list your number of patients per Ma So instead of looking at you know, we often used to look at number of physicians and how many Emmys you have to support the physicians were like, well, let’s actually look at the number of staff to actual patients. And then let’s also look at number of patient messages. So we started creating ratios from that. And that’s still led to more questions right and more discussions around the highest need. So that continued to evolve, but it was really incredible to see the managers come together each day and just share across multiple specialties. I always say that before COVID, you know, things would take us two years. And after COVID, we would find a way to do it within two weeks.

Chris Backous:

Well, you know, I think what’s exciting to hear about that – it’s the transparency of information. And also acknowledging that not every department is the same and measures the same things to the same level. And so it’s, it puts it back in understanding, who are we here to care for? And what does it mean to produce the care by our department, and really empowers the team to think beyond their own walls to say, you know, how do we serve our community, if we’re a community of clinics are we are departments in an organization, we can help make any patients experience better when we have the opportunity. And if we do so then others will come to us. So it really creates that kind of cross functional collaboration, by making the data not only transparent, but meaningful. And I think you’ve talked a little bit about that of, you know, looking at things and testing data points to look at to really get to what matters. And I know, I had a chance to listen in on a weekly report out where you had talked about this idea of a weighted score. And you’ve been kind of talking a little bit about that. I’m wondering if you could give us a little bit more insight about this idea of a weighted score? And how you might have arrived at that and if it’s valuable.

Neha Patel:

I just lead a workshop around this work to see how we can evolve it to the next level. And one of the things that the team really honed in on right away was that discrepancy that I said that, you know, there might be, you know, six patients to one in rheumatology, and I’m just making up these clinics, by the way. And then, you know, 20 to ortho, and really, that’s because the work behind the patient is different, right? rheumatology has different needs than an ortho patient, right, complex medications, prior authorizations, maybe more patient questions, sometimes more, more of a multidisciplinary approach with other medicines, specialties, and then an ortho patient may come in and need an X-ray, and just a quick evaluation and then be on their way. And so it was really important to the teams to share the work behind those numbers and let other team members know, hey, we want to help, but this is why we can’t help. And it really helped making things visible actually helps build the trust between the teams, right? What with our KW team did after listening right to the team members on the Gemba and collecting data, and looking at the data we collected before the event, they said, you know, it sounds like it’s not enough just to look at the ratio of visits to, to MA, why don’t we create a weighted score, that weights, the patient messages coming in a little bit more appropriately to the patient visits. And so, for example, rather than just saying, you know, today in rheumatology, you know, they’re going to have six patients to one medical assistant. Why don’t we give them a way to have .4 to patient messages for their 60 patient messages and a .6 for their patients, and create an actual score? And so what ended up happening was, we ended up creating that formula for all departments, you know, on a glorified Excel spreadsheet that populates every single day. And the numbers, you know, appear, along with the color gradients. And then it actually helped us more even we see the needs across all the areas, right? It wasn’t just, you know, five green areas and ten red, you know. It was just kind of a gradient of support need or how well the team felt they were doing. And so using that, it’s actually still in PDSA, because I just had the RKW but the feedback so far as they liked it, right? It seemed it helps people understand when they were trying to make a decision. Like I only have one me to share, but both urology and nephrology need help. Oh, am I going to give that me too, it kind of made the decision a little bit easier. Clearly, both areas were in need, but sometimes one area was more me than the other. The other thing about the weighted score is it’s actually based on previous, you know, retrospective data, right? So what the demand has actually been over previous weeks, so it gave them something to compare to it. So it gave some comparative information when making the decision about what the score really should be.

Chris Backous:

Right. You know, just a backup. We’re so you know, we’re so versed in the Virginia Mason production system that these terms are great for us. So the RPi W that you lead the rapid process improvement workshop. It was a five day workshop, that you as a leader facilitated, but it was really the people who do the work so they Ma’s and others in clinic. It was their problem to solve but it was really as leader and worship leader You were bringing the problem to the team. And they had five days to come up with something you could prototype. And then the PDSA or the Plan Do Study Act, implementation trial really helps inform where you’re going to go next. What I love about the RPIW it lines up so beautifully with daily management because it uses the same expectation that it’s the people who do the work are best –  are the ones best to improve the work. But what they need from us is direction and the structure of the methodology to be led through the process. Have you found  that as a leader, as people are working their daily management, having their huddles, putting meaningful data on their boards and talking about it, that you’re more facilitating their problem solving and less being that superhero coming to the rescue?

