Why there are 3 versions of every process: Interview with Moffitt Cancer Center's Director of PEX

Ashly Mason

Florida-based Moffitt Cancer Center has been annually ranked on US News & World Report’s America’s Best Hospital list of top cancer centres since 1999, but that’s not to say that there haven’t been some improvements needed along the way.

A few years ago the hospital realised that it was facing a potential future shortfall in the number of beds needed to serve a growing number of people requiring inpatient treatment for cancer. So, short of building a new and bigger hospital, how could Moffitt continue to provide high-quality care to the growing numbers of people who required it?

In this PEX Network interview, Ashly Mason, director of process excellence at Moffitt, talks about process excellence helped them tackle these challenges, what she learned along the way, and explains why there are three different versions of every process.

This interview is a transcript of a recent podcast. Listen to the original podcast here: Tackling a hopsital bed shortage through process excellence

Note: this transcript has been edited for readability.

PEX Network: Process excellence and continuous improvement mean a lot of different things to a lot of different companies. What does it mean at Moffitt Cancer Center?

Ashly Mason: We look at process excellence as a strategy for the organisation, which is very focused on improving value for our customers. Most of our customers are patients and their family members. But those aren’t our only customers. We also have research and other services as well. So, we add value by improving delivery, increasing satisfaction, and reducing cost.

In our projects we focus primarily on improving service delivery and improving the satisfaction of our customers and internal staff because cost can sometimes tend to scare our staff a little bit. We truly believe if we look at how we can eliminate waste from the process, we get the benefit of the cost reduction as well. So, while we measure cost savings it’s not what our focus is on.

PEX Network: Eliminate waste and the rest will follow?

Ashly Mason: Yes. It’s very heavily based on lean techniques even though we don’t really use lean terminology. We just coin everything as process excellence. That way, really whatever tool or technique or method fits a situation, we can seamlessly integrate it and it’s not a flavour of the month. When new things come along, too, we can easily integrate that into the programme.

PEX Network: I like that because it sounds like it means you’re not focused on tools so much as the outcomes.

Ashly Mason: Yes, exactly. We "Moffittise" the tools and terminology. People then feel like it’s more directly related to the organisation and something that applies to their process. Sometimes people can get turned off if they perceive a practice to be from another industry [such as Lean] even though it works very well.

PEX Network: One of the things that you’re presenting on here at PEX Week Europe is some of the work that you’ve done around reducing the length of stay of patients in hospitals. What were you doing?

Ashly Mason: This is something we started a couple of years ago; it’s a larger project focused on improving the inpatient throughput and getting the patients in and out of the hospital in an efficient way. As a result, there’s a lot of people involved – a lot of folks from my team and a lot of people from the hospital and different divisions.

What we’ve been focusing on is reducing length of stay because any waste in terms of how long the patient is in the hospital is a waste in that patient’s time – especially since we have very sick customers often with limited time left. So, any waste is just... it’s unacceptable.

At the same time we have 206 hospital beds. In the past that was enough but now it’s not since we have more and more people getting cancer and therefore more and more people coming to our organisation and needing the beds. So, any waste in the length of stay metric is also keeping us from being able to service additional patients who need to come see us. That’s a loss of revenue if they can’t come to us and go somewhere else, but we also have the best quality outcomes and so we want the patients to be able to come and see us as well - so, it’s not just financial. It’s also for the quality of care.

PEX Network: I understand that one of the most important aspects of this project was that you involved patients in the work that you were doing. What did you do? How did that work?

Ashly Mason: We’re very lucky in that we have a patient and family advisory programme. These are customers who have become advisors to us and they sit on committees. They get involved in project teams. So, we utilised that programme and had a variety of advisors consisting of both patients that are currently going through our system or they have formally gone through the system.

But we didn’t just involve the patients. Their family members also experience the process just like the patients do – almost sometimes more so – because when a patient might be in a treatment, they’re the one who are sitting out there in a waiting room and going to other services and so forth. So, we involve them from the very beginning.

