Speaking at The King's Fund Annual Conference 2016, Dr Stephen Swensen, Medical Director, Office of Leadership and Organization Development, Mayo Clinic (United States), shares lessons from the Mayo Clinic model of care.
This presentation was recorded at The King's Fund Annual Conference 2016 on 9 November 2016.
Thank you so much for the privilege of being here at The King’s Fund, your wonderful country and city. You have an exemplary system and it’s a model for the world and part of the reason it’s a model of the world is you care about you and you want to make it better and so I’m here learning a lot from you and thank you for that opportunity.
I would like to share with you a few lessons we’ve learnt at Mayo Clinic over the 153 years that we’ve been around and to summarise what I’m going to share with you, there are two messages and one is that there is a rock solid business case for quality, and quality is not for money, it’s for the people you care for, the families and the communities to give them more reliable, safer care with a better experience and if you do that properly then there’s a solid business case. We published this mail quality focus didn’t make the numbers up, our chief financial officer of our $12 billion dollar are not for profit was a co-author and now he’s our chief administrative officer partnering with Dr Nosewood the ER president and he continues to track this. We distinguish hard and soft dollars in the article, we can guarantee from our real life experience a five to one return on investment for driving our waste variation and defect of care of patients.
And during that period it was a $46 million, three year role, an average return investment and over the decades since, we’re now over $600 million in cost structure reduction from improving the care of patients.
Other business sectors have understood this for generations. You take out waste, variation and defect you have long term cost structure reduction and better care for patients.
The second message is, and these are both the most important, leading in the caterers of success for healthcare versus business, it is quality, it is business strategy and the second is the joy in the work of the colleagues with whom you work. The emotional and behavioural engagement of human beings in the mission of their organisation and in their work is a huge driver of organisational success and that’s all of our jobs, as leaders is to bring that joy back where it’s gone from our nurses and social workers and managers and doctors, who are there in what should be the most joyful profession, and if you look at burnout rates across the west, in the OECD countries, in America they are over 54% for physicians, 1 in 3 nurses is emotionally exhausted, socially isolated and cynical and that in of itself is a huge opportunity to prove the quality and experience of our care on either side of the ocean.
So those are the two leading indicators of success for any healthcare organisation and I want to weave those into four stories about Mayo Clinic.
An English man, Canada geese, conductors and Newcastle cows. So Mayo Clinic was started in 1963 by an English man and a Scottish woman, who came over in 1845, this is William Worrall Mayo, he was a physician and ended up in Minnesota, god knows why he stopped at Minnesota, but he was in these corn fields of South Eastern Minnesota where he and his wife settled and set up the Mayo clinic. Still today Rochester is a company town. We’re surrounded by corn fields and soya bean fields, when I arrived there 30 years ago we had more cows in the county that we did human beings, and we’re a destination medical centre. We don’t have a population to serve, anybody that comes to our care has to inconvenience themselves by riding in a plane, train or car and staying in a hotel. And that’s forced us with our 300 systems of years and our integrated practice, pure salary system, like yours to make sure that we are same or next day access for surgery, for MRI scans, for laboratories, for neuralgic consults, otherwise our customers, our patients, the people that we serve, aren’t going to wait three days for those services. So we have to work together as a team in order to have those kind of itineraries.
Rochester is one of the great cities of the world, like London and like, and being a great city of the world that has a defining landmark as well.
So Mayo clinic is the first and largest integrated practice in the world. Last year we saw patients from 152 different countries, and all 50 American states. We have 23 hospital. We have 64,000 colleagues, we have 4,100 physicians, we have 3,800 students, resident fellows and other trainees.
So Canada geese, we have tens of thousands of Canada geese in Minnesota and they’re amazing birds. They fly at 40 miles an hour, they can go at speeds of up to 60 miles an hour and travel a thousand miles in a day, but they can’t do that alone. They do that as a team. There are huge efficiencies by working as a team for their communication, no single goose knows the destination but collectively they do. They rotate leadership as we rotate our administrators and our physicians, because of the efficiency of working together as an integrated, collaborative high social capital team. It’s about this teamwork where the focus is on the name up front of the jersey and not the back of the jersey.