Neha Patel:

Absolutely, yeah. 100 100% I think there’s so many of our frontline team members, you know, every day when they’re when they’re working, just like we think of like genius ways that we can become a millionaire, right? What if – no, I think they have ideas every single day that can improve processes all around us. And so I’m always amazed, you know, when we have the data right there in front of them, and we ask them, you know, why do you think this is so? Or what do you think we can do to improve it? I? I hardly ever get silenced, which is interesting, right? Because it’s their work. They’re so engaged. I mean, this is their everyday life. This is – they’re the biggest stakeholder, right? And these decisions that are being made,

Chris Backous:

you know, now one of the one of the things I think people worry about is they get so focused on the doing the activities of daily management that it becomes a check the box, get we did it, we’re moving on, get it out of the way, get it done. As a as a leader of leaders, how do you encourage people to not let that happen? So that, you know, what advice do you give to people for having their huddles and doing their daily management activities, so that it never really just becomes check the box done and move on with the rest of the day?

Neha Patel:

I think it’s easier to say that what I’m about to say now, because healthcare is constantly changing, but I think leaders, leaders of the leaders need to attend, you know, visit the Gemba, attend and listen occasionally, and make sure the information that’s being discussed and metrics being discussed, the information on the production boards is relevant, right? I actually, right now have a metric on our production words, that is no longer no longer should be used. And this week, I need to quickly work right to find all the places where that metric exists, not only because we move to a new model, but also because there’s a better way to depict that data, not only when you attend, you get to make sure that the data that they’re sharing and discussing is relevant, you know, and tied to our higher level organizational goals. But I think you can then listen to how the team members are feeling and what’s important to them, and then connect your work to what they’re feeling is important to our organization. That’s great.

Chris Backous:

What do you think people get the most out of by attending? They’re huddles?

Neha Patel:

Like the average frontline team member?

Chris Backous:

Yeah, if we were to ask them. So what’s the huddle? What’s the value of the huddle for you? What do you think they would say?

Neha Patel:

I mean, I think it would range from something really basic, like, I know who I’m working with today, right? You know, my coverage, buddy, when it’s lunchtime, too, I’m really excited about this new modality we’re introducing and you know, and wanting to learn more to- I really have this, this problem, that’s a thorn in my shield. And this is my place where I bring it up. Right, and I have an audience, not just team members, but oftentimes leadership that can help me pull the resources into problem solving.

Chris Backous:

And that that really hasn’t changed in evolving from kind of the pre COVID. Very, in one location to a more virtual connection delivery. Have you seen that? That change at all that court kind of that those core values

Neha Patel:

I’ve seen? I’ve seen the difference in modality, right? The production boards have that are sent out via email, right, have evolved to anticipate more information that the team members want to see because they can’t have that conversation. You’ll see these productions more and share things like inclement weather, or there’s cake in the break room, right, because that used to be stuff that was that in the huddles. I do see actually have for all the departments that we’re looking at I have them send me their production boards, so I get all those emails. Um, so I see all the email exchanges that occur. I think with us transitioning to Google, a lot of those discussions are transitioned to chat. But I think the conversation is still there. And, you know, we’ve had challenges having in person huddles on and off right for the last few years. One thing that I truly, though, do, I am concerned about, and it’s on my radar is our people link, I think which changes truthfully, what changes in leadership, and, and just, and sometimes even gaps in leadership, there might be a little bit of a refresh, that needs to happen to make sure that we’re having our people lean cuddle, you know, during the week to help our frontline team members know what’s going on at a higher level of organization and not just focused around daily metrics.

Chris Backous:

You know, that’s an important thing to call out is I think that’s where many organizations lose the value of the huddle is they try and pack in too much to that moment of connection. And so you talked about, so the huddle is for one purpose, the daily huddles for one purpose, and then there’s another kind of opportunity to connect dots and align the strategy on a weekly basis. How do you explain that for a new leader? Who’s going to have some responsibility with both the daily management huddle and maybe a people link weekly strategic huddle?

Neha Patel:

Yes, that’s a good question. Because I had a conversation about this today. And one of my ideas is, we want to have a little mini back to basics retreat, where we talk about standard work for leaders, and our dealing management production boards as well as people link. And I think the best way to explain people links is to show them examples of it. So go see where it’s done well, and we have a lot of video examples here at Virginia Mason that we can share. But if I had to just explain it using words, I would say, you know, there’s a lot of information that’s shared at the higher level, I would say weekly, monthly, maybe not daily, related to integration updates, new programs, we’re rolling out, larger scale, larger scale, financial updates, you know, things that really impact our ability to serve our patients as an organization, and the frontline team member who contributes to that who’s working so hard every day to serve our patients. And sometimes even support revenue generating activity that supports our bottom line, you know, they don’t get to see our growth, or our new programs, or what we’re doing to attract new team members. And it’s really important. I think, right now, recruitment is a great example of that people need to hear what we’re doing to recruit and retain nurses, for example, and where else will a frontline nurse hear with organizations doing about that, right, we need to make the space even if it’s a quick 15 minutes once a week to really share with them just at a high level some of the exciting things that are happening.

