“If everybody is doing something exactly the same each time, you now have reliability and that gives you visibility to see what is and isn’t working.”

- Martha Purrier

In our most recent blog installment, we reported on the use at Virginia Mason of a technique called Training Within Industry (TWI). In essence, TWI is standard work for training where the goal is to train every worker doing the same task in exactly the same way so that the standard work is as precise as possible.

Martha Purrier, RN

One of the leading national experts on TWI in health care is our own Martha Purrier, director of Nursing at Virginia Mason’s Bailey-Boushay House, an inpatient and outpatient center for people living with HIV/AIDS. Martha has a rich mix of experience having served in the Virginia Mason Kaizen Promotion Office and also as an oncology nurse.

A little more than four years ago, Martha took on the assignment of scouting TWI to determine its applicability in health care generally and within the Virginia Mason Production System in particular. At the time, Virginia Mason’s kaizen efforts were producing some dramatic improvement gains.

“It seemed like we had nothing but great ideas and we were really getting some fantastic results,” she says. “The question was how do we keep it going? How do we sustain the gains?”

As she studied TWI, Martha was drawn to the precision of the method. “It’s a really old school method of showing while telling and combining the two because neither is adequate on its own. TWI is a very prescribed way of figuring out the best way to do something and then teaching that by showing and telling the person exactly how to do it.”

Before teaching someone a particular piece of standard work – preparing intravenous medications, for example – the teacher carefully identifies the best practice and then breaks that down into a series of simple steps. Figuring out the design of how best to teach a particular piece of standard work demands precision and accountability from the teacher given that the goal is a defect-free process that can be repeated reliably every time.

“And if everybody is doing something exactly the same each time, you now have reliability and that gives you visibility to see what is and isn’t working,” says Martha. “We value research-based discovery and when you have a large number of people doing something exactly same way it is so revealing.’’

TWI has been introduced in a number of Virginia Mason departments, but by no means across the medical center. “We are still learning how to do the methodology and that takes a lot of practice − breaking down a job and really engineering it well. And it also takes real skill to effectively do the training.”

Martha’s expertise led her to write a book on TWI called Getting to Standard Work in Health Care: Using TWI to Create a Foundation for Quality Care. Martha’s co-author, Patrick Graupp, is an expert on Training Within Industry at the TWI Institute. The collaboration is a powerful one, pairing a leading TWI expert in the world of industry with a leading TWI expert in health care.

“In health care, training is part of your world all the time,” says Martha. “There are always new people and new advancements, so it is something that everybody in health care needs to know how to do well.”

More health care organizations throughout the country are adopting TWI, and Martha and Patrick write about other organizations as well as Virginia Mason. The whole point of the book, says Martha, is to help health care organizations understand and apply TWI.

Essentially, it is a how-to training manual, yet the book is very accessible and easy to read and learn from. (Click here for a free download on the book chapter about hand hygiene.)

“We created a system that brings services to the patient instead of the patient having to go to the services.”

- Karen Gifford

In 2011, Virginia Mason opened a state-of-the-art Emergency Department that was like few EDs anywhere in the nation. The opening came after years of study and planning in the previous department where VM teams applied a variety of Virginia Mason Production System tools to design a unit that put the needs of patients before all else – and in every way.

The ED’s design offers team members excellent line-of-sight into patient rooms.

The new ED, located in the Floyd & Delores Jones Pavilion, stands as a singular achievement in Virginia Mason’s pursuit of the perfect patient experience. We’ll talk more about this unit in future blogs but today we are focusing on key elements that are foundational to the ED functioning at the highest possible level of quality, safety and access.

For decades, the issue of time has been a bedrock problem in emergency care. Traditionally, patients wait at every turn and it is not uncommon to hear of waits of many hours to be seen by a provider.

The experience at our new ED is totally different. When patients arrive, they are greeted by a nurse who assesses their acuity level. This is done using an Emergency Severity index scale of 1-5* (1 being the most acute). The nurses are so well trained and experienced in emergency medicine that they often make their assessment (based on how the patient presents and his or her chief complaint) in minutes and sometimes seconds.

During the recent years’ improvement work, various kaizen events showed that flow in the ED could be improved significantly (and wait times reduced in a big way) if patients with relatively straightforward conditions were treated in an area set apart from the ED.

Rapid Medical Evaluation Area

Karen Gifford

Virginia Mason created a separate physical area consisting of four rooms where patients in the 4 and 5 categories are treated right away. “One concept from our VMPS work was to not have patients penetrate further into the ED than they needed to,” says Karen Gifford, RPh, administrative director, Emergency Services. “So when patients with lower acuity go through our rapid medical evaluation area, they get seen quickly, get the care they need and leave in a much shorter amount of time.”

Here was but one example where the voice of patients – who were involved in the redesign of the ED throughout the process – made a difference. Initially, the triage area was called the “sort area” by clinicians, but patients didn’t think that sounded quite right; it seemed dehumanizing. So the name was changed to better represent what actually took place – the Rapid Medical Evaluation Area.

Bring Services to Patients

During the course of the design process for the new ED, VM teams – working closely with patients – came to understand that a major stress point for patients was leaving the Emergency Department to travel to other areas of the hospital for services.

A CT scanner in the ED means bringing services to patients instead of sending patients to services

“We created a system that brings services to the patient instead of the patient having to go to the services,” says Karen. “We now have a CT scanner located in our ED and expanded our lab services. Before, especially for patients with strokes and high acuity needs requiring a CT, it meant having to leave the department, travel down a hallway, take an elevator ride and often wait. It was stressful for them.”

Quiet Zone for Team

Whether nurses, doctors, technicians or those in any number of other roles, ED team members are exposed to a non-stop flow of urgent, often immensely challenging, medical conditions. They never know what will come through the doors or when. They just know it will be a challenge.

The stress of these positions is considerable. As part of our commitment to putting the patient first, we created a quiet area so team members can get a break and reenergize to take the best possible care of patients.

“This space for the team is separate from the clinical area, and it is a nice quiet zone where they can eat or read or just unwind for a bit,” says Karen. “The team’s reaction has been wonderful. There are big windows with natural light and it is very rejuvenating. They work so hard they need to be able to go somewhere close to the work space but that lets them feel like they are away from it. It is really important that team members have time away from daily stress and mental fatigue.”

Great Results

There are many measures of effectiveness in the ED but among the most important is patient satisfaction. On that score, Virginia Mason’s ED rates a 90-percent-plus satisfaction score through Press Ganey.

 Another measure involves time – how long it takes to discharge patients to home or to admit them to the hospital. (On average, about 70 percent of ED patients are discharged home while about 30 percent are admitted to the hospital.)

As recently as the start of 2013, the average amount of time patients spent in the ED before discharging home was 191 minutes. Through the use of Rapid Process Improvement Workshops and other VMPS techniques, that is now down to 171 minutes. For patients admitted to the hospital, the time at the start of the year was 263 minutes and is now down to 233 minutes.

Virginia Mason has been able to accomplish this with a new ED that has fewer beds – yes fewer beds – than the previous unit. It has done so because the VMPS techniques used – including crucial patient input – has created a much more patient-centered and efficient ED – among the finest anywhere.

*For example, while a heart attack would be a 1, a simple abrasion on the arm would be a 5. A patient presenting with a lot of gastrointestinal pain, nausea and general malaise would be a 3 (and could be sicker than how they appear).

“The flow process works so well now that the current door-to-balloon (intervention) time at Virginia Mason is 42 minutes – cutting more than half the time recommended by the American College of Cardiology and American Heart Association.’’

- Sharon Mann

Flow matters in every area of health care, but perhaps no where is it more important than in the Emergency Department (ED) where it can save lives. Virginia Mason’s new ED is the result of years of work aimed at perfecting flow in pursuit of the perfect patient experience.

Sharon Mann

“When patients arrive at the ED in an urgent or crisis situation, we want to make them feel as though we’re expecting them and welcoming them, not that they are an inconvenience or that we are busy and they are a nuisance,” says Sharon Mann, RN, MS, NEA-BC, director, Virginia Mason Emergency Services.

The welcoming environment the VM team has created wouldn’t sustain itself long if the underlying processes within the ED were not so focused on the flow of patients.

A key part of the flow is setting up the system so patients with lower acuity problems never have to penetrate deeply into the ED, but are quickly evaluated in a Rapid Medical Evaluation Area. These patients get diagnosed and treated quickly in a separate area, leaving the bulk of the ED free for higher acuity cases. This one change in flow among many has made a significant difference.

A great example of the advanced flow work that makes a huge impact on the patient experience involves heart attack patients brought into the ED. The old protocol was siloed. But a deep dive using tools of the Virginia Mason Production System (VMPS) broke down the silos and integrated the teams with a laser-like focus on what is best for the patient.

This is where the tools of VMPS really pay dividends for patients. The two teams – ED and cath lab – came together and looked at the entire process from the patient’s point of view. The challenge was how do we work together to create the best possible patient experience?

A key part of the answer proved to be the idea of external setup, an important VMPS concept. It used to be that the ED did ED work and the cath lab did cath lab work, and they did not cross borders. But a breakthrough came when the teams agreed the ED team could do most of the setup work for the cath lab in advance. Thus, heart attack patients in the ED receive an EKG, sign consent, are gowned and ready to roll into the cath lab where the interventionist procedure can be done right away. Flow in the ED is now smoother than ever.

“We had a kaizen event that brought the two teams together to leverage what both teams could do for each other,” says Sharon. “So now, the ED does setup for the cath lab – the prep work – so the patient is already prepped when they arrive in the cath lab and they can start the interventional procedure for the patient right away.”

In fact, the flow process with heart attacks starts before patients arrive in the ED.

“Medics call in from the field and let us know they have a patient with chest pains or, in some cases, they have done the EKG in the field and confirmed the heart attack,” says Karen Gifford, RPh, administrative director, Emergency Services. “We immediately prepare a team and a bed. We have an alert that brings techs, nurses and physicians to meet the patient on arrival and begin working right away.”

Thus, the whole team is in place and ready before the patient arrives.

The Virginia Mason goal is to complete an EKG within five minutes of the patient’s arrival and to get the patient to the cath lab within 15 minutes upon arrival to the ED. When they began the focus on this work a few years ago, the American College of Cardiology and American Heart Association (ACC/AHA) urged hospitals to achieve a door-to-balloon (intervention) time of 90 minutes or less.

But the VM team wanted to do much better. Through the years, VM teams had applied VMPS tools and concepts to a variety of areas and eliminated enormous amounts of waste. Thus, they started their work setting a goal of 60 minutes for door-to-balloon time.

“The flow process works so well now that the current door-to-balloon time at Virginia Mason is 42 minutes – cutting more than half the time recommended by the ACC/AHA,” says Sharon. “This is a great boost to patient experience and to the lifesaving quality of care provided in the ED.”

The flow work in the ED has certainly paid off. The ED patient satisfaction rate is pushing 90 percent (according to Press Ganey), a truly impressive number. It is important to note this has been achieved in a new ED unit with fewer beds than the previous unit, a testament to the relentless kaizen work by the team and a clear confirmation of the power of VMPS to reduce waste and improve efficiency and patient-centeredness.

“We really created that relational shift between the two departments that didn’t exist previously,” says Sharon. “Now, we work as one team for the patient.”

“One of our great strengths at Virginia Mason is that team members feel very connected to the organization and its mission.”

- Sarah Patterson

At Virginia Mason, things were going well. It was 2007 and the organization was in its sixth year of applying the Virginia Mason Production System (VMPS). Thousands of kaizen events had enabled Virginia Mason to provide higher quality, safer care, and do so more efficiently.

But data tracking results of the improvement events revealed a bothersome trend: In too many cases, improvement gains measured 90 days after the end of an event had slipped. Some slippage was to be expected, but what was concerning was Virginia Mason was only measuring 90 days post event. What would they find if they re-measured one year after the event? Would any of the improvements still be in place?

Sarah Patterson

This challenge was hardly unique to Virginia Mason. Sarah Patterson, executive vice president and chief operating officer, spoke to many health care leaders around the country who were also confounded by their organization’s inability to sustain improvements.

“I talked to a lot of people who felt like they had to solve the same problems over and over, work unit by work unit,” says Sarah. 

When Sarah and her colleagues analyzed the problem they went back to the roots of their work adapting the Toyota Production System to health care and realized there was an important module they had not studied in any particular depth. That choice had been made deliberately at the time – there was only so much Virginia Mason could handle at any given moment.

