“If we are discharging someone who has had a total knee or hip replacement without them being able to practice how to get in and out of a car, and they twist or turn the wrong way, it could do damage.”
- Debbie Cutchin
Imagine a patient is about to be released from the hospital. She had a total knee replacement and is taken from her room to the hospital front entrance to be picked up. She is then wheeled to within a couple feet of a wide-open car door. Now what?
Yes, she had been working with physical therapy in the hospital on mobility and yes, she knows the rules and guidelines for keeping her knee safe as she recovers from surgery.
But by entering a vehicle, she is about to perform a maneuver – with a new knee – that she has never done before. How should she do this? Could she harm herself by doing this in an awkward manner?
Debbie Cutchin, director, Virginia Mason Kaizen Promotion Office (KPO), makes a crucial point: A patient should be trained on how to get in and out of a vehicle before she has to do so.
That brings us to the powerful effects of the moonshine process (sometimes known elsewhere as “skunkworks”). “Moonshine is an inexpensive way to try something out, something new that solves an immediate need,” says Cutchin. “Sometimes, we find that we need something that doesn’t exist in the marketplace or it does exist and is pretty costly. When we have a unique need for a supply or piece of equipment we work through the moonshine process.”
And that is exactly what happened when a Virginia Mason team sought to solve the problem of knee- or hip-surgery patients being released and never having learned how to enter and exit a vehicle.
“If we are discharging someone who has had a total knee or hip replacement without them being able to practice how to get in and out of a car, and they twist or turn the wrong way it could do damage,” says Cutchin.
When teams were helping design a new section of the hospital in the Floyd & Delores Jones Pavilion at Virginia Mason, they aspired to include a practice vehicle for a variety of patients − including those with knee and hip replacements, and those who had suffered a stroke or had other neurological conditions.
There were many challenges for the team constructing the car, including the reality that the space they were allotted was only 52 inches wide. Cutchin and her colleagues came together for a two-day improvement event in 2011. The team included occupational and physical therapists, a patient transporter, a patient care technician and a KPO specialist.
“When the team came together we said, ‘OK, the seat doesn’t have to be able to recline or move because we will always transfer the patient into car with the seat in the reclined position,’” she recalls. “We knew the practice vehicle did not need a roof or a steering wheel, and it doesn’t need a door because the patient will always get in with the door open.”
What the team did need to reproduce was the door angle because it affects the placement of the walker. During the improvement event, the team determined the functional needs for the car: whatever they built had to fit into a defined space; it had to be easily adjustable – preferably having no more than three moving parts; it had to be easy to clean in two minutes or less; and it had to be portable so it could be moved to any part of the hospital, bringing it to patients rather than having patients with serious mobility challenges going to it.
Once the functional attributes were agreed upon, “team members drew pictures of what they envisioned, and then we mocked them up in three dimensions with pipe cleaners, Popsicle sticks and tongue depressors,” says Cutchin. “By the end of the first day of work, we had what the team considered a good basic design. Our next step was to create a life-sized mockup based on our tabletop designs.”
A key aspect of the two-day event was the inclusion of a representative from Creform, a firm that manufactures structural elements – “lightweight components somewhat like an erector set,” Cutchin noted. Creform is devoted to helping clients do rapid mockups in pursuit of “lean manufacturing goals.”
On day two of the improvement event, the team focused on using Creform components to build the new chair.
“As we went through that process a lot of questions were raised,” says Cutchin. “Can we crank it up to the height of an SUV? Can we crank it low enough for the smallest car?”
The result of this work is a remarkable piece of equipment designed and built by frontline workers who recognized the need to keep patients safe by preparing them for their release form the hospital. (Watch video.) As a Virginia Mason report noted:
The therapy car, which weighs less than 150 pounds, is constructed of lightweight plastic tubing and connectors that allow a variety of configurations to help patients practice mobility. It includes a cushioned car-like passenger seat. The device’s height can be adjusted to correspond with the type of vehicle (i.e., compact, sedan or sports utility vehicle) the patient is likely to get in when he or she leaves the hospital. It also has wheels, allowing therapists to easily move it to meet an individual patient’s post-surgery rehabilitation needs. Most of the time, the car is “parked” in the Virginia Mason Orthopedics Unit therapy gym and used there by patients.
Now, when patients are wheeled out the front door to head home, they are ready to enter and exit any kind of vehicle safely and without fear of damaging their surgical repairs.
The therapy car has been an important advance, but Debbie emphasizes that not all moonshine work is that impactful. “Moonshine doesn’t have to be a mind-blowing experience like the car,” she says. “It can be something as simple as the supply chain needing a stand for an odd-sized printer, so we went through the moonshine steps to build a printer table. The team in sterile processing used moonshine to build racks to hold blue wrap for sterile instruments. If we can avoid spending a lot of money on something and build it ourselves that is where moonshine is really useful.”
What is moonshine?
(aka: bootleg, skunkworks, prototyping)
- A fast and inexpensive way of testing a concept or trialing an idea before purchasing.
- A method to create a product to meet a specific need if there is nothing that currently exists on the market.
- Try-storming: try it before you buy it.
- The learning is in the doing: testing, even in simulation, provides so much education and insight before we commit to a solution.
- Building to fit a need or function rather than adapting a current product.
From concept to construct: getting ideas from paper into a testable product: idea generation small scale mock up large scale mock up test
The MOONSHINE LABORATORY and PATHWAY provide the structure, resources, and space to do this work.
Why moonshine at Virginia Mason?
- Supports our management method: Virginia Mason Production System (VMPS) is built on principles from the Toyota Production System and lean. Moonshine is a tool used in the application of lean concepts.
- Supports our vision: To be the Quality Leader and transform health care – we have to be willing to create the right products if they don’t currently exist.
- Innovative culture: We foster a culture of learning and innovation, this is a pillar on our strategic plan. Looking at better ways of delivering the right care requires innovation or a different way of approaching our work.
- Utilizing our people resources: Every team member should have the resources to do their job most effectively, generate ideas to improve their work and avenues to act on those ideas.