Chris Backous:

That’s, you know, so that that kind of gets to that it is possible to share too much information on a daily basis. And – but yet, when and where is it most appropriate to share information that people care about? Because that continues engagement, doesn’t it? Absolutely. So I’m going to circle back to our conversation about the weighted score and the boards and the virtual boards, because I know there’ll be people listening, who will say, can I get that? Can you please tell me what that score is? I want to use that. How would you respond to they’re like, can you just give me what you have? So I can copy it? How would you respond to them with an ask like that?

Neha Patel:

Yes, um, you know, this is something that I’m actually working through right now. I think maybe a leader would be very excited about it. Right? I think team members are very protective about their work and what it means and understandably so. So when we rolled out this idea, one of the questions that came up was: How do national benchmarks play into the score? [inaudible] or even our larger Virginia Mason Franciscan Health Partners? What kind of benchmarks are they using? And so that’s actually going to be the work of our director cohort, and myself and Vonda, the other senior director of amatory over the next few weeks, we want to further define those weighted scores. Right now we’re just using variables, just the two variables actually visit and message, but in some departments, there might be another variable that’s important, like procedures, right? would want to add to that weighted sport. So I think we just decided to not sacrifice good for perfect right and just start with the base. The basics say try something. Let’s just try it and see where PT is saying it and seeing how it’s helping us. In simulation, people are really excited about it and interested in continuing to use it, and then I think we’re going to start deciding what else should what else should on that weighted score? And how should we incorporate national benchmarks or, you know, benchmarks from the rest of the organization? Because the way that the way that organizations measure productivity is different, right? From organization. So, I would that would be my biggest caution is, you know, how, how does your organization measure productivity? And is that in alignment with this way to score?

Chris Backous:

Well, and it’s looking at productivity, but it’s also looking at burden of work and work responsibility. So, you know, it’s not just what do we have to achieve, but how are we doing that? And is there a way to do it better? And I think, hope that that should come up during the daily huddles is, you know, I know what we’re trying to do. It’s just too difficult. Well, let’s talk about that. Do you have any ideas? Do you find that those are natural conversations that occur is – you’re looking for the right thing to measure?

Neha Patel:

Yes. Absolutely. And then the other thing that kind of ties into the question that you’re asking, is staffing models. The metric is very dependent on your on the staffing model at your location, right? And so I think those sorts of things are coming up in question as we use this, because people, I think the team members want to make sense of this metric, that that we’re using to support them and their work, right? And so as we explained it to them, and I was actually very impressed with their engagement and their interest in this mathematical equation related to work, right? But it’s because they want it to be meaningful and accurate to their work, which is totally understandable.

Chris Backous:

Well, and what I love about that is it’s really modeling the leadership of looking, looking past just what feels to what actually is, because if we can measure it, we can improve it and react to any activity that we’ve taken because we have a base of real objective measure. So I want to – I want to shift back to just your role as a leader, as we kind of reached near the end of our podcast. And, you know, looking back at all the work you’ve done at Virginia, Mason Franciscan health. Is there anything that like a specific win or a big shout out opportunity that you feel great about as a leader?

Neha Patel:

Yes, there are many. And I’m thankful that Virginia Mason has provided those experiences and opportunities. And when I was thinking about this question, I was thinking about it as it relates to production boards. I was thinking about something that I just thought was so simple, but so wonderful that happened in urology when I was the director of that department. And it was, you know, right when COVID happened. And we were used to having one nurse per physician, so we had about roughly one nurse per physician. So we had about nine nurses and 12 surgeons, and each day, we would allocate one nurse to a physician, and that nurse would follow that physician all day and support them in their practice, and, but the biggest thing they supported was procedures. And because of just all the reasons why people made decisions to leave during COVID, you know, whether it was their age before the vaccine, you know, they were concerned about how that might affect their health. Or to be closer to family or to stay home to take care of kids, we went from nine nurses to three, and really just a couple of days, it felt like days, but it was probably a couple of weeks, which is days. And so we had to, we had to dial back on procedures a little bit. But what this is just kind of the silver lining of COVID, it really made us think about how we can do things differently with the limited resources we had. And so really using leveling, or, you know, Heijunka, we, we had a nurse, instead of calling one doctor all day, we have the nurse follow the procedures in the clinics, and we made a master production board, where we would show the procedures, you know, throughout the day on a grid and the different times you guys can see my hands that your mind has are just showing the different procedures at different times during the day. And we actually have the nurse follow the procedures instead of the doctor. And what was fascinating about it is, you know, we were still able to do a significant I think we lost, you know, 60, you know, over six, or actually 75-80% of our nurses and we were still able to do about 60% of our procedures, which was just amazing. And so when our staffing came back to normal numbers, we were able to support more procedures per nurse than we ever had before. And that was really by using you know, a version of a production word and making it visible and guiding the nurses to use they became very in that particular case the nurses became very lost without that production work, which was a whole other interesting thing that occurred And we had to get them away from leaving the production where because they became so reliant on using that to tell them where they needed to go each day.