The module, called World Class Management, has three components:

-          Management by Policy (hoshin kanri), which is a method to provide focus, direction and alignment within the organization;

-          Cross Functional Management, which provides alignment across the organization toward full customer satisfaction;

-          And Daily Management, which is essentially standard work for leaders.

“Management by Policy provides focus and direction,” says Sarah. “It is really the process by which the organization determines what it will work on, how it will do the work and how it will measure the results.”

Sarah and her colleagues could see throughout the organization there could be better alignment on goals that really mattered. It seemed clear that Management by Policy (hoshin kanri) was designed to help improve how connected people felt to the work being done.

Debra Madsen

“We use it to set our organizational goals and direction for the year,” says Debra Madsen, associate general counsel and administrative director, Legal and Administration Operations at Virginia Mason. “The bottom line is in order to align and engage everybody in the organization on what the organization considers the most important work, you need a very inclusive process for setting your goals.”

Says Debra, “It shines a bright light on our most important goals so team members understand our priorities. It is a great way to establish goals and engage everybody in the process.”

In the past, to develop annual goals, executives would make a list. But that’s all changed. Now, under the hoshin kanri approach, there are four elements to annual goal setting:

• Reflection
• Catchball
• Deployment
• Check and Review

Reflection is an environmental scan to make sure multi-year plans are still focused on the right things. “We look at what is going on both in the national and local environment – do we have any big changes (health care reform might be a good example) that we need to take into account in our annual goals?” says Sarah. “We also look at internal data from our staff and patient satisfaction surveys – is there anything they are telling us that we should take into account?

“The reflection phase involves preparing a written analysis of our strengths, challenges, and opportunities both externally and internally, and then sharing it throughout the organization,” says Sarah. “This transparency is really critical. If managers and team members don’t know what the challenges and opportunities are, how can they possibly feel a sense of urgency and engagement?”

Catchball is all about feedback and engagement with as many Virginia Mason employees as possible. It involves leaders throwing ideas to the organization, seeking input, and having staff throw back the ideas for revisions. It involves exchanging ideas and hashing things out in both formal and informal sessions.

“A lot of catchball is letting people know what we are working on already, why it is important and what we are shooting for next year,” says Sarah. “There is a real richness in the conversations. It isn’t about sending out emails or just formal meetings, it’s about a lot of one-on-one communication.”

[We’ll discuss Deployment and Check and Review in an upcoming blog installment]

Why is this important to our organization?

An essential part of the hoshin kanri process is identifying a problem or objective and making clear why it matters to the medical center; who needs to be involved to reach the goal; determining what resources are required and how progress will be measured.

The planning process thus involves a good deal of negotiating among and within departments. There is only so much any one organization, department, division or individual can accomplish. During annual goal planning – which typically starts the beginning of June and runs through the remainder of the year – there is enough openness, negotiation, give and take to arrive at consensus.

“When you do this right, the impact is that you have people who are engaged and empowered,” says Sarah. “They know what the organization is about and they understand how they can contribute to it every day. So it is not all about leaders making every move. You have created an ability for the entire organization and everyone in it to make improvements. At Virginia Mason, we use our strategic plan to start many of our meetings, and we talk about how whatever we are discussing will contribute to our strategic plan.”

The intensive focus by Virginia Mason leaders on communicating and having dialogue with team members has resulted in survey results showing one of the organization’s great strengths is that team members feel very connected to the organization and its mission.

“This is an essential part of creating a learning organization and an engaged workforce that’s out there moving your key initiatives forward,” says Sarah. “If everybody is contributing to the effort you will go further faster.”

“It gives us focus and alignment,” says Debra. “There are places where people go to work and face a lot of ambiguity about what they are doing and why they are doing it. With this process there is not a lot of ambiguity. People know the goals, they understand the why of the goals and they know their personal role in helping to reach those goals.”

“The kaizen fellowship program builds its own set of senseis who continue improvement and question whether we have waste within our own improvement processes,” Gillian says. “It helps make the application of lean even more dynamic.’’

“The idea is: let’s fix it in the moment.”

- Linda Hebish

In our last post, Sarah Patterson, Virginia Mason Executive Vice President and Chief Operating Officer, explained the essential power of applying a technique known as World Class Management within the medical center. Sarah noted that World Class Management has three components:

• Management by Policy, which provides focus, direction and alignment within the organization;
• Cross Functional Management, which aligns across the organization toward full customer satisfaction; and
• Daily Management, which is essentially standard work for leaders.

Daily Management has become a critical aspect of the Virginia Mason Production System.

Linda Hebish

“Our vision is to go from firefighting to creating capacity so you can see what is coming down the pike,” says Linda Hebish, administrative director, Virginia Mason Kaizen Promotion Office. “With Daily Management, we want to determine how we did today and how can we do better tomorrow.”

Virginia Mason has achieved striking improvements over the years due in large measure to five-day Rapid Process Improvement Workshops (RPIWs). While highly productive, these sessions are also time-consuming, requiring substantial preparation by the teams before the workshops even begin.

“We also do a lot of two-day events and now we are saying, with Daily Management, the idea is: let’s fix it in the moment,” says Linda.

Since adapting the Toyota Production System to health care more than a decade ago, Virginia Mason teams have continued seeking ways to improve care delivery by learning from industries outside health care. For example, Linda has learned valuable lessons during gatherings of the Association for Manufacturing Excellence.

“In 2010, we were not moving as fast as we would have liked,” says Linda. “We had been to Japan multiple times, gone to different manufacturing conferences and one thing we would always see in manufacturing settings is production boards and genba walks by leaders at all levels. We were seeing it all the time yet we weren’t doing it here.”

After extensive internal discussion and study, including reading Creating a Lean Culture: Tools to Sustain Lean Conversions, by organizational psychologist David Mann, Virginia Mason leadership decided to implement the changes required that would support the daily management component of the World Class Management system.

“Daily Management – which is really leadership standard work – is considered by many people in manufacturing to be a game-changer and I believe it’s true,” Linda says. “What better role model for front-line workers than leaders being present where the work is done –  teaching, guiding and coaching. Leaders are on the genba to coach, mentor and improve daily work by reducing waste.”

She explains the method has five key elements: 

Creating a Production Board

Production board from Virginia Mason Bellevue.

First is creating a production board. The boards serve as a quick, visual display of what a particular department produces in its value stream and shows whether the department at any given moment is in a normal or abnormal condition. Boards vary significantly from one department to the next.

A simple example comes from the clinic. “Let’s say there is a group with five doctors and the board shows that Dr. A has six appointments in the morning, while Drs. B and C each have 10 appointments. The question is how to get Dr. A’s schedule in sync with the others.”

When the board displays such an imbalance, team members immediately let the call center know that Dr. A has openings. The board also provides concise information about the team – who is sick, on vacation or working on an RPIW, for instance. It lists the care nurse for the team, as well as the overflow physician if all doctors get fully booked.

The board also displays indirect care – the emails, paperwork and phone calls that flow into physicians throughout the day. In past analyses, Virginia Mason physicians have noted, on average, primary care physicians receive upwards of 60 pieces of indirect care daily and much of that work can be handled by a medical assistant (MA) or nurse. When indirect care is handled in flow by MAs and nurses – and physicians when necessary – it makes a significant difference in keeping the physician in flow and on time throughout the day, even as it allows doctors more time with patients and less on indirect care.

One of the most interesting things about Daily Management is that teams voluntarily fill in for one another when needed. At the beginning of each shift the team leader – usually the supervisor – reviews the board with the nurses, MAs and physicians when available.

“Help Me” board from Virginia Mason Kirkland.

Throughout the day the board is updated. For example, when the number of pieces of indirect care for a physician exceeds 18, that fact is noted in red on the board and nurses and MAs step forward from other teams to reduce the number and help the physician get back in flow.

“When a team is behind, they might need an MA to help with setup for the next patient or they might need a nurse to counsel a patient over the phone,” says Linda. “It is very important for us to understand what normal status is and what to do when we are in abnormal status. We have struggled with that; it is easy to create a board but not so easy to create the action you take as a result of what the board is telling you.” 

Daily Accountability

The second element of Daily Management is daily accountability. This is accomplished by having the team huddle around the board and set their plans for the day making whatever adjustments in terms of personnel or scheduling are necessary. It is about knowing the reality of the moment – what do you need that you do not have – and filling gaps.

“With the daily huddles what we’ve found is that once the leader does it a few times he or she will hand it off to the staff, and the leader then observes as frontline staff members go through the huddle process,” says Linda. “It really helps create staff engagement and empowerment.”

Standard Work for Leaders

The third element of Daily Management is for the leader to create his or her own standard work and to make that work visible to team members. Some leaders do this with a board on their office door or posted somewhere centrally so any team member can readily see it. The leaders list will indicate his or her standard work for each day, week and month.

“The closer you are as a leader to the frontlines the more standard your work,” says Linda.

The approach has been impactful. Danna Priest, RN, Kaizen Promotion Office, made this observation from her time as an assistant nurse manager in Medical Telemetry: “I used to go home at the end of the day and think ‘what did I even do today?’ Before Standard Work for Leaders, I felt like my day was spent putting out fires and reacting. Now, I feel aligned with my team and vision, and it allows me to be proactive in meeting goals.”

Root Cause Analysis

The fourth item within Daily Management is root cause analysis, which involves teams getting at the root cause of any issues within their work areas to eliminate waste. Root cause analysis helps team members capture those abnormal items and track them so they can feed into their kaizen work. It is critical to spend time understanding the real problem by using a defined approach. Many issues can be solved in the moment, while others may require additional resources from upstream or downstream areas. These cross-functional issues can lead to an RPIW or other kaizen activity.

Cindy Rockfeld, administrative director, Ambulatory Services, explains that root cause analyses are particularly effective when applied to multi-faceted challenges. When a physician says there are holes in the schedule, for example, root cause analysis brings all stakeholders together to get at facts, not assumptions.

“As a result,” says Cindy, “we get different perspectives from different stakeholders. While the physician may say the hole in the schedule is due to lack of demand, the scheduler may say there are holes because the schedules are blocked. Getting the big picture of the root causes for a particular problem is powerful and enables the team to do better planning of the improvement work.’’

Genba Walks

The fifth item Linda refers to as genba walking. “It’s a prescribed routine where leaders walk the genba and not only look for accountability, but are also working with and coaching frontline team members. It is a teaching role that guides and empowers staff members,” she says.

Thus far at Virginia Mason, all these elements have been rolled out in primary care while the first three elements have been introduced to the rest of the organization. The Kaizen Promotion Office is partnering with operational leaders to roll out the final two elements throughout the rest of the medical center.

“World Class Management and Daily Management in particular are game changers because you are embedding accountability throughout your leadership team at all levels. You are seeing in real time what your production is today,” says Linda.

“By tilling the soil you are making certain your team is prepared for what’s to come.”

- Cindy Rockfeld

One of the most important advancements at Virginia Mason has been learning how to effectively prepare clinical teams for kaizen. One of the concepts from the Toyota Production System that speaks to this need is nemawashi – or “tilling the soil” (laying the groundwork) to prepare clinical teams for change.

Cindy Rockfeld

Cindy Rockfeld has been leading nemawashi work in her position as administrative director of Ambulatory Services. She says the value is that when the soil is tilled properly before an improvement event, changes are much more likely to stick.

“If the team isn’t ready for the adoption of change, for a new way of doing things, it is very hard to make it work,” she says. “By tilling the soil you are making certain your team is prepared for what’s to come. We till the soil and plant seeds for something to blossom. It’s getting everybody prepared for improvement and change.”

In an organization like Virginia Mason where change is a constant – continuous incremental improvement is at the heart of the organization – preparing team members for change is critical.

As Cindy explains it, nemawashi consists of five components:

1)      Standard work for leaders/production board

2)      PeopleLink board and team huddle

3)      Presence on the genba

4)      Team readiness and engagement

5)      Leader preparation

“All of these are foundational elements to get teams ready for change,” says Cindy.  

Standard work for leaders includes a production board, which we described in a recent post. The board serves as a simple visual marker to provide essential, real-time information about what is happening in a particular clinic or department.

“The production board tells you the lay of the land and lets you know at a glance whether conditions are normal or abnormal,” says Cindy. “It is a visual tool that tells team members where particular help is needed at any given moment.” 