We’ve a pure salary system. The integrated practice is designed to leverage the intrinsic motivators of human beings, meaning and purpose, community, collaboration, excellence. Some flexibility in your life as a professional and a member of the team. Money is an extrinsic motivator and it demotivates professionals as an incentive, and we’re a pure salary system because we think that is the most patient centred way to interact with other people, we don’t have a financial conflict of interest in a stamped for their coronary artery or in removing their gallbladder.
If you ask any of the 64,000 colleagues at Mayo Clinic what our purpose is, everyone from custodians to managers to finance colleagues will say the needs of the patient come first and every day you’ll hear that in our committee meetings and board meetings and we talk about well, I originally talking about the interest of the physicians or what about the needs of the patient. The closest parking to our facilities is for patients, not for our consultants. And if you study human motivation you find that the intrinsic motivators are what drive us.
Adam Grant looked at the use of hand sanitiser in American hospitals and the research he did, he put two different signs and hand sanitisers. One sign said use of hand sanitiser prevents patients from catching diseases, the other half of the sign says use of hand sanitiser prevents you from catching diseases. There was a huge difference in the amount of hand sanitiser used in these studies. When human beings were reminded of the meaning and purpose of reducing infections in patients, not themselves they pumped the hand sanitiser an extra time. And so as leaders, that’s what we have to leverage is the reason we went into healthcare, is to help people and communities and families, not ourselves and so money and hand sanitiser for yourself, it don’t get there.
We’re a consensus driven organisation. The idea is for everyone to feel like they’re architects and not construction workers. It’s a way to engage colleagues as a team instead of treating them as car centres or profit centres or functions. They’re someone’s precious children and we need to treat them as such.
In the great depression, within a year our patient volumes dropped by 40% and a 1 in 3 patients didn’t have the nickel to pay for their care. So, we had twice the capacity that we needed. The culture of Mayo was and is, to say we’re all going to take a pay cut instead of sending half of you home. Like the early decades of the London Symphony Orchestra, we’re driven and guided and led by our musicians.
We had a visit to Mayo Clinic a few years ago and her summary of our culture and our innovative practice was that we were socialism run by conservatives.
We are not a holding company, we’re a single operating entity with 23 hospitals, 70 some clinics in 7 states. We have a single sheet of music we play from. We have one strategic plan, we have one operational plan that is interpreted and manifested from orthopaedics to primary care paediatrics. So instead of optimising the verticals of our hospitals and clinics as separate holding company units, we think the most patient centred and efficient and effective way to organise ourselves is to connect all of those urology departments and radiation oncology departments and medical oncology departments across horizontals so we can learn from each other with a high degree of social capital. Social capital is trust and interconnectiveness of the human beings that work in our organisation.
So we looked at synergies and for practice education research integration, administrative support services, supply chain that drives out waste and variation so we have more resources left over for better patient care, and we connect up across our clinics, in hospital in the mid west, in our three major academic centres in Minnesota, Arizona and Florida with 41 special contours. So every clinical group from transplant, we’re the largest transplant service in America, we aspire to have the same care, the same results, the same cross structure at each of our entities and so when we find out the cost structure for a lung transplant in Florida is half of what it is in Rochester, we want to know how we can improve the value of that care.
So everything we know about our practice, infection rates, re-admission rates, patient experience, cost structure, we share transparently across all 64,000 so we can look for ways to improve.
Standard work in that of itself is not a virtue, but we have to standardise at every opportunity where it creates value for the people and the communities and the states and country we serve and it frees up time for professionals to think and so if we hit those two litmus tests of standard work creating value for the people we serve and the professionals that deliver it, then absolutely we move forward fast.
So a decade ago when you look anticoagulation with Warfarin, that year we anticoagulated 18,700 patients with that high risk drug. We had dozens and dozens and dozens of protocols for administering Warfarin and all of them were reasonable and all of the doctors were competent but that high variation environment was an unsafe environment and our defect rate was unacceptable. We had one positive deviant in the health system in Auclair we said that’s what we want to standardise to excellence. We showed physicians the data, their own data, it made them uncomfortable, they wanted to get better and we fixed it. So now we have the best possible defect rate across all of our 23 hospitals with a CPO we activated pharmacy led algorithm that gives a standard of work. It had the trifactor. Patients are safer, there are few complications, shorter length of stay, they’ve saved us money and it freed up time for professionals to think.