Chris Backous:

Right. But is that is that exercise of taking the work? We think we know and actually detailing the work we actually do to understand how best to resource and accomplish objectives that transparency of real meaningful data that comes from engagement with the team. I’m wondering, as you look ahead, what is exciting to you about the future? I know, it’s easy to say there’s a lot of barrier to success right now. But there’s also something to look forward to. I’m wondering, what are you looking forward to?

Neha Patel:

Yes, I’m very excited related to this production board work is the next layer of problem solving in a proactive form. So one thing I didn’t mention before is the managers are huddling to look at how they can share staff. And now we’ve actually started a director huddle, so, at 7am the daily production work boards go out 8:30, the managers huddle about 9:30, the directors huddle, but what the directors are looking at are more higher level aggregated metrics. Things like department fill department fill looking ahead, right and fill is physician schedules and how the percent of – by which they’re filling. And they’re actually not only anticipating barriers, and problem solving, looking weeks out, but they’re actually, you know, figuring out mitigation strategies for no show rates, and things like that. And so that’s very exciting to me, because we’ve been reactive. I mean, quite a bit during Cova. But even before that, and so it’s really nice to see how we can be a little bit more proactive and predictive.

Chris Backous:

That’s really cool. So now how, what’s your favorite example of the Virginia Mason production system in action?

Neha Patel:

Process Flow mapping.

Chris Backous:

Process Flow mapping. So tell me a little bit about why you think process flow mapping is the favorite approach.

Neha Patel:

Process Flow mapping is like my favorite thing ever, just because we and our colleagues, Shauna will always tease me because I love to like process flow mapping over value stream mapping all the time, but I love getting a group of people together to map out a current or future state and you know, this, even the biggest resistors get engaged in an hour, you can have, you know, entire process visible and you can identify barriers together. And you know, people start finding solutions together. But the My favorite thing about it is that they’re able to see each other’s point of view, I cannot It’s like my favorite thing during process flow mapping where, you know, a nurse and the owner is able to see the medical assistants challenge in the clinic that leads to the downstream defect, and they’re like, Oh, my God, I had no idea, you know, if I would have known that, you know, I would have done a, b, and c. So just working, having everybody together seeing something in one place. Yeah.

Chris Backous:

So finish this sentence. My favorite example of our approach to getting teams to try something new is

Neha Patel:

really to try something, my favorite thing to say is we’ll just try it, but giving them a PDSA to try and that there’s no commitment, right? Like, you know, if you think that this is not a good idea, you know, that will come out in the PDSA give it a try. It was a great idea, you know, we’ll even go further or find that in the PDSA. And even if they’re super resistant, just like stimulating it, right, because the beauty of PDSA, even as a leader and asking someone to PDSA sometimes, believe it or not, we’re actually wrong. Sometimes RPC is not a good idea, you know, or we’re going to find things out by doing that PDSA, and so already evolves into something better than we could have even done, you know, for sure than we could have thought of on our own.

Chris Backous:

Great. Well Neha, thank you so much for taking the time with us today. I think it’s just such a great opportunity, from an engagement opportunity standpoint to just share the value of daily management, the habits and behaviors, making the work visible, engaging your team, giving them tools and methods that allow them to really do their best work, solve their own problems. And you know, as a leader, not stepping forward, but stepping back and letting them it’s almost like the leading is now from behind the team because it’s really their ingenuity and their ideas that will probably make the biggest difference. So thank you so much for your time today.

Neha Patel:

Thank you for having me.

Chris Backous:

Well, we hope you enjoyed today’s podcast and learned a little bit more about how our leaders know, run and improve their business every day using daily management tools and techniques. Stay up to date by subscribing to our podcast on Apple, Spotify or wherever you get your podcasts, get in touch and submit any questions you have for us on social media. We’re on Twitter, LinkedIn, and you can email us at podcast@VirginiaMasonInstitute.org. Thanks for listening. And remember transforming healthcare is not just a pursuit of perfection, but a mindset that we can always do better, because better never stops.