PeopleLink and huddles involve getting teams together on a weekly basis so they understand our business (our metrics) and how we are doing (what our patients are saying). Brief daily huddles around the production board help ensure everyone is on the same page with the work at hand.

Genba presence brings leaders at a variety of levels to the front lines where care occurs. “Basically, this involves rounding with teams, asking questions, and being visible so everyone  feels comfortable coming forward with concerns, issues and ideas,” says Cindy. “It is really important to be on the genba with team members to see and understand the daily work – as opposed to managing from behind a desk.”

Over time at Virginia Mason, more and more leaders in every department have invested time in genba walks, recognizing that teams truly appreciate leaders who actively lead and guide — demonstrating they truly understand the demands of the work on the front line.

“Our team members do not want leaders who sit in their office generating reports all day,” says Cindy.

Team readiness and engagement involves a practical understanding and recognition that demonstrates everyone’s engagement with implementing change with the tools and techniques of the Virginia Mason Production System (VMPS).

“It’s about the team understanding and engaging with VMPS so they are ready for change. When team members are not engaged with VMPS methodology, implementation inevitably fails,” says Cindy. “But when they are engaged – as they are now – the energy is tremendous.”

Often, one of the barriers to improvement with organizations using a lean methodology is that team members sometimes feel techniques are being imposed upon them. Nemawashi facilitates frontline solution generation. At Virginia Mason, one common method is through the Everyday Lean Idea system in which all team members are encouraged to identify opportunities for kaizen activity.

“That’s why team readiness and engagement is so important,” says Cindy, “It helps make sure all team members, including physicians, play an active role in the improvement process – as opposed to the perception that the Kaizen Promotion Office is imposing change on them.”

Leader preparation involves a leader’s capacity to plan, guide and implement kaizen work. This is part of nemawashi where Cindy says she and her team need the most improvement since she is the only VMPS certified leader who can lead a Rapid Process Improvement Workshop. She and her colleagues are working to get additional members of the team to work their way through VMPS for Leaders training, which provides them with the background and skills they need to lead daily improvement events.

The result of this work is that team members are more engaged than ever. It allows Cindy and her leadership team to lead improvement work that team members are ready for; work that improves productivity and safety, and reduces waste.

“All this work leads to better patient satisfaction because with the team so engaged – with the soil so well-tilled – we are constantly working on changes to improve the department,” she says.

A simple but telling example: The procedural team found that during the three and a half hours patients spent having colonoscopies, 90 minutes consisted of wait time. Cindy and her team pulled the group together and, after a quick Plan-Do-Study-Act (PDSA) during which team members contributed numerous ideas for improved efficiency, lead time (from arrival to departure) was reduced 45 percent.

“All due to team members coming up with idea after idea,” says Cindy. “Our teams are ready for improvement.”

“3P is a form of reinvention. It’s blowing things up, changing our mental model.”
- Katerie Chapman

For more than a decade now, thousands of kaizen events have fundamentally altered quality, safety and efficiency at Virginia Mason Medical Center. Continuous, incremental improvement – day after day, shift after shift − has transformed Virginia Mason in our pursuit of providing the perfect patient experience for every patient, every time.

Occasionally, however, traditional kaizen events, such as Rapid Process Improvement Workshops, aren’t the right fit for a needed process improvement.

This is where 3P comes in. 3P (Production Preparation Process) is neither incremental nor gradual: It is a turbo-charged process that has enabled Virginia Mason to make significant leaps forward in improving the way care is delivered, particularly with respect to facilities or the environment in which care is delivered. 3Ps can be used to design new products or processes, and they can be used when a program must be expanded to accommodate more patients.

Katerie Chapman, VP, Perioperative and Support Services

“3P is a form of reinvention,” says Katerie Chapman, vice president, Perioperative and Support Services. “It’s blowing things up, changing our mental model. It is an important part of the Virginia Mason Production System (VMPS) especially, relating to facility design.”

When Virginia Mason began the process of constructing a significant new addition to the medical center – the Floyd & Delores Jones Pavilion – the leadership team knew that 3P was the process that could help guide both the transformation of processes and the design of the facility. (In fact, it was so useful that two separate 3Ps have been conducted for the internal build-out of Jones Pavilion.)

“The traditional way of doing the design for the Jones Pavilion build-out would involve bringing in architects who would work with a small team of leaders, and they would design the facility,” says Katerie. “They would create a footprint, build it, and the teams would then have to figure out how to reorient functional components of their work into the new space.”

VMPS recognizes this approach as inherently wasteful. Ideal processes should be designed first with VMPS tools including 3P, then facilities should be designed to support those processes – form following function. And the people who know those processes, and therefore the requirements of the supporting environment, are the frontline team members. Why should people who will not use a facility design it? Why should the frontline workers who will work in it every day have to scramble to rework their processes because designers wanted to do the facility their way? Further, doesn’t it make sense to include our patients – those who experience the facility firsthand and rely on us to provide the best care possible?

3P facilitates an entirely different approach aimed at creating ideal processes first, then a new space that facilitates team members doing their best work (or facilitates delivery of the highest quality care and service).

The start of the process tries to answer the question what do we need out of this process? What do patients, families and team members need in this space? Answering these questions takes work. It requires an in-depth analysis of the current state, including an examination of all applicable value streams.

“We start by gathering as much data as we can to better understand our current needs and demand, and what the data might suggest in terms of trends and what future trends we need to think about,” says Katerie. “For example, is there a new care delivery model we need to factor in? Will MRIs be required in the ORs of the future? All of that analysis about future needs has to be taken into consideration during the early phase of the 3P as we define what we are trying to achieve.”

Two leaders guide the 3P process. The 3P workshop leader and team leader have the advanced VMPS training needed to lead the week-long workshop that is at the core of the 3P process.

While the leaders and others invest months of research, study and data gathering, they must boil it down to the kind of information that is easily conveyed to the entire 3P team, which gathers for the first time on a Monday morning for typically a five-day event. The team may include two dozen or more people – representing all of the different frontline disciplines, as well as patients and family members. 3P teams often include housekeeping team members, transporters, nurses, various technicians, physicians and administrators.

“Our team members and patients are the ones driving the process design and therefore the facility design,” says Katerie. “Architects are our partners. They are there to listen to the conversation and really hear what it takes to deliver the services we are talking about.”

The process for designing the Jones Pavilion hospital floors was particularly exciting for the 3P team because it involved a large project with important implications for the future.

“There is more excitement and energy around 3Ps because people are freed to think vastly differently than we normally do day-to-day,” says Katerie. “There is also more anxiety in the event because of the stakes. But we need to trust the process because during the evolution of the 3P it is not always clear where you are going.”

3P teams struggle with a wide variety of challenges. “How do we get the patient safely into and out of the bathroom?” says Katerie. “How do we bring all services to the patient? In the OR, one challenge was optimal orientation of the table.”

During the 3P, team members sketch, measure, time and create mockups out of cardboard and on paper as a way to execute ideas. The activity is intense as subgroups break off and work on a variety of ideas and approaches to solving the countless challenges that arise in the design of new care delivery processes and a brand new state-of-the-art medical facility.

The 3P teams working on the Jones Pavilion build-out focused on how to provide continuous monitoring of patients, how to keep patient areas as free of noise and disruptions as possible, how to accommodate visiting family members, and hundreds of other challenges. A few examples of the results:

• Universal treatment rooms: The 3P team designed universal treatment rooms that significantly cut down the times patients are taken from their rooms for tests. This reduces the number of times a patient is handed off to another caregiver. It also allows team members to spend more time with patients.

• Onstage vs. backstage: Because the noise and buzz of a hospital can be terribly distracting to patients, the 3P team designed an “onstage vs. backstage” structure with parallel corridors dividing the flow of patients and clinicians. This created a quiet zone for patients.

• Clustered rooms: The 3P team responded to the concern of nurses about their ability to closely monitor patients by designing rooms in a pod format in close proximity to nurses who can visually monitor multiple patients simultaneously.

“This is a hospital designed to reflect the patient’s point of view and their experience” says Katerie.

In addition to hospital design, Virginia Mason has used 3Ps in other areas such as redesigning its Patient Safety Alert system to handle more volume and developing a new primary care model for the future.

With more efficient care in a facility designed to eliminate waste in the care process, analysis shows that patients in the Jones Pavilion enjoy a 20 percent shorter length of stay than comparable patients in other facilities. This means 11 to 46 additional beds are available for other patients in the hospital every day.

When the Jones Pavilion opened in 2011, it was clear the 3P teams had produced a space with unique design elements, and that the shaping of the space by team members and patients clearly served the interests of both in important ways.

How have you involved team members and patients (or customers) in the design of your facilities?

“We had some great results, some important safety improvements. But … we need to take the next big step, and I am hoping someone out there has cracked the code.”

- Joanie Ching, RN

Joanie Ching, RN

Every morning around 8 to 9 a.m., the vast majority of the more than 5,000 hospitals in the United States experience the same routine: Nurses administer medications to patients. Virginia Mason’s Joanie Ching, RN, MN, administrative director, Quality and Safety, says this phenomenon seems to have been cemented into the medical culture for several decades. Joanie worries because she doesn’t think it is the safest way to protect patients from medication errors.

Joanie’s expertise on medication safety is well established. She is the lead author of an article in The Joint Commission Journal on Quality and Patient Safety entitled, “Using Lean to Improve Medication Administration Safety: In Search of the ‘Perfect Dose’” (May 2013). She and her co-authors (see below) are currently working on a follow-up to the article.

The problem with this longstanding approach to the distribution of medications to patients, says Joanie, is that it happens in batch production, which is inherently inefficient and wasteful. Uneven flow stresses the system, and when the system is stressed, people rush. That results in defects, including medication mistakes.

“Continuous flow is an essential hallmark of the Virginia Mason Production System because we know how much better any process works when it is in flow,” says Joanie. “When we studied the medication administration process in our hospital, it was clear that under the traditional approach, nurses cannot achieve continuous flow. During that morning peak period of medication distribution, nurses are unavailable to other patients and team members. So they may not respond to an opportunity to add value in the patient’s experience — patient education or emotional support, for example.”

Why is the absence of smooth flow not in patient’s best interests?

“Think about it this way,” says Joanie. “Every morning nurses line up at the medication dispensing station where all of the process is computerized for efficiency and safety. And that’s great. But there is a line of nurses waiting to get meds for their patients, and nurses hate to wait. So what do they do? They say, ‘OK, I know the rule is that I should only take one patient’s medication at a time, but because I’m pressed for time, I’ll take two or three patients’ medications and separate them as best I can — one patient meds in my right pocket and another in my left pocket.’”

Nurses do this not because they want to care for patients in an unsafe manner, but because they are trying to get the patients’ medications to them “on time.”

“The irony is that nurses find a way around the process because they’re trying to do a great job!” says Joanie. “They don’t know any differently but they see it as a barrier between themselves and their patients. Still, the fact is that a majority of meds are being given in the morning and not in afternoon when it is perfectly fine to give meds.”

When Joanie studied the medication administration process at Virginia Mason, she found too many errors and realized many, if not most, resulted from distraction — nurses getting interrupted during the medication distribution process.

After a significant amount of study strengthened by several Plan-Do-Study-Act (PDSA) initiatives, a new process was implemented that placed a visual boundary on the floor at the medication station. The new rule was that when a nurse was in that area getting medication, no one would talk with the nurse or interrupt them in any way except in an emergency. The clinical teams also agreed that anyone waiting to use the dispensing station would wait outside the medication room, rather than inside where conversation with others may distract the person preparing medication.

This new approach resulted in significant improvements. As Joanie and her coauthors noted in the Joint Commission article, “Overall ‘perfect dose’ delivery increased from 37% to 68%, and medication administration errors decreased from 10.3 to 2.8 errors/100 doses.”

“We had some great results, some important safety improvements,” says Joanie. “But — and there is an important but — we need to take the next big step, and for all of our work and analysis, we are having trouble getting there. So I am hoping someone out there has cracked the code.”

What does get there mean in practice? It means Joanie and her team would like to distribute medications in a smooth and continuous flow. This would include administering medications that must be given on a specific schedule — at mealtime for certain medications, for example, or every six hours for antibiotics. Still, other meds are delivered on a patient-preferred schedule.

“We honor all of that absolutely,” says Joanie, “But we found through a PDSA two years ago that these categories account for no more than about one-third of all medications — meaning if we could figure out a way to distribute the remaining meds scattered evenly throughout the patient’s waking hours, it would be much safer and reduce the burden of work on nurses, freeing them to do their jobs more effectively.”