The advisors have said it helps to involve them from the very beginning. We believe that helps as well. So, when we’re looking at the process and trying to determine what the issues are, trying to determine what is value add and waste, who best to tell us what is waste or not than the patients themselves?

PEX Network: In this work that you’ve done, what kind of results have you achieved so far with it?

Ashly Mason: In the first year, we struggled a bit. We weren’t focusing on the right parts of the process for a variety of reasons – leadership and fear of involving key roles such as the doctors – but even so we still worked with patients and staff and we did get some point improvement results using the lean techniques and the process excellence techniques.

However, those results focused on certain parts of the value stream that didn’t really end up impacting length of stay. We did get some wins - for instance, getting the next patient into the bed faster - but overall we didn’t impact the length of stay.

Then we got some new leadership onboard, which enabled us to work with more roles, more patients, and more staff. That combination allowed for improvements in length of stay.

Last year alone we got a 3% decrease, which sounds like a small percentage, but it’s really the right metric. So, 3% allowed us to meet the goal of that year to see the additional demand and we ended up seeing 219 more patients last year. That ends up – to the bottom line – being about $1.7 million. So, we were very pleased with what happened last year and it feels like just icing on the cake because we have additional solutions to work on this year and more to come in the future.

PEX Network: You mentioned that initially one of the challenges was that the doctors were ring-fenced off. You could improve everything, but couldn’t involve the doctors. Was it when you could start involving the doctors that you started to see real improvements?

Ashly Mason: Sometimes in healthcare there’s a lot of finger-pointing at the beginning of a project. They say, "if the doctors would just do X...". Do the doctors play a role? Absolutely. Is it the first place that you need to focus? No. I’ve found that if we say, look, we’ve worked on these parts of the process and that has enabled this type of improvement... doctors, now we need to involve you for this part of the process and we can get that much more improvement. It does help sell it a bit.

I’m glad we didn’t have to focus the doctors at first. But there was a little bit more fear than necessary. Thinking that they didn’t have to get involved or change at all was a little extreme. We involved them last year and although it wasn’t all about them, we involved them as part of the team and that worked really well. So, they saw the benefit to the process.

This next year and the years ahead there is more focus on some of the processes that involve them more, but I think we’ve laid the foundation to allow that to work a little bit better.

PEX Network: I guess part of it is demonstrating that you’re achieving success?

Ashly Mason: Exactly. In any role we’ve got people who are very excited about change and then people who are just going to resist it no matter if it’s a good idea or not. So, we do have some more faculty or physician leadership now that is new and onboard and promoting process excellence and removing waste and transforming the experience. That’s going to help over the next couple of years with not only just promoting the change but helping with those pockets of resistance that we will meet.

PEX Network: What have been some of the key lessons in this project along the way?

Ashly Mason: How critical leadership is. This one was the largest project we have worked with and the largest value stream and the lessons learned from the smaller projects – where inadequate leadership had impacted results - hadn’t really been learned by our executives when we started. So there was a pressure there.

We thought that it didn’t really matter and felt that if we just kept going then the results would follow. So that’s what we did - we just kept going. But true impact did not follow.

When we got a new vice president of nursing – nursing plays such a huge role in that project – it really showed how with the combination of process excellence and leadership you really can do anything.

That was one of the big lessons learned because we still have opportunities and projects going on now and coming up in the future where we might not have the right leader in place. I think Moffitt and the leadership team is starting to realise that maybe this same type of leader they needed over the first 25 years of Moffitt’s existence might not be the same type of leader they need for the next five or ten years of their transformation journey. So, they’re starting to see how big that leadership role can take.

That’s more of the lesson learned from what we need to do differently. The involvement of the patients and the staff and the empowerment - that has worked very well and we’ll continue to do that.

PEX Network: What is an ideal leader for helping to enable process excellence? What are some of the characteristics that executives need to have?

Ashly Mason: Good question. One characteristic is more of a mindset: leaders must not think that process excellence is not part of their role. That it’s just for the process excellence department. It’s really everybody’s role.

