Using the Nemawashi gauge to guide improvement in patient safety

By Celeste Derheimer, RN, CPHQ, MBA, Transformation Services Sensei

A culture in support of safety is inextricably linked to a culture where continuous improvement thrives. Leaders drive values, values drive behaviors, and the collective behaviors of the individuals in an organization define its culture. These same leaders must be involved in creating the transformational change that is required to develop and sustain a culture of safety. Then they must implement and maintain a system that continuously engages staff. The Nemawashi gauge is a tool that can help leaders succeed in improving patient safety and engaging staff to contribute to continuous improvement.

Defining the Nemawashi gauge

Nemawashi is a Japanese term that means “to prepare the soil for planting or transplanting a tree so that it will live,” and it speaks to the adaptive aspects of change. In recent years, Virginia Mason identified five foundational elements needed to support improvement and developed the Nemawashi gauge to assess an area’s readiness for change:

    1. Leader preparation
    2. Genba presence
    3. Daily management
    4. Creating a line of sight
    5. Staff readiness and engagement

The Nemawashi gauge can help leaders discover the blend of technical and adaptive change required to successfully create and sustain a culture in support of patient safety.

How can leaders use the Nemawashi gauge to engage their staff?

To create and support an improvement culture, leaders and staff need to define the problems and participate in solving them. It’s just as important to move beyond complaints and generate new ideas. With these points in mind, readers can engage staff in the following ways:

  • Encourage your staff to speak up, and then reinforce that message. If a staff member believes that there is a process or an obstacle creating a barrier to patient care, the team needs to know. Also let staff know that you would like them to come to work with ideas for improvement, and then reinforce this by asking the team for ideas during huddles, genba walks and meetings.
  • Now that you have enabled your staff members to speak up about problems and new ideas, be sure to allow and reward courageousness. Staff need to know that their ideas are important, and that it is OK to feel vulnerable and take chances.
  • Be sure that the people who do the work improve the work. Let it be clear that an idea won’t languish in a suggestion box, waiting for someone else to act on it. Ideas need to be tested by the staff who will potentially implement the new ideas in their daily work.
  • Support staff as they test their ideas. Check in with them at the genba as part of daily management. Create a line of sight at weekly huddles, too, so staff can report on their progress to the team.
  • Remember that staff who see their ideas implemented become more engaged and more likely to continuously generate more ideas. Engaged staff are the ones who regularly seek improvement and make your organization better and your patients safer.

How has the Nemawashi gauge been received at Virginia Mason and other organizations?

At Virginia Mason, the Nemawashi gauge has helped leaders assess the readiness of their teams for change. As a result of using this tool and other patient safety tools and methods, we have seen a steady increase in continuous improvement, especially in clinical engagement. Most notably, we have seen an increase in our staff’s reporting of safety concerns—in fact, our Patient Safety Alerts (which are part of our system for empowering all team members to report any perceived threat to patient safety) have increased significantly because staff are paying close attention and feel empowered to speak up.

In my work as sensei at organizations worldwide, I know that daily management is crucial to sustaining the improvement culture, so I reinforce the constancy of purpose with every leader. At Virginia Mason, we know from our years of experience that discipline is necessary, even with all the other competing priorities and the surprises that come our way in health care. We also know that the resulting culture of engaged staff—and improvement of patient safety—is worth the effort.

To learn more about the Nemawashi gauge and other ways to improve patient safety, register for our course Creating a Culture of Patient Safety.

To learn more about how leaders can create and sustain an improvement culture, register for our course Engaging Staff to Drive Improvement.

Celeste Derheimer, RN, CPHQ, MBA, is a Transformation Services sensei at Virginia Mason Institute. A Kaizen Fellow graduate, with certification in the Virginia Mason Production System, she has led multiple kaizen activities to improve safety, quality and administrative processes. Prior to joining Virginia Mason Institute, she served as administrative director for Corporate Quality and Safety at Virginia Mason, where she was responsible for organization-wide quality improvement and patient safety. She has held leadership positions in numerous health systems in Washington and Oregon and has served as an examiner for the Malcolm Baldrige National Quality Award since 2006.

How Change Can Energize and Motivate an Organization

By Diane Miller, Executive Director, Virginia Mason Institute

Introducing the Virginia Mason Institute Team to Our Blog

Diane Miller

Diane Miller

I’d like to introduce the Virginia Mason Institute team to readers. In the coming months, more faculty members will be featured on the Virginia Mason blog, sharing their experience and explaining the ways that lean concepts can successfully be used in health care. A collection of lean thinkers and teachers, rigorously trained in the Virginia Mason Production System (VMPS), the team officially began transforming health care in organizations outside Virginia Mason in 2008. Today’s team comes with a variety of skills—in ambulatory flow, primary care and specialty medicine, nursing, patient safety, lean financial processes, lean architecture, and kaizen promotion—and they enjoy being lifelong learners and teachers.