We want to smooth flow, because by doing so, we reduce the likelihood of making errors,” she says. “The goal is more even distribution of the other meds not tied to a specific schedule or time of day — throughout the whole day — optimizing medication flow throughout the 18 hour waking day.”

Accomplishing this, says Joanie, would “create smooth, continuous flow with nurses getting meds to patients in more level manner throughout the day with less stress on the system. This would free nurses to be part of multidisciplinary rounds in the morning and it might make patients more satisfied.”

The question for Joanie and her team is how to optimize the med administration schedule so there is less batching in the morning, and then continuous smooth flow throughout the remainder of the day. This means abandoning the old model, while at the same time honoring patient preferences and respecting staff members.

Having spoken with a variety of people at universities, the Institute for Healthcare Improvement, the Joint Commission and Cerner, Virginia Mason’s electronic health record vendor, Joanie believes the answer must be out there but she has not found it. And she is looking for help.

“There is huge opportunity for level loading,” she says. “And I am hoping to find someone who has solved this so we can do the same thing.”

Can you help Joanie? What have you done at your organization to improve the safe administration of medication to patients?

“Nurses are much more focused during handoff at the bedside than they had been under the old method.”

- Charleen Tachibana, RN

How would you like to implement something in your hospital right away that would dramatically improve the safety of your patients, as well as the overall patient experience?

At Virginia Mason, this was accomplished by doing handoffs at the patient’s bedside.

The difference between the old way of handing off and the bedside approach is night and day. Under the old approach, nurses gathered in a conference room tucked away from patients. Behind closed doors, incoming and outgoing nurses would exchange information on patients.

Charleen Tachibana, RN

“And it was after that when nurses would do their check-ins with their patients, so it meant that nurses had met and talked with their patients 90 minutes after the shift started,” says Charleen Tachibana, RN, Virginia Mason Hospital Administrator and Chief Nursing Officer. “Now, with bedside handoff, the nurses are in all their patients’ rooms in the first 30 minutes of the shift.”

At this point, it should be noted that while it may sound simple, implementing bedside handoffs didn’t happen overnight at Virginia Mason. This kind of transition is a process and depends on organizational culture, foundational elements and other factors.

Under the new approach, the incoming and outgoing nurses are together at the patient’s bedside discussing their care, usually with the patient included in the conversation and often with family members joining in.

“Nurses are much more focused during handoff at the bedside than they had been under the old method,” says Charleen. “When they were sitting back in the conference room, there was a social component mixed in and they might be distracted and were not as focused. The quality of the exchange at the bedside is just so much better than when it happens in the conference room over coffee.”

When nurses do the handoff together there is a synergy to the work. One nurse will point out certain things about a patient to the oncoming nurse, who might then notice something else important or who will then ask a question he/she might not have otherwise thought to ask.

For example, in the case of patients with neurological issues, think about the difference in the quality of a handoff when it happens at bedside as opposed to away from the patient in a conference room.

“At the bedside the nurses do a neuro check to make sure they are both seeing the same thing,” says Charleen. “This way, they establish a baseline together so if there are subtle changes to come the nurse will see them. Think of how much better this kind of care is than when a nurse in a closed conference room explains neuro symptoms. Seeing those symptoms first hand – it is just a huge difference.”

At the bedside, nurses also do a high-risk medication check – double-checking the highest risk medications. “Together, they check the medication, its concentration, the rate of flow,” says Charleen. “They visualize it – seeing the machine and the rate it is running.”

A significant benefit of the bedside handoff is the inclusion of patients.

“There was an instance where a significant error was caught by a patient,” says Charleen. “It related to an allergy and if the handoff had been back in the conference room the error would not have been caught. The fact that the patient was involved meant that inaccurate information was corrected and not passed along to the next shift.”

Just as patients play a critical role in the handoff process, so too do patients’ families – a great source of information and support for the care team.

“Family members are so much more comfortable and relaxed when they see the handoff take place and they know that critical information has been passed along from one nurse to the next,” says Charleen. “That was really a significant development – family engagement and satisfaction – that we really had not anticipated when we made the shift to the bedside.”

There was one particular family member who carefully watched over the care for her husband and she would remain in his room during the nurse handoff from the evening to the night shift. “She told us that when she saw the handoff and knew that all the important, accurate information had been passed along, she felt comfortable enough to go home and get a night’s sleep,” Charleen says.

The whole idea of moving the handoff to the bedside was originally driven by an effort to improve efficiency and eliminate various wastes – such as time and manpower. But an enormously important byproduct of the change has been making patient care safer.

“It took us by surprise,” says Charleen. “We didn’t think we’d be catching so many things during the bedside transfer of information.”

Virginia Mason now has five years experience with the bedside handoff. While there was a bit of resistance at the beginning (“Patients don’t really want us to do it in their presence …” “It will take too long …”), there is no question it is one of the more effective changes the organization has made. When one change yields such rich rewards – in safety, quality, and patient and family satisfaction – it is clearly the kind of approach that could spread nationally.

What seemingly simple changes have you made to improve patient care or customer service in your organization?

Come Chat with Us

Mark your calendar for noon PDT (3 p.m. EDT) Thursday, Sept. 5, for a Twitter chat with Chris Backous of the Virginia Mason Institute. He’ll be discussing Virginia Mason’s lean transformation and the Virginia Mason Production System, and answering questions to help in you in your organization’s improvement journey. Join the conversation at #ASKVM.

 “I no longer feel intimidated by it. I feel I can embrace it. In a sense, it is the scientific method.”

- Michael Gluck, MD

Many physicians instinctively resist change in their practice areas. As scientists, doctors rely upon evidence that a new approach will work. Thus, when doctors heard some years ago that an adaptation of the Toyota Production System would be the Virginia Mason management method, there was a predictable level of skepticism.

Most Virginia Mason physicians adapted to the new approach within the first few years of implementation, but certainly not all of them. Some physicians were reluctant to engage with the new approach out of fear it would reduce their productivity or distract them from their core work caring for patients. Others remained deeply skeptical of any management method that seems so foreign to health care.

We call the adaptation of the Toyota Production System to health care the Virginia Mason Production System. Others know it as lean management.

Engaging physicians in this approach is sometimes challenging. Yet it is also essential to the future success of efficiency, safety and quality in American health care.

That is why we will be devoting a series of blog entries to this topic during the next few weeks.

From talking and meeting with colleagues throughout the country, we are well aware resistance from doctors can be a major barrier to implementing lean methodology. At Virginia Mason, we are intimately familiar with this challenge. We have been working on it at one level or another, in one department or another, for more than a decade. And we hope our experience will provide you with some useful ideas.

Let’s stipulate from the start that a reaction of skepticism from a scientist is entirely appropriate. Why should a doctor believe something about a new method? A method he never heard mentioned a single time during eight to 12 years of education and training?

So let’s start our series hearing directly from physicians themselves – from one in particular whose initial reaction to the introduction of the Virginia Mason Production System was, to say the least, skeptical. 

Michael Gluck, MD, Chief of Medicine

Michael Gluck, MD

“When the Virginia Mason Production System was first introduced in 2001, I was appropriately skeptical about any new business model to be imposed on a medical system. I had been at another organization and had gone through TQM (Total Quality Management) and a number of other efficiency-based models and each had fallen flat on its face.

“When VMPS was introduced, I was skeptical about how effective it would be. There was all this language that emerged from it. It made me feel as if we were going to separate the educated from the naive. If you know the language and played the game a certain way you will be part of the elite structure.’’

The passage of some years failed to diminish Dr. Gluck’s skepticism. That is, until a number of significant changes occurred within the GI section, and he was asked to take over as section head. He previously held a comparable position at another institution and he was initially reluctant this time around. When he decided to accept the role, Dr. Gluck realized he “needed a good business model to make changes in the operations of our clinic and in the behavior of physicians toward creating access for patients.”

“In 2010, we had disarray in our delivery of endoscopic care,” he said. “It was all over the place and it was always a top-down process. So, we held improvement events where leaders, line workers – everybody involved in the process – came together to try and figure it out. Input came on every aspect of the process from everybody involved – wonderful ideas and insights from techs, scope cleaners, everybody.

“We had a 3P [Production Preparation Process, a five-day event in which a team focuses on building a production system for a new plant, process or product] focused on how to build our entire GI care delivery system. We brought in outside eyes – medical assistants, docs, techs, nurses, the whole mishmash. The first day was dizzying. There seemed so many opinions. But slowly, during the course of the week, we pared down our thoughts and came up with a vision that has guided us for three years.

“And now we are getting patients moved through much more effectively. We have better care in recovery and patients are going home with better instructions.

“We have had piece-by-piece accomplishments. RPIWs (rapid process improvement workshops) to take care of problems we encountered in the process of developing this plan. The result is that we have built a world class endoscopy center and a lot of that is because of VMPS.

“And I realized: this really works! We were able to reduce hospitalization, improve flow, markedly reduce readmissions, and lower morbidity and mortality.

“I was working hand-in-hand on VMPS with people from the Kaizen Promotion Office. They were well-informed and very effective teachers. It was eye-opening for me. They really did hold the patient at the top of the pyramid. They really were working on eliminating waste. They really were creating a mistake-proofing environment. They really were improving quality.

What experiences have you had in your organization with team members who are skeptical about lean practices?

“I want to jump immediately to solutions, but the process of VMPS makes you slow down and listen better. You hear so much that is valuable especially from the people on the front lines of care.”

- Dr. Julie Pattison

After four years of medical school, seven years of training and 26 years practicing primary care, Julie Pattison, MD, half seriously considered leaving medicine altogether. Day after day, her frustration grew as the chaos of her practice environment – Virginia Mason’s largest primary care site – mounted.

Julie Pattison, MD

“It was chaos,” she says. “There were about 20 physicians in the clinic and we struggled to get the supplies we needed. Things kept running out and there was no system to replace things. Staff turnover was very high so we were constantly working with untrained staff. The clinic was chaotic and staffing was always inadequate. There was deep dissatisfaction.”

But a combination of leadership and the Virginia Mason Production System (VMPS) changed all that. The general internal medicine (GIM) clinic on the Virginia Mason’s Seattle Main Campus is now superbly well-run and its transformation offers important insights into the challenge of managing change in a difficult environment.

Encouraging physician leadership

A central lesson in the turnaround involved active and sustained encouragement from a strong leader to engage other physicians in leadership. Joyce Lammert, MD, who at the time was deputy chief, Department of Medicine, and interim section head, GIM, approached Julie Pattison about taking on the deputy section head position, but Julie was reluctant.

“I felt very overwhelmed working in a place where the systems were not working and I didn’t think I could add one more thing to my plate,” she says. “There was a lot of chaos.”

But doctors tend to listen to colleagues for whom they have respect and Julie had high professional regard for Joyce. “It was a really big impetus having Joyce encourage me,” recalls Julie. “She felt I had the capacity to become a leader and she encouraged me.”

Julie took the leap and became deputy section head for the GIM clinic in 2004. She started where the best leaders begin their work: listening to her colleagues. In face-to-face meetings, she listened carefully to concerns of other doctors and focused on specific steps she could take to respond. “We had eight doctors leave in the two years before I came on board. Morale was really low and I felt that the key thing was to listen and continually solicit input.”

Joyce’s leadership in getting Julie to see her own potential was the first key step. The next was Julie learning the VMPS methodology. At Joyce’s urging, Julie took the VMPS for Leaders course, which provides a strong foundational understanding of the Toyota Production System’s methods and tools. Every year, teams of Virginia Mason leaders travel to Japan to learn deeper lessons in the Toyota methodology and, in 2005, Julie participated in the Japan trip.

“I loved it,” says Julie. “It gave me the time and experience to learn everything more in depth.”

Julie’s leadership style – consistent with the fundamental tools and principles of VMPS – was to pursue continuous incremental improvement, in partnership with the clinic administrative director. They knew no single silver bullet existed; rather, they had to work at identifying opportunities for change every day. It was a relentless process that paid off.

There was a doctor, for example, who returned from a week’s vacation and discovered none of her patients’ lab results had been looked at by any other physician. Nor had the doctor’s phone calls from patients been managed for two days by anyone else.

“Nobody had been sweeping her boxes to make sure the person assigned to managing her messages and labs had done it and that was a big safety consideration,” says Julie. After studying the root causes, Julie and her team set up a series of steps that ensured coverage for doctors was air tight for patient calls and lab results.