For instance, when we had a new chief nursing officer who came into play, the first thing she said was that change is not a bad thing. Change is good. We need to become the best of the best and so we shouldn’t have processes that look the same as they did in the late eighties. (And we have some of those!) So, change isn’t scary. Change is here to stay. Let’s all be part of the solution.

What that meant was that she was out there, marketing for change, and she was also very visible. She wasn’t just a vice president to be a vice president. She was actually out on the floor, talking to nurses, talking to social workers, and doctors and that helps bridge the gap with leadership as well.

She stands firm and involves not just one person but all the many roles that need to be involved and all the many managers and directors because we can have a lot of silos in healthcare. Bringing all of those people together, requiring that they work together, holding them accountable, but then also allowing them to share that ownership and share the success really played a big role.

PEX Network: I think that’s really an interesting point. I love the show Undercover Boss because you have these executives that have been in their offices and watching their spreadsheets for so long finally getting out to the front line to see what’s really going on. It really sounds like that’s the kind of leaders that we need, particularly in process excellence?

Ashly Mason: Yes. I taught a process excellence basics class; a four-hour class to all of the supervisors, managers, directors, and vice presidents last year. One of the things we talked about was just that - that every process has three versions: what it should be (which is probably in some old, outdated documentation somewhere), what people think it is (which is where leadership and management live), and then how it actually goes.

Really the only people who know how it actually goes are the ones who do it and so that’s why we promote going out and observing and talking to folks about what they do. That’s what the process excellence team does and there’s no reason that the leadership team can’t do that as well.

It’s very eye opening and we just try to iterate that it’s really hard to make a good decision with bad information. How you think it’s going is bad information. Going out and talking to people and observing and "going to gemba" allows them to see how it actually goes and allows for better decision making.

PEX Network: Excellent point. So, I think my final question, then, is a more general one about healthcare. There are some people out there sceptical that process excellence – which has been synonymous with cost cutting – can really be beneficial to healthcare organisations. How do you handle the critics out there?

Ashly Mason: That’s a good question because even right now with healthcare reform and a lot of different things that are happening within the United States at least with lower reimbursements, it’s very easy to focus on cost.

Even right now looking at transformation, there has probably been too much senior leadership communication on cost: "We have to remove 160 million from the system in five years."

That’s a good burning platform, but that can’t be what we focus on. We’ve been working with the leadership team and also just doing our own communication to say let’s just focus on the patient experience. If we focus on that, remove waste, and increase satisfaction, we will get the cost out.

That’s the same thing we’ve really been doing for the last few years and it really helps the staff focus on the right thing. The cost piece can create fears of job loss and so we’ve worked with the leadership team as well to get a message out that transformation and elimination of waste is not synonymous with elimination of jobs.

Our COO heard a statement somewhere that it’s either stuff or staff. We don’t want to cut staff, so we must figure out what the stuff is. Is it inventory? Is it waste? Is it extra processing? Whatever it might be –we want to remove it so that we don’t need to talk layoffs.

I also see an opportunity in healthcare for process excellence and finance to partner more. If there are six different projects we can work on or maybe even six different solutions within a certain project, it would be helpful to partner with finance and ask, which one could impact that cost metric the most?

That doesn’t mean we have to communicate that or focus on that in the project, but what will help the organisation from a financial perspective? We’ll still focus on the delivery and the satisfaction, but we’ll also get the cost benefit in the end. So, we’ve already started that partnership with our finance team to see if we can collaborate more and align more so we can get that cost, but still be focused on the customer experience.

PEX Network: Great advice. I think the other thing that is interesting about the project that you did on the beds is that it increased the revenue and also meant that more patients - more terminally sick people - could get treatment. So, it’s a win-win all around, it seems.

Ashly Mason: That’s the whole work smarter, not harder thing. I know people hear that a lot, but when they hear that we’re not going to be adding people, but we’re going to be increasing our volumes, the first thing is, oh, my gosh, you just want me to do more. It’s like, well, no, not necessarily. We can actually do more and get you out of work on time. So, it really is about working smarter and that’s why we focus on that elimination of waste; because we can get more patients in, the cost down, and less overtime so people are getting home to their families as well as the patients being able to.