Through the years, we’ve grown in number and in scope, so that now we’re training leaders on site in the United States, United Kingdom, Denmark and more. In our classrooms in Seattle, we’re training leaders from Maine to California, from the Netherlands to Japan and from Iceland to Brazil. In every one of our courses, we’re asking providers and organizations, one by one, to learn from Virginia Mason’s successes and failures and find the courage to change the culture and put patients first in all that they do.

Why is change necessary?

Change, as we know from experience, can be a rough road to travel. Health care providers naturally want to provide the best care, at all times, to their patients. Asking them to change processes may seem foreign or unnecessary—something they and their colleagues don’t have time for. But we know from years of experience that using Virginia Mason Production System tools and a new management method can not only change the way an organization operates, but also dramatically alter the patient and staff experience in a positive way. With the concept of continuous improvement embedded in our culture, we know that change can energize and motivate providers—providing multiple opportunities for innovation, teamwork and accomplishments that weren’t possible with an old management system.

Virginia Mason Institute team members in our new training facility

Virginia Mason Institute team members
in our new training facility

Here at Virginia Mason Institute, we’re undergoing a new change of our own as we take our model of continuous improvement to heart. First, based on feedback from attendees at our classes in Seattle, we’re building new classrooms. With seating arrangements that allow for more teambuilding, windows that allow natural light in all the spaces, corridors that enable thoughtful time between sessions and streamlined check-in processes and refreshment stands, the new space will better serve the national and international clientele who travel here to learn from and engage with us.

We’re also updating our courses to incorporate new case studies and simulation exercises to help the lean concepts we teach continue to powerfully resonate with health care providers and leaders. In every class, we pledge to deliver an extraordinary learning experience and be sure attendees leave with a greater capacity to reduce waste, improve patient safety and increase patient and staff satisfaction. All of our work is exciting to us, and this feeds our mission to energize and motivate health care teams around the world.

What to look forward to

In addition to introducing new voices to our blog and opening new classrooms, this year we’ll be redesigning our website and debuting more ways to interact with us on social media. We want you to learn from the lean journey that we have experienced for more than a decade and that we continue to experience every day. Our enthusiasm for transforming health care knows no bounds, and we’re proud to develop more and more connections to the broader community that wants to transform health care, too. Please connect with us to let us know what you’d like to see—in the blog, in our classrooms, in our courses—as we work to continuously improve the learning journey.

The beauty of intrinsic motivation

Charleen Tachibana, RN

Charleen Tachibana, RN

“For me, leadership here is a vocation and I think that’s true for many of us.”

Charleen Tachibana, RN

A lot has been written lately about burnout among health care workers in the United States. Too much stress in too many dysfunctional organizations has clinicians and administrators on edge.

Health care is an inherently stressful business. The work flow is constant and the very nature of the work is unlike any other professional pursuit. Every minute of every day in our clinics and hospitals, patients’ lives are at stake. Every day, the people we care for come to us with challenges large and small. Many arrive in our clinics worried, fearful for their own health, or that of a loved one.

We have a profound responsibility to do our very best for each and every patient − always. And we do. From a certain perspective, this is a heavy burden. The work is difficult and relentlessly challenging. But at Virginia Mason we never see it as a burden – we see the challenges as a gift. The gift is the opportunity to care for people who truly need us. The gift is the deep trust they have in us.

This is not to suggest that we are entirely immune from the stress and pressures endemic to health care. We feel the pressure. We struggle with the challenges.

Julie Morath

Julie Morath

But we also have something within our DNA that sets us apart, and that is a deep desire on the part of our people to stay focused on the most elemental mission to help human beings who are suffering, fearful and vulnerable.

Charleen Tachibana, RN, hospital administrator and chief nursing officer, says that for most members of the leadership team the mission is about values.

“We have aligned people’s beliefs with those of the organization,” she says. “People have passion about their work. Their job is a personal mission to make a difference; to change things for the better. Some people internally describe it as a moral imperative. I can’t not do this. There is a synergy there that ignites the connection between clarity of values of the organization connected to people’s personal values.

“For me, leadership here is a vocation and I think that’s true for many of us. It’s a calling here. It’s such a gift to do it with others who are in vocations with you and want to travel there with you. For me it’s a very spiritual journey here. I can’t imagine doing it elsewhere because the risk of losing that component of it. But I would say leadership here, for most people, is a vocation. It’s a calling.”

Joyce Lammert, MD, Chief of Medicine, holds a similar view. “I think most of the leaders here are intrinsically motivated,” she says. “They’re values-driven. We have something that gives meaning to what we do every day − the opportunity and ability to comfort and heal and guide.”

Getting to a place of intrinsic motivation doesn’t happen overnight. It is developed over many years and requires a clear vision, with a mission and set of values that ring true throughout all levels of the organization. It becomes ingrained as part of the culture and is modeled and exemplified by top leadership every day.

Joyce Lammert - Virginia Mason Chief of Medicine

Joyce Lammert, MD
VM