Julie discovered lab results were being printed multiple times a day on six different printers scattered throughout the clinic – a blizzard of paper. “Sometimes the staff didn’t pick up the lab results and there would be three days worth of results sitting on a printer,” says Julie. “That was a big dissatisfier for doctors receiving three days of labs all at once.” And it was anything but patient-centered.

An improvement process revealed massive waste and the result was a reduction to two printers and a designated individual to collect and distribute lab results to doctors at established intervals throughout the day. This enabled physicians and their medical assistants to deal with the lab results in flow – a far safer, timely and patient-focused method. (The process has since been streamlined further to minimize paper and leverage electronic reporting by feeding individual lab results into the flow station just-in-time to improve the timeliness of patients getting their results.)

Another change seems minor on the surface but proved to eliminate significant waste and provide a much better situation for providers and patients. In the clinic, when a doctor wanted to perform a procedure – for example, a steroid injection in a knee or shoulder, or a biopsy of a possibly cancerous lesion, or drainage of an abscess – they would have to retrieve supplies from a distant central location then set up the procedure in the patient exam room.

But kaizen focused on this challenge resulted in the creation of procedure trays – two trays in each of the six pods (each pod has three to four physicians). One of the trays was a complete kit for joint injections while the other was a complete kit for wound care. Both kits contained labeled containers for each tool and photos of the appropriate medical assistant setup for the six most common procedures.

A standard process was established that allowed providers to do more procedures in a much more timely fashion. This improved quality and timeliness of care and eliminated patients having to return to the clinic at another time to have the procedure.

Flow station early adopter

One of the big breakthroughs in the GIM clinic involved adoption of flow stations. Doctors throughout the Virginia Mason system had heard about the innovation of flow stations at the Kirkland clinic where physicians sat at a desk in the hallway next to their medical assistant.

The flow station provided continuous flow throughout the day, enabling physicians to see more patients and deal with paperwork in flow throughout the course of the day – rather than batching it at the end of the day. Medical assistants (MAs) proved immensely valuable in this setting, dealing with much of the paperwork without having to check with the physician and passing along only the work that he or she absolutely had to deal with.

Flow stations were set up at the GIM clinic in 2003 and 2004 but, initially, very few doctors used them. They preferred to work out of their private offices. This is where leadership means action and Julie began working shoulder-to-shoulder with her MA at the flow station and found it so much more efficient that she gave up her office. She also found that by day’s end the vast majority of her visit documentation, messages and paperwork had been handled in flow throughout the day and that she got to go home at a reasonable hour.

“When you are in a leadership position it helps to be an early adopter yourself,” says Julie. “And the flow station just worked so efficiently and well that working there with my MA I was happier, the environment for patients was safer because we were dealing with labs and other concerns in real time in flow – nothing was batched or falling through cracks. Things were safer and less chaotic.”

Within just a few months, in addition to Julie, another half dozen doctors worked at flow stations. Not long after that, the great majority of doctors in GIM – witnessing the tangible benefits of the flow stations and hearing their colleagues’ positive comments – were using the flow stations. Many still held on to their offices and a few physicians remained working out of their offices – uncomfortable at the flow stations.

But there came a time, says Julie, when clinic expansion meant the need for space for exam rooms. The most logical alternative was to turn some physician offices into exam rooms, the others into shared offices, then have the doctors do their clinic work at flow stations permanently. There was some pushback on this, but most of the physicians saw the obvious wisdom of the plan. And when you put the patient at the top of the pyramid – as Virginia Mason does – how could one not see that this was the right approach?

What were the key lessons Julie took away from this experience?

“I am a typical physician,” she says. “I want to jump immediately to solutions, but the process of VMPS makes you slow down and listen better. You hear so much that is valuable, especially from the people on the front lines of care. And when you listen to the flow managers and the patients you learn so much. Listening is one of the biggest foundations to physician leadership. A lot of times we think we know what is wrong but unless you are on the shop floor listening to the people who do the work you won’t really know the root causes.”

Another key lesson she learned? It is critically important for physicians to step up into leadership roles because of the credibility they have with other physicians. “If you do the work the other physicians do, and if you do it well and hold yourself to high standards, other doctors are much more likely to follow. It helps being similar to other doctors – obsessive/compulsive. They trust me more because I know exactly what they are talking about.”

A final note: The flow in GIM has become so seamless that earlier this month the clinic totally eliminated one of its two patient waiting rooms. The flow improvement means far fewer patients wait at all.

What does leadership look like in your organization?

“Everybody has to designate their personal commitment to this process. If you have passive agreement you really don’t have engagement. It’s easy for someone to not pay attention.”

- Dr. Steve Rupp

The concept of a pre-surgical timeout in the operating room is rapidly gaining popularity throughout the country with strong advocacy from the Joint Commission, Institute of Medicine, World Health Organizations and others. The beauty of the timeout lies in its simplicity: stop, think and double check before every invasive procedure.

But Virginia Mason’s experiences indicate not all approaches to timeouts are equal in their efficacy. There is a world of difference between a perfunctory timeout and one that is well thought out and derived from input from all OR team members.

Steve Rupp, MD

Virginia Mason followed a standard approach to timeouts in early 2009, adopting a version of the WHO checklist, says Steve Rupp, MD, medical director, Perioperative Services. “A single person − usually the surgeon – would recite things on a list and we certainly had better compliance after we put up a poster. But we were still having wrong-site surgeries.”

In 2009, teams dug to the root cause of wrong-site surgery. During a series of improvement events Virginia Mason team members studied the timeout, seeking weaknesses in the approach that could be fixed. Consistent with the Virginia Mason Production System, the improvement process included all team members involved in OR timeouts: surgeons, scrub technicians, circulating nurses, anesthesiologists and team members from the Kaizen Promotion Office.

“During the root-cause analysis, we looked at the psychology and hierarchy of the people involved in the timeout and it had a clear hierarchical culture,” says Dr. Rupp. The root-cause analysis gets to the bottom of things quickly and encourages direct and honest conversations.

Dr. Rupp says, “At one point during the analysis process a surgeon asked a scrub tech this question: Would you stop me from making the wrong incision? The tech briefly considers the question and then replies: No, I would not.”

This was a critical moment for it revealed a critical cultural weakness in the standard approach to performing timeouts. Part of the problem was in the nature of hierarchy but part of the problem was also a lack of information on the tech’s part: Has he/she been included in the process to the point where he/she has all the information needed to do the job effectively?

“We all have to be willing to stand up and say no,” says Dr. Rupp, “But we were asking surgical scrub techs and others about things they don’t know about for sure. With a lung tumor or nodule it’s not readily obvious which side it’s on to surgical scrub tech. They don’t look at X-rays ahead of time. How could we expect them to say it is definitely right or left?”

Mike Mulroy, MD

Dr. Rupp says that anesthesiologist Mike Mulroy, MD, played a key role in leading a good deal of the improvement work. In parallel with the work of Dr. Rupp’s team, Dr. Mulroy and Rosemary King, RN, director, Acute Care Services, conducted an audit and discovered that fewer than half the surgical technicians paid attention during the timeout, and that attention was less than perfect from other team members, as well. Dr. Mulroy observed, “I am in the OR basically every day and I found it disappointing that we did not take full advantage of the opportunity to communicate effectively during the timeout. Sometimes the surgeon would just read the list off the wall and that was it. It was a real loss of opportunity for every member of the team to speak up.

As a result of all of this work, the team came up with a new approach to the timeout that has proven much more effective than the previous process.

“Everybody has to designate their personal commitment to this process,” says Dr. Rupp. “If you have passive agreement you really don’t have engagement. It’s easy for someone to not pay attention.”

Virginia Mason has 24 operating rooms and about 350 team members who work in those rooms. “When you say your full name and role, it breaks down some barriers to communication,” says Dr. Rupp.

Dr. Mulroy reports that an informal study by doctors in Michigan found that when “members of a surgical team knew one another by first and last name, it correlated with a high teamwork attitude score.”

• The change made at Virginia Mason requires precise standard work for the pre-surgical timeout (or “attestation”). First and foremost, ever member of the team states his or her first and last name and explains his/her role:
• Surgeon starts by calling for the timeout
• Circulating nurse states his/her name, confirms the identity of the patient, verifies the consent form and notes all required equipment is arranged as needed.
• Scrub tech indicates all medications are properly labeled and that “yes” (the organizational standard site mark) is visible in the draped field
• Anesthesia team members review allergies and discuss whether the patient might be on a beta blocker and whether the patient has diabetes, and indicates the antibiotic was administered.
• Surgeon then might summarize some clinical history, define the procedure, how long it is expected to take, how much blood loss is anticipated and whether there were any special issues/concerns.
• The final step is critical: The surgeon assures the team that everyone has the right to speak up and asks whether anyone in the room has any additional input or any concerns.

“We wanted to reverse the hierarchy,” says Dr. Rupp. “We wanted the surgeon to be the last to go.”

Once the initial root-cause analysis had been completed and this new process was created, a team of informal OR leaders, including Dr. Mulroy and members of Dr. Rupp’s team, presented it to the several hundred others who worked in the Virginia Mason ORs. Dr. Mulroy and his team trialed the new approach in several ORs, and in the process, they audited performance and did some coaching.

One idea came from a surgeon who suggested that a radiological image be posted in the OR clearly showing the patient and the correct site for the procedure. “It was so powerful coming from a surgeon saying, ‘I should be able to look right at the image while I’m in the OR and ready to go and verify the target site just prior to the incision,’” says Dr. Rupp.

Inevitably there is pushback when change is proposed in almost any area of the hospital, and pushback in this case came from some surgeons who worried that the more detailed timeout would hinder their production.

Dr. Mulroy and the team were ready for this. They went into the OR and videotaped a simulated pre-op timeout. “We recorded it with a time stamp so we could play it for everybody at the next periop forum,” says Dr. Mulroy. “And the video showed that it took one minute and 45 seconds for a complex patient.”

He added, “We changed the culture in the OR to where everybody spoke up, everybody had a part. We are doing it every day in every OR and it has made a giant cultural change.”

Dr. Rupp is certain the timeout has significantly increased communication among team members in the OR. “We’ve measured that the amount of clinical information sharing has increased about 30 percent,” says Dr. Rupp. “It is the best kind of standard work. It is not seen as an administrative hoop that has to be jumped through. People realize that when the team gets really grounded on what they are about to do.”

He points to an article in the Annals of Surgery indicating “mortality was significantly decreased after checklist implementation …” but only in the ORs where the full procedure was completed. [Effects of the Introduction of WHO’s “Surgical Safety Checklist” on In-Hospital Mortality, A Cohort Study, By W. A. van Klei, MD, PhD, et al]

Does your organization have an effective timeout process?

“The fellowship was transformative for me”

- Dr. Alvin Calderon

Perhaps as much as anything else, Virginia Mason can be described as a learning organization. We hear this term used frequently in health care but what does it mean?

In the case of Virginia Mason, it means a relentless search to learn new ways – within the organization as well as outside it – to improve patient care. At the core of the Virginia Mason approach is a management method – the Virginia Mason Production System — that provides the method and tools for continuous learning and improvement.

One of the most robust and challenging learning opportunities within Virginia Mason is the Kaizen Fellowship. The Kaizen Fellowship program provides current and future leaders deep training in the management method. The program typically includes six fellowship candidates in an 18-month training period. It is exceptionally rigorous, requiring fellows continue their “normal jobs” while simultaneously carrying a fellowship workload.

The program was developed internally and is an important element of Virginia Mason’s journey as a learning organization. (Note: a subsequent post will take a closer look at how the program works.) For all the program’s demands, however, fellows say that the experience is one of the most important they have had at Virginia Mason.

Ingrid Gerbino, MD

“For me, the fellowship was an incredible opportunity,” says Ingrid Gerbino, MD, an internal medicine physician at Virginia Mason Lynnwood who also serves on the faculty of the Virginia Mason Institute and as deputy chief for the Department of Primary Care. “So much of the value of the fellowship was the relationships I built with my co-workers who were fellows with me. Your professional relationships are nurturing, but you also definitely want to perform better for your colleagues and make them proud.

“Through the fellowship, the organization invested a lot in me and because of that I want to give a lot back to the organization. The fellowship immensely deepened my knowledge and understanding of the principles of the Toyota Production System. Seeing the principles performed to perfection confirmed for me that we have been settling for less than we are capable of at Virginia Mason, and heightened my expectations of myself and my colleagues.’’