We have a formal diffusion model for the care we want at every corner Mayo Clinic but the most important part of the diffusion model, is not that engineering way of spreading the practice, it’s mediated and effected by this hormone called oxytocin. Oxytocin levels relate to trust. You shake someone’s hand and your oxytocin levels go up. This is a human brain and the emigular without enough oxytocin. We’re built to fear differences and strangers and people who don’t look us or sound like us, even if they’re general surgeons from Florida and we live in Minnesota. So we need to get together, shake hands and plan together and build social capital. Brook Institute looked at the valuation of major OECD countries thirty years ago it was intangible bricks and mortar resources. Thirty years later now in the 21st century the valuation of most companies is in intangible assets. Human capital, and social capital. The most important of which is social capital. That is the trust and interconnective of people, and it looks more like this as the organisation, we were comfortable speaking up, we were comfortable learning from each other where we enjoy the camaraderie and the glegiality and the community that we work in, this is a learning organisation that will thrive in the 21st century.
It’s not about bricks and mortar, it’s about how people work together on the micro systems of teams with nurses and doctors and pharmacists and social workers, between departments and between institutions in regions and trust. That’s the formula for success.
So conductors, this is the Orpheus chamber orchestra. It’s a New York City group, they make great music. They don’t have a conductor. The musicians take turns leading the organisation, make decisions as a group and the violinist might lead the Mozart and the cellist might lead the Beethoven. Leaders among peers. And this is the model we have at Mayo. We are a physician led organisation, all of our physicians still practice medicine, we can do that as a $12 billion not for profit because we partner with excellent administrators. They’re all MBAs, MHAs, and they see the big organisation, they understand the business, the physician leaders understand practice of medicine, it’s different form the business of medicine, and they have this social capital, the trust and relationships with the, we still call our physicians consultants like you do, and I think that that’s from William Worrall Mayo. They’re connected to the real work. It’s not the only way, but it’s a natural way for us to lead and it’s easier to get connected to the people doing the real work at the organisation. Our nurses are led by nurses, our pharmacists by pharmacists, our social workers by social workers. So our basic premise for this clinician led organisation is that we would prefer to have a violinist be our conductor, in partnership with an administrator and a nurse instead of someone who just studied the violin.
And the design of this organisation is for engagement, it’s for joy and work, it’s to make sure that we do everything possible so that our staff don’t feel like construction workers and they feel like architects. That they feel like they’re part of the team.
Next slide is a researcher with a micrometre. Published his work in Harvard Business View a couple of years ago. He measured the signature size of Fortune 500 presidents and CEOs under annual report and looked for a relationship between the signature size and the success of the company.
The bigger the signature size of the president of the company, the more likely it was to overspend budgets, have a lower margin and a decrease in market share.
So we hire people at Mayo who have small signature size.
We actually measure signature size metaphorically. We have 3000 frontline leaders, of groups of about 20 and the physician side that I lead, we have 242 incumbent physician leaders all still taking care of patients, all partnering with full time administrators who rotate throughout the organisation, so their perspective is on the big Mayo clinic, and every year we ask the staff if they had the privilege of serving nine questions about their performance, that are basically five behaviours, and for every point on a 60 point scale upward, there is a 9% increase in the engagement, the satisfaction, the joy in work of those physicians working in that unit and a 3.3% decrease in the burnout of the staff.
And it’s not rocket science, these five behaviours we train to, we hire to and we measure and here they are; the first is I appreciate your work, I appreciate you as a team member, thank you; the second behaviour is that I value your ideas, tell me what you think, what should we do together in haematology to make it better, I communicate transparently, here’s everything we know about vascular surgery division, let’s together figure this out. It’s participated management with collaborative action planning. The fourth is I take an interest in your career; what do you want to do at Mayo Clinic next year, what do you want to be in five years, how can I help you with your dreams for your career. And the fifth behaviour is inclusion. You may recognise this woman, it’s J K Rowling.