Alvin Calderon, MD

Alvin Calderon, MD, hospitalist and director of the Virginia Mason Internal Medicine Residency program, says, “The fellowship was like going to night school for an MBA. We were doing improvement work in our day jobs anyway, and we used examples of our work for fellowship projects and homework – the same thing we do for the VMPS for Leaders program. But this was much more in-depth. It was a group of people holding each other accountable for results – pushing each other, challenging each other, asking one hard question after another.”

Japan Trip: Key to Fellowship

One of the foundational learning experiences for fellows happens during a two-week trip every fellow takes to study in Japan. 

“The Japan trip is an essential part of the fellowship,” says Henry Otero, MD, oncologist and faculty member with the Virginia Mason Institute. “It allows us to look at things at a deeper level. We had gone on the genba kaizen tour in Japan, but as a fellow I went on a flow tour learning to think more deeply about the concept of flow. It was like going from a 100-level course to a 500-level course.

Henry Otero, MD

“The fellowship was very influential for me. The concept I pulled out most from my fellowship was the concept of the flows of medicine. The fellowship experience was very influential for me in that respect. We went back to Japan as part of program, and did the flow tour at a mattress factory, and I am thinking ‘how are we going to extract anything out of this experience?’ 

“But I am watching and there is a guy stuffing foam into a mattress, and you can see on the visual display board production is falling behind and all of a sudden a supervisor comes to the bottleneck and works with the workers stuffing foam, and very quickly they bring production back up to pace. I sat there and said, ‘wow, health care just tells you you’re behind but there’s no mechanism to make sure you catch up quickly.’’’

The process and learning Dr. Otero experienced in Japan has been adapted to improve primary care at Virginia Mason. When a primary care team is out of flow, there is help from others, including leaders, to get back on track. 

Dr. Gerbino had a similarly valuable experience in Japan. “We were at a factory and the sensei pointed out one particular screw in a piece of machinery on the assembly line. He asked us to follow that one piece all the way through the line. That was difficult because all along the line different things were happening and often quickly.”

But for Dr. Gerbino the point was clear. In health care, she had to take one patient and “flow” that one patient all the way through the process to ensure they received the integrated, quality care needed. It informed her work on improving the flow of care for patients with diabetes. It helped her think about flow in planned diabetes care: How to pull patients into the system who need care but who are not actively seeking care.

“Following the flow enables us to see a big gap in care from the time the patient leaves the primary care physician’s office with instructions,” Dr. Gerbino says. “Why is the patient not meeting goals? Maybe it is a lack of understanding, or maybe the patient is overwhelmed with how many meds they take, so we loop in a pharmacist to work with them on medication.

“The fellowship renewed my sense of urgency that we can do better in providing care for our patients with diabetes. We have so many team members with strengths that we were underutilizing.”

The fellowship started Dr. Gerbino on a deep dive into the flow of planned diabetes care, and she has carried it through her work in the years since.

“At Toyota we read, ‘Action for the future is taking place at this moment.’ We need to use the tools to leverage our team to relentlessly pursue the perfect patient experience,” she says.

Dr. Calderon also appreciated the Japan trip and its focus on flow. He says it helped him think about the in-depth work he was doing to improve the work flow of residents and hospital wards.

“We went to Japan to learn by observing what flow looks like in museums and factories,” he says. “By really studying it.”

More to Fellowship than Japan

But there is much more to the fellowship than the Japan trip. For Dr. Otero, his intensive fellowship study and work led him to the clear realization that, as a leader, it was not incumbent upon him to solve a problem, but rather to be a “problem framer.”

“I had to create the sense of urgency framing a problem from the patient’s viewpoint and then work with the people who are actually doing the work to find the solution,” he says. “The answer doesn’t lie with me. It lies with the people doing the work.”

All three physicians have progressed significantly in the time since their fellowships, and all three credit the fellowship with enabling them to take a deeper dive into understanding VMPS methodology, as well as the tools to foster improvement.

Dr. Gerbino says that in her work with planned diabetes care, moving the metrics is a significant challenge. But by sharing the care of patients with the appropriate professional – nurse, pharmacist or another physician − the planned diabetes care has improved noticeably.

“Through all of this work, the primary care physician now can spend less time with a patient with chronic illness, enabling the doctor to have more access to new and more complex patients,” she says. “At the same time, the patients are exceptionally well served by pharmacists and nurses. Sitting one-on-one with each patient, our nurses do a phenomenal job of coaching and empowering our patients to meet their health goals. Our pharmacists are most skilled at medication adjustment, and partnering with our patients to help improve compliance and outcomes.”

For Dr. Calderon, there was a significant breakthrough in improving the flow of interns rounding on patients.

“The fellowship helped me get a theoretical design and conviction that a change in rounding by interns was the right thing to do,” he says. “Operationalizing it took more time.”

Now, rather than interns rounding in a way that is similar to batch processing – which leads to forgetfulness and errors – they focus on one patient at a time all the way through the round. It’s the same as Dr. Gerbino following that screw all the way down the assembly line, and how she seeks one-piece flow all the way through planned diabetes care.

“The fellowship was transformative for me,” says Dr. Calderon, “in that I could look at medical education and see the flow of interns from a completely different perspective and that helped me solve a lot of problems.”

Dr. Otero sums it up this way: “As I was approaching the concept of zero defects in my fellowship mistake-proofing module, I reflected on any quality statements that our profession embraces. And there it was all along, ‘First, do no harm.’ The Hippocratic Oath predated Shingo, Taiichi Ohno and Toyota. If ‘do no’ equates to zero and ‘harm’ equates to defects, then even the ancients knew that respecting the patient meant ‘First, Zero Defects.’”

How is your organization a “learning organization?”

“As a leader, I don’t want or need to be the one to point out the opportunities for improvement. The team sees it in the value stream, with the data.”

- Shelly Fagerlund

As a leader, what do you do when a certain procedure goes extremely well from a clinical standpoint, but makes for a less than ideal patient experience overall?

Shelly Fagerlund

Shelly Fagerlund, vice president of Clinic Operations at Virginia Mason, faced precisely this conundrum not long ago, and the ultimate solution serves as a wonderful case study in how a leader can successfully lead an improvement process – as long as the leader has a keen grasp of culture, lean tools and a facilitative approach.

Here was the challenge: Virginia Mason is one of the few medical centers in the country that performs a procedure known as ESWL+ERCP.* This is a two-stage process. In the first stage surgeons (urologists) break up stones that have formed in a particular part of the body – often within the pancreas. In stage two, gastroenterologists operate to remove the stone fragments.

“So we had these two different clinical groups, both highly skilled, doing a superb job at their piece of it,’’ says Shelly. “Both groups are world class — really amazing.

“But when you look at it from the patient perspective, it was just not the kind of experience we want our patients to have,’’ she says. “First the patient would go to the OR, receive general anesthesia and have the stones broken up. Then they would go to recovery for a period of time. Then, hours later – or even the next day in some cases – the patient would be moved to a GI procedure suite where they would receive general anesthesia for the second time, have the procedure and go through recovery again.’’

Changing this proved to be a formidable logistical and cultural challenge. These were two excellent groups getting great results on these procedures, and they were, therefore, reluctant to change. If it ain’t broke, don’t fix it. But when you make the patient the focus of everything you do, as Virginia Mason does, it was clearly broken.

“We asked ourselves does this experience meet our best thinking about how to care for patients, and the answer was clearly no,’’ she says. “The patient experience did not meet our requirements for what a great patient experience should be.”

This is where the Virginia Mason strategic plan – the pyramid with the patient at the top – commands such power and respect in the everyday operations of the organization. The strategic plan has served as the organization’s true north for a decade plus now, and the concept of patient first is deeply embedded within the Virginia Mason DNA.

Shelly led a Rapid Process Improvement Workshop (RPIW) to explore the reality of the current state.

Leaders at Virginia Mason are required to be certified in VMPS, which means they lead at least one RPIW each year. Just the fact Virginia Mason has executives like Shelly leading a workshop is a powerful signal to the organization and team members that leaders are aware of what is really going on in a particular area or process and are able to work side by side with team members – doctors, medical assistants, nurses and others – to understand the problems and develop solutions.

“As a leader, it is really important to be thoughtful about what you sponsor so when you lead events or when you support events for improvement work, you have an opportunity to use the bully pulpit to further a particular area of work. When you step up to run or sponsor an event, you are signaling what you want the organization to pay attention to.’’

And the RPIW in this case was not an easy one. “People had a hard time letting go,’’ she says. There was some pushback  – this is the way we have always done it and we do it extremely well.

So it is crucial, says Shelly, to set the right tone as a leader throughout the RPIW.

“You have to be Switzerland in a way as the leader,’’ she says. “You have to let the VMPS process work. If you use the tools, they will do a great job showing a picture of the current state. And when we did that, and we saw the value stream map everybody could clearly see there were waits and delays. The process reveals the reality and people on the RPIW team – regardless of what section they’re from – discover for themselves this is not something they would want for family members and it is not something we want for our patients.’’

There is a critical lesson here for leaders doing and leading improvement work: “As a leader, I don’t want or need to be the one to point out the opportunities for improvement. The team sees it in the value stream, with the data. When we walked the steps of the patient, the team knows we have to change. As a leader you are creating the conditions for change.’’

After challenging simulations – solving practical issues such as the movement of OR equipment to the procedural suites – the team had a new approach where they set the two procedures up back-to-back. This meant the patient received general anesthesia once and remained in the same procedural suite, never moving until recovery. The new approach is faster, safer and more efficient than the previous one.

This improvement event is one of thousands that have taken place at Virginia Mason during the past decade plus. And each event that relies on the VMPS method and uses the tools and improves the patient experience, serves to embed the management method ever more deeply into the organization’s culture. Not only did Shelly’s brand of leadership in this case help foster improvement, it also served to strengthen an already robust culture.

*Extracorporeal shock wave lithotrips + endoscopic retrograde cholangiopancreatography

“You have to get in and use the tools — if you’re not facile with them or you expect somebody else to do it, you won’t lead the team through it. And then you’re just not doing your job as a leader.”

- Sue Anderson

Have you ever experienced a situation where a senior leader mandates a certain change – a certain way of doing things – then fails to follow the new protocols himself? This sort of top-down “leadership” is far too common in health care today.

The best leaders do any and everything they ask their team members to do. That is why, at Virginia Mason, it is central to improvement that executive leaders get in the trenches and learn the details and tools of improvement. Leaders who work to learn improvement skills are able to walk the talk and are much more effective than leaders elsewhere who merely issue directives. 

Like most things in health care, it is easier said than done for leaders to learn the improvement skills and apply them just as frontline staff members do.

Sue Anderson

“When you’re learning improvement work it’s all about getting your hands dirty and it’s hard because many of us at Virginia Mason learned these skills as an executive,” says Executive Vice President Sue Anderson, chief financial officer and chief information officer. “So you’re in an unusual position. You’re supposed to be this leader who knows a lot, but when it comes to learning improvement skills, you are starting at the beginning.”

It requires not only a commitment to the lean method and learning lean methods and tools, it also demands a healthy degree of humility from executives.

“It really requires you to admit that you don’t know to be open to learning from everybody around you and to be vulnerable as a leader,” says Anderson. “So you have to put the I-know-it-all aside.”

Anderson likens it to going back to being a student. That, she says, is difficult for many executives, but because the Virginia Mason culture is based on learning and continuous improvement, executives embrace the challenge.

“What we’ve learned is the more we learn, the more we know we need to learn and so we see our improvement work as a journey and I think our education and learning of the improvement skills is also a journey,” she says.

There is no question the investment of executive leadership time yields improvements.

“We definitely get better as leaders,” Anderson says. “I know I’m better at leading an improvement event today than I was when I first started. I started with a team learning in 2001 before we went to Japan the first time, and I can tell you that was a painful experience. We had a person from the outside who was an expert in the Toyota Production System (TPS) coming in to teach us and we knew nothing about it.”

Over time, the executive leadership team at Virginia Mason has immersed itself in a learning journey and all executives at the organization are now deeply schooled in the methods and tools of the Virginia Mason Production System, which was based on TPS.

This helps advance rapid improvement work on many levels. A crucial aspect is that all other workers throughout the organization plainly see executives are present on the frontlines of care guiding, teaching and supporting. The power of this – executives walking the talk – is frequently evident. Regular genba walks by all executives sends a strong message. And Friday report-out, where the whole organization watches the results from leaders’ work, shines a bright light on executives and their performance as improvement leaders.

A rapid process improvement workshop (RPIW) Anderson led not long ago reveals the power of leaders knowing the method and tools, and respecting the knowledge of all other team members, as well.

“You have to have a mindset that every single person on the team is a very important contributor,” she says. “We’ve had that reinforced for us time after time. When we think about what we consider some of our breakthroughs, they really came from frontline staff.
So you have to be open to listening, and when you do and you make progress, you just get reenergized.”

The RPIW Anderson led earlier this year focused on a process called an esophagectomy – a procedure in which a patient’s esophagus is removed, usually due to cancer. It is a lengthy and complicated process during which surgeons draw from the patient’s stomach to create a new esophagus.

“It is a major operation – eight or 10 hours,” says Anderson. “We do it world class here. The average length of stay around the country is 12 to 14 days, and we’re at 7.6 days and our goal was to get it down to six.”

To do that, a team was constructed that included a nurse from the Intensive Care Unit, a nurse and leader from the floor the patient eventually is moved to, a dietitian, a physical therapist and others, including a first-year surgical resident who had recently completed her thoracic rotation.

It is in the midst of challenging improvement work such as this that an executive’s knowledge of improvement skills and tools is most powerful.

“You have to get in and use the tools − if you’re not facile with them or you expect somebody else to do it, you won’t lead the team through it. And then you’re just not doing your job as a leader.”

Difficult but inspirational
Improvement events are often difficult and complex, but they can also be inspiring. During the event she led, Anderson says that by Thursday (the event started on Monday) – the surgical resident came to her and was struck by the power of the process.

“She told me ‘this has been an amazing week,’’’ Anderson recalls. “She said that during the week, ‘I learned to be quiet and listen, and I learned how the other members of the team contribute. As a doctor I thought I just wrote my orders and everybody did them and then if they didn’t do them, I was just frustrated by it. But now I understand the process better and I’ll be a better doctor because of this.’”

“When you hear someone just starting their career with all that passion and energy to do good in the world who is so affected by the experience that it will have a profound impact on the patients she sees over time, it is really rewarding.”

“Creativity and innovation don’t have to be noisy or showy. They are often stealthy and quietly effective.”

- Jennifer Phillips

Type the words “health care innovation” into Google and you come up with 530 million results. Clearly innovation in health care comes in many shapes and sizes. But when you ask Virginia Mason team members what innovation means, you get a consistent response: “Creative thinking that is implemented.”

At Virginia Mason, innovation is the bedrock of change – it’s at the core of what the Virginia Mason Production System (VMPS) is all about. The VMPS management method and tools are a powerful combination for teams seeking to innovate in pursuit of the perfect patient experience. We asked a number of leaders at Virginia Mason for their views on innovation generally and, in particular, how innovation is used to advance lean improvements within Virginia Mason.

Jennifer Phillips

Jennifer Phillips, Director, Innovation, Kaizen Promotion Office
I think as a foundational principle we recognize that creative thinking is not an exclusive sport of a few. There’s this perception that only some people are creative thinkers or that creativity is about totally wild or wacky ideas.

But I have found in our work that creativity and innovation don’t have to be noisy or showy. They are often stealthy and quietly effective. We’ve learned that the right conditions, setup and methods unleash the creative thinking in everyone. When we apply VMPS methods and tools, creativity flows.

In a very practical sense, innovation enables us to break through assumptions. We keep finding situation after situation where we can think differently from traditional approaches and get traction with new ideas. VMPS gives us tools to peel away the layers.

Lynne Chafetz

Lynne Chafetz, Senior Vice President and General Counsel
We have focused significantly on fostering our culture of innovation. The elements that demonstrate a culture supportive of innovation − resources, information sharing risk taking, target setting, recognition, tools and relationships − all help to create an environment more open to change, learning and continuous improvement. This in turn serves to better enable teams to see opportunities for improvement, try out new and improved methods and more rapidly adopt and spread improvements.

Lean and innovation go hand in hand. A key element of VMPS is eliminating the waste of unnecessary variation and creating standard work. Standard work is not static − it serves as a platform for further improvement and innovation. So we use innovation to further our lean improvements by reinforcing the importance of standard work as a platform for innovation.

There are specific, effective creativity tools that enhance idea generation, harvesting and setup for implementation. One area of our focus is training our leadership and team members (building competency) to use these tools and techniques in our workshops and everyday lean to help stretch our thinking further beyond “the way we’ve always done it.” These tools are integrated into our workshops and useful in furthering lean efforts.

Alvin Calderon, MD

Alvin Calderon, MD, Hospitalist and Director, Internal Medicine Residency Program
Innovation is a means to an end, not an end in itself. We should not innovate simply because we can; rather, our needs should define the innovation necessary. At Virginia Mason, we have used (aircraft industry guru) Rolf Smith’s seven levels of change.

• Do the right things
• Do things right
• Do things better
• Do away with things
• Do things other people are doing
• Do things no one else is doing
• And do things that cannot be done. 

It’s easy to fall into the trap of believing and acting as though a more extreme level of innovation is better, but the reality is we should innovate to the extent that we meet our needs. (You could say that striving to innovate beyond what we need is waste!) For many problems, the best innovation is determining how to consistently do the right thing.

Amy Tufano

Amy Tufano, Faculty, Virginia Mason Institute
Delving more deeply into our innovation work in the last several years, I have come to a clearer appreciation of how integral this is, and has been, to our management system. There’s this concept that I learned from Paul Plsek (Virginia Mason’s chair of innovation): the principles of attention, escape and movement as three mental activities that are behind all creative thinking. I like to apply these principles to an even broader context when thinking about VMPS as our management system. VMPS teaches us such tools as time observation, percent load, value stream mapping, P-Q analysis, etc., to understand, document and analyze current state.

I see these tools as helping draw attention to where we are today − they highlight the reality of today − good or bad. As we evolve our culture to one where team members feel free to speak out, the environment is ripe for using creativity tools to facilitate “escaping” from their current mental valleys, getting unstuck from the insanity of the status quo, and ultimately “moving” to a new world order. It is because of this that I see innovation as key in accelerating our process improvement, fueling our lean efforts.

The synergy between innovation and lean thinking is described in a new book by Virginia Mason’s chair of innovation, Paul Plsek, entitled Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience (CRC Press, 2013). Here is an excerpt: 

Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Healthcare

Many believe that lean thinking and innovation do not mix. Virginia Mason Hospital Quality and Safety administrative director Joanie Ching, RN, recalls that when she was considering taking a job at Virginia Mason several years ago, friends counseled her to reconsider, saying that with its emphasis on lean she would not be allowed to be as creative as they knew she liked to be.

Ching found the opposite to be true, and over a decade of experience at Virginia Mason Medical Center further suggests that lean and innovation can be mutually supportive partners in the transformation of healthcare. In fact, CEO Gary Kaplan, MD, now calls standard work “the foundation for innovation.”

It is true that lean emphasizes standardization and elimination of unnecessary variation, while creativity and innovation is all about purposefully violating the current standard and temporarily creating variation for the purpose of testing. However, rather than being polar opposites that can never meet, it is more correct to see these as complementary points in an upward spiral of improvement. 

Standardization provides a stable substrate on which to generate and experiment with innovative ideas for transformation. It makes clear what the current thinking is, so that one can purposefully “think outside the box.” Further, without standardization, baseline performance measurement has so much variation that it is difficult to determine if an innovative new way is better. Finally, as an internal medicine physician observes, “once you start standardizing the day-to-day work, those become sort of automatic and it gives you the benefit of time and energy that you can invest in new ideas.”

In a sophisticated organizational culture, like that at Virginia Mason, leaders and staff have no difficulty understanding that they sometimes need to be in the zone of standardization, and sometimes in the zone of challenging the current standard and testing innovative new ways. There is complexity, but no dichotomy. One follows the other naturally.

When an innovation has proven its value, it then makes perfect sense to standardize the practice and spread it widely, the hallmark of lean thinking. This completes a loop around the spiral. However, the culture of lean and innovation does not allow this new standard to become the proverbial “we have always done it this way” that blocks subsequent innovation and change. Rather, it is just another temporary phase on the upward journey to better and better performance. Transformation emerges over the various cycles of this spiral across a value stream.

We have noted before that Virginia Mason is a learning organization – drawing from a variety of fields and sources to improve patient care. But Virginia Mason is also a teaching organization. Much of the teaching comes through the Virginia Mason Institute. The institute’s goal is to educate and train other health care organizations, including providers, in our management methodology, the Virginia Mason Production System (VMPS).

But our clinicians and administrators also teach annually at the Institute for Healthcare Improvement (IHI) National Forum. Next week, while a number of Virginia Mason team members will be in Orlando learning, a number of others will be teaching. Here is a rundown of their classes from the IHI course catalogue. (And, if you are at IHI next week, please stop by the Virginia Mason Institute booth and say “hi.”) 

Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience

It’s time to dispel myths such as the belief that lean and concepts such as standard work are “anti-innovation.” Drawing on the experience of Virginia Mason, as well as general innovation theory and its application, the presenters in this mini-course will describe how lean and innovation can not only coexist in a health care organization, but intertwine to create a powerful approach that deepens and accelerates improvement. Participants will be given concrete examples of how specific innovation and creativity methods can be integrated into Lean implementations.

Objectives:

• Support their organization’s implementation of lean methods through culture change and application of innovation concepts and tools.
• Recognize opportunities to apply creative thinking in a more deliberate way within the context of a chosen improvement approach such as lean.
• Describe how Virginia Mason has integrated innovation and lean to accelerate its quality and safety improvement efforts.

Presenters:
Amy Tufano, faculty, Virginia Mason Institute; Jennifer Phillips, innovation director, Virginia Mason; Lynne Chafetz, senior vice president and general counsel, Virginia Mason; and Paul Plsek, consultant, Paul E. Plsek & Associates, Inc.

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Engaging Frontline Staff in Real-time Improvement
Traditional suggestion systems can be ineffective in engaging staff and creating real impact. In this session, participants will hear an organizational case study on equipping frontline leaders with a different approach. Grounded in lean and innovation principles, a staff idea system, and standardized leadership routines, including regular rounding and huddles, this approach enables staff to chip away at the rampant waste in health care. Presenters will describe design elements, examples and critical success factors.

Objectives:

• Discuss the difference between a suggestion system and a lean-influenced idea system.
• Describe daily leadership routines that engage staff in improvement.
• Identify critical success elements when implementing such an approach.

Presenters:
Jennifer Phillips, innovation director, Virginia Mason, and Sharon Mann, RN, director, Emergency Services, Virginia Mason

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Improving the Flow of Resident and Hospitalist Work

Hospital teaching rounds are a time-honored tradition and a fundamental aspect of residency training. In most institutions, the basic format of rounds has not changed for decades. In this session, we describe how Virginia Mason improved the work flow of residents and hospitalists by applying the principles of the Virginia Mason Production System. Morning rounds were redesigned to allow residents to complete high-quality and timely patient care one patient at a time.

Objectives:

• Recognize the impact of batched rounding on the clinical operations and education experiences of hospitalists and residents.
• Demonstrate the differences between batch rounding and one-piece flow rounding in their organization.
• Plan a cycle of improvement to reduce batching in their hospital rounds.

Presenters:
Alvin Calderon, MD, director, Internal Medicine Residency Program, Virginia Mason, and Daniel Hanson, MD, hospitalist, Virginia Mason

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Engage Physicians to Transform Care

Improvement cannot be embedded into an organization’s culture without the active engagement of physicians. In this mini-course, we will describe a comprehensive model for successful physician engagement, including the role of a new physician-organization compact, and explain how participants’ organizations could adopt it. We will also share relevant perspectives from the ongoing efforts at Virginia Mason to improve care and efficiency through implementation of the Virginia Mason Production System, illuminating the critical role of physicians in this work.

Objectives:

• Describe how urgency, shared vision, change sponsorship, a compact (reciprocal expectations between doctors and their organization), and a comprehensive method facilitate physician engagement in improvement efforts.
• Address the loss of autonomy that often blocks physician engagement.
• Draw lessons from Virginia Mason’s experience that can be applied to their own organization.

Presenters:
Gary S. Kaplan, MD, chairman and CEO, Virginia Mason, and Jack Silversin, President Amicus, Inc.

“Continuous flow maximizes quality, reduces defects and makes waste much more obvious so that you can eliminate it. Flow reduces waste, chaos and costs. And it makes your value stream transparent – you can see it.”

- Cindy Rockfeld

In the turbulent world of health care today, success depends upon the ability of an organization to excel in many areas. One of the essential areas is learning.

Every day, it becomes clearer that the status quo is a prescription for failure. An organization choosing the status quo over continuous learning and improvement will inevitably fall behind.

Virginia Mason, at its core, is a learning organization. Team members are engaged in an ongoing learning process based on the Virginia Mason Production System (VMPS), adapted from the Toyota Production System.

While Virginia Mason team members learn in a wide variety of ways, one of the most important is known as the Kaizen Fellowship, an advanced 16-month program for a select group of leaders designed to provide a deeper understanding of the Toyota methodology and tools. Fellowship applicants must have completed the organization’s VMPS for Leaders curriculum and Rapid Process Improvement Workshop certification.

Linda Hebish, administrative director, Kaizen Promotion Office, was among the early Kaizen fellows in 2006. “It is intense because you do the fellowship while doing your regular job,” she says. “The intent of the program is to offer additional leadership development opportunities to those already certified and knowledgeable in the Virginia Mason Production System and to have them go through a concentrated application of tools and principles to gain a deeper understanding of how the management method works.”

Linda points to two leaders who recently completed the program: Roger Woolf and Cindy Rockfeld. 

Roger Woolf
Roger serves as administrative director of Pharmaceutical Services, and he found the initial phase of the fellowship – extensive reading and then discussing the readings with other fellows – to be particularly valuable (See below for a sample of readings).

Roger Woolf

“The fellows would get together, and we would try and teach our colleagues about our own value stream and how we hoped to improve it during the fellowship,” says Roger. “We were helped immeasurably by the active engagement and guidance of our leaders, including Linda Hebish, Kathleen Paul (vice president, Communications and Public Policy) and Diane Miller (vice president and executive director, Virginia Mason Institute). And Sarah Patterson (executive vice president and chief operating officer) participated in vast majority of our academic sessions, which shows you the commitment executive leadership to the fellowship and our learning. She really challenged us.”

Roger, Cindy and the other fellows would gather to dig into a particular aspect of lean, such as mistake-proofing, visual controls or level-loading. “We would read about it, discuss it within the group and then apply it to our own value stream,” says Roger.

He found the combination of academic study, intense discussion and presenting to senior leaders within the organization, to be challenging and immensely edifying.

In his fellowship work, Roger focused on sterile drug preparation. “In the pharmacy we have a sterile compounding room with very clean airflow to make drug preparations. We focused on creating flow and mistake-proofing the processes since many of these drugs are high risk and making a mistake could be catastrophic.”

The fellowship, says Roger, helped immensely in improving the safety of sterile drug processing preparation. Perhaps more than that, the program helped Roger become a stronger leader. “I loved it,” he says. “It challenged me immensely. It taught me a lot about reflection – reflecting on what we have done in the past and what we can do today to improve. And I now have a much better understanding of VMPS concepts.” 

Cindy Rockfeld
Cindy serves as administrative director, Ambulatory Services, and says her fellowship experience “gave me deeper knowledge of VMPS and how to apply it. I feel like I am a lot more thoughtful about it.”

Cindy Rockfeld

She says the goal all along was to better understand the tools and methodology to improve flow throughout her area. “One of the most valuable things about the fellowship is the deeper discussions we had as a group,” she says. “Some of the discussions were theoretical, some were operational and they all collectively helped deepen and solidify our knowledge.”

The Japan tour for Kaizen fellows focuses on the concept of flow and the fellows witnessed flow in a variety of manufacturing settings. “We visited factories making airplane engines, circuit boards, farm equipment and more,” says Cindy, “Our focus was always on how they implemented flow and how we could apply the lessons at home in our value streams.”

Cindy found the cumulative impact of the fellowship learnings very powerful. After all the rich discussions with colleagues and work on her value stream, and reading and the Japan visit, a light bulb switched on for Cindy.

“I realized that all of the concepts together – the tools and the VMPS method – get you to continuous flow,” she says. “If you apply the management method, use the tools and trust the process, you will get to flow, and the benefits of that are really significant. Continuous flow maximizes quality, reduces defects and makes waste much more obvious so that you can eliminate it. Flow reduces waste, chaos and costs. And it makes your value stream transparent – you can see it.”

Cindy applied much of what she learned in her fellowship to the value stream for patients undergoing colonoscopies. “We want continuous flow for our patients and our providers,” she says. “We want patients flowing seamlessly from check-in through the procedure and through recovery without any breaks, defects or waits in our system.”

Consider this striking improvement: The amount of time it took for a patient to go through the colonoscopy process from entering the clinic to going home was 3 hours and 25 minutes. When improvement techniques were applied, that was reduced by more than an hour to 2 hours 23 minutes. This makes for a much improved patient experience and enables Virginia Mason to increase productivity.

“And I know we can get it lower still,” says Cindy.

Sampling of books Kaizen fellows read during their studies

• A Study of the Toyota Production System by Shigeo Shingo and Andrew P. Dillon
• The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer by Jeffrey Liker
• Creating a Lean Culture: Tools to Sustain Lean Conversions by David Mann
• The Hunters and the Hunted: A Non-Linear Solution for Reengineering the Workplace by James B. Swartz

“It is a thrilling learning journey. We are evolving from leaders being managers and directors to being coaches and teachers, and the impact of that on the experience of our patients and team members has been amazing.”

- Diane Miller 

At its core, Virginia Mason is a learning organization. Learning is in the bones of the best health care organizations as clinicians seek to understand the latest techniques for treating a wide variety of conditions. And this is certainly true throughout all departments at Virginia Mason.

But there is much more to learning at Virginia Mason than that. In addition to clinical learning, there is active, continuous learning on how to improve by eliminating waste, improving efficiency, safety, access and much more. This learning focuses on gaining an ever deeper knowledge of the tools and methods of the Toyota Production System.

Diane Miller

More than a decade ago, Diane Miller, Virginia Mason vice president and executive director of the Virginia Mason Institute, created a series of development sessions for all Virginia Mason executives. Her initial approach – to have physicians and their administrative partners go through learning experiences together – proved so effective it has been sustained for more than a decade.

“One of the keys for us from early on was not to separate the doctors,” says Miller. “Fairly typical training back then was more like continuing medical education where people did things on their own and their was no team continuity, no shared experiences among teams. We have found the shared learning experiences of teams makes for much richer, more effective learning.” And in every department the leadership involves a dyad with a physician leader whose partner is an administrative leader.

In 2002 when the organization declared Virginia Mason Production System (VMPS) to be its management method, the focus of these development sessions became education and training for executive leaders to learn how to adapt lean management to health care. Miller co-led training for leaders with Virginia Mason’s consultant so they could receive lean certification and thus competently lead kaizen events, such as Rapid Process Improvement Workshops. Soon thereafter she cascaded that training throughout the organization to section heads and managers.

The progress has been significant. The goal at the end of 2013 is for every leader at Virginia Mason – even if they supervise just one other individual – to complete (or be in the process of completing) a rigorous course called VMPS for Leaders. This robust learning process digs deeply into Toyota tools and methods.

“Having so many people complete VMPS for Leaders is a milestone,” says Miller. “It means these leaders demonstrate an ability to apply the concepts effectively in their work areas. I know of no other health care organization in the country that has achieved that level of internal training.”

Virginia Mason team members learn skills that help them integrate care across the continuum. They learn to identify waste, which often remains invisible unless one has the tools to ferret it out. They learn to huddle and try a Plan-Do-Study-Act cycle. They learn how to use their value stream to run their business.

Just as the ability to apply VMPS methods and tools has improved through the years, so too, has the quality and effectiveness of the teaching. “We’ve gotten better at learning what it takes to manage events and apply standard work throughout the organization, including standard work for leaders,” says Miller. “It is a thrilling learning journey. We are evolving from leaders being managers and directors to being coaches and teachers, and the impact of that on the experience of our patients and team members has been amazing.”

As executive director of the Virginia Mason Institute, Miller and her team take the lessons learned at Virginia Mason and teach them to men and women from health care organizations throughout the world. Thousands of health care professionals throughout the United States and more than 20 countries have traveled to Seattle to learn how to apply lean principles in health care from Miller and her team.

“Many people come to our institute to see a very different way of running a large, complex health care organization,” Miller says. “Being able to take many of the lessons we have learned within Virginia Mason about how to improve the patient experience and pass those lessons on to people from other health care organizations is really gratifying and completely aligned with our vision to transform health care.”

“In primary care it is all about the team. Everybody plays an important role and everybody is assigned to what they do best.”

- Ingrid Gerbino, MD 

Virginia Mason makes five promises to patients in their primary care practices:

• We will prevent you from getting sick whenever possible.
• We will provide enhanced access to your care when you do get sick.
• We will partner with you to manage your chronic/complex conditions.
• We will ensure your care is coordinated between providers.
• We will keep you informed about and engaged in your care. 

How does Virginia Mason fulfill such an ambitious series of pledges to patients? 

The answer is teamwork by skilled clinical professionals aligned around the needs of the patient. This approach is a marked departure from the way primary care has traditionally been delivered. 

Perhaps the key to its success is that this approach does not pile every detail of a patient’s care onto a doctor’s shoulders. Instead, other talented team members – nurses, pharmacists, medical assistants and others – play critical roles in delivering care along with the physician. 

Ingrid Gerbino, MD

“In primary care it is all about the team, says Ingrid Gerbino, MD, an internal medicine physician and deputy chief for the Department of Primary Care. “Everybody plays an important role and everybody is assigned to what they do best.” 

One of the positions that is relatively new in recent years – and was essentially invented at Virginia Mason – is the role of “flow manager.” Flow managers are medical assistants who keep care moving for the maximum benefit of patients and to enable physicians to focus on “doctor work” rather than bureaucracy. 

“I partner with my flow manager throughout the day,” says Dr. Gerbino. “Every piece of information that comes to me – electronically, by fax, paper, phone – is scrubbed first by the flow manager.” 

What this means in practice is that flow managers are trained in standard work to take care of many requests that come to the doctor. Some questions and requests the flow manager handles herself. Others she steers to nurses, administrators, pharmacists or behavioral specialists. In other words, the flow manager reduces the burden of work on the doctor, meaning the doctor’s time is used much more efficiently diagnosing and treating patients. 

External Setup
Perhaps the most valuable contribution of the flow manager is what is known as external setup – an essential element within lean management. External setup involves the flow manager getting everything ready for the visit before the visit so that the physician can concentrate on what doctors do best – diagnose and treat patients. 

When the flow manager rooms a patient she is guided by standard work. “They review health maintenance items, such as mammograms, colonoscopies, immunizations, etc., and they are very good at making sure patients are up to date on these critical tests and screenings,” says Dr. Gerbino. 

One of the major challenges in health care in the United States today is burnout and dissatisfaction among large number of primary care physicians. Many primary care doctors throughout the country feel overwhelmed with so much bureaucratic work that they are unable to do what they are trained to do. 

The solution at Virginia Mason, says Dr. Gerbino, is “leveraging the talents of the whole care team, and I think that’s what we’ve done well. It’s better for the patient and it’s better for all team members.” 

While medical assistants focus on patient setup and flow, nurses spend much of their time treating and counseling patients with a variety of chronic conditions, and nurses have proven highly skilled and effective at this work. 

Also, there is now a clinical pharmacist in every Virginia Mason clinic to fill the essential team role of managing medications for all patients, but particularly for patients with chronic conditions whose medications require continuous monitoring and regular adjustment. This is the area where the pharmacist’s skill is so valuable. 

Roger Woolf

The team approach, says Roger Woolf, administrative director, Pharmaceutical Services, improves overall productivity in clinics “and helps keep the physicians in flow. It allows our physicians to focus on the most important things they need to focus on which is diagnosing and treating the most complex patients.” 

Catherine Potts, MD

Catherine Potts, Chief of the Department of Primary Care, says the team approach is fundamental in establishing a patient centered medical home model. With the primary care physician as the leader of the team, and utilizing skill task alignment with the other team members, care is comprehensive, coordinated and provided by the right person on the team. The entire team is focused on the patient’s health needs, including wellness and prevention and acute and chronic care.