So why do we call her J K Rowling for the Harry Potter series books that she wrote. The publisher said, if we used her real name, Joanne, teenage boys in New York City and London wouldn’t buy her books. So they marketed J K Rowling. In order to have the highest possible interconnectiveness of your teams, everybody regardless of genome or phenome or generation or at least he has to feel included. And that’s a leaders responsibility. We measure it and we hire for it and we fire for it.
So here is the bell curve of the actual individual leadership composite scores on those nine dimensions for the department and the vision sharers in Mayo Clinic Arizona, Florida and Rochester, and there’s a bell curve, and those bottom segments, that’s unacceptable behaviour for a leader. We coach them on the side behaviours, we make sure they have a good administrative partner, we make sure that they have developmental opportunities to really authentically live those five behaviours and most of them get better. If they don’t we move them back into the practice where they can do something they’re good at, take care of patients, because leadership that doesn’t exhibit those five behaviours is harmful for patients.
So it’s about the name on the front of the jersey, not the back of the jersey.
And so finally, we’re going to get to the Newcastle cows. So this some research done up in Newcastle eight years ago now. What single thing can you do to a cow to increase her milk productivity by 240 litres of milk a year? Give her a name and use it every day. And guess what, the same thing is true for human beings, and there are more dividends for patient safety and experience and teamwork and productivity, lower rates of burnout, engagement, if you have colleagues and unit leaders, not C suite but unit leaders with high degrees of social and emotional intelligence. It makes a difference in high performing teams, enjoying work and it’s incredibly important. And so from the early days we measure that and hire to it. This is Martha Lacy, she’s a chair of haematology, when she took over four years, the burnout rate in haematology were at the highest 10% of Mayo Clinic. She flipped it by doing two things; first of all she turned from being a middle manager into being the champion. Instead of saying this is what they’re telling us to do, we’re just construction workers, when you do it, she said “what can we do to improve the care for our patients and to take control of this” and so she turned her staff from victims into champions. And the second thing she did is, she asked each member of her team from nurses and social workers and docs, what brings you joy in work? What are the pebbles in your shoes and then they remove the pebbles one at a time together. And she flipped the numbers.
We actually measure emotional intelligence in approxiamtley 150 position we hire every year. Before we hire them as consultants after three years. It’s not a pass / fail test for emotional intelligence but it’s a chance for them to reflect with a coach about how they work as a team member, healthcare is a team sport, it’s not individual fields anymore, and if you don’t have a high degree of social and emotional intelligence you’re not safe and we don’t want you on our staff.
So this was, when I chaired radiology, we did an intro collaborative to our reliability. This is a patient here from New Orleans, that year was crucial, we did a million exams in Rochester in radiology, and we understood that even if we were 99.9999% reliable, we’d still have two patient harm events a week, so we set out to address that. And I learned from Roger Resar who helped support our work as a senior fellow at IHI that multi disciplinary team based improvement work is a gateway drug to engagement and satisfaction staff.
And so on these slides you’ll see 43,000 names of Mayo Clinic colleagues. All of them are bronze, silver or gold quality fellows in our academy because they’ve done improvement work and know the basics of rapid cycle improvement or vena six sigma. They’re doing their second job at Mayo. We’ve stuck everyone to two jobs at Mayo, to do their work and improve their work, and done right improving their work brings them joy because they’re being asked to help in the care of the people that we are entrusted with.
One of the improvement works in that collaborative was looking at our 21 MR scanners of the year, at the time, and six months of lean work, we saved seven minutes per appointment which by filling that appointment was hard, our savings are $4.1 billion from just seven minutes of lean work.
Drew Smith was a cardiologist at The Mayo Clinic at the time, said good work team, but can you do better. So overnight we doubled throughput, and once we figured out that secret, we doubled it again.
And the recent America with the tolls out, we can double bill for therapy.
So I’m going to end with a story of Iris Cogger. Eight years ago the Discovery Channel came to Mayo Clinic to film a documentary on patient safety, they interviewed Dr Bob Cima, for someone’s colorectal surgery work, and he said let’s shoot some B roll and it’s this woman down the hallway. Her name is Iris Cogger, she’s a custodian, she cleans toilets and changes soiled sheets, the director asked her what her job at Mayo Clinic was. She said “my job is to save lives”. She comes to work full of joy, she doesn’t come to work, look in her job description, she comes to work as a team member to help with the best interests of the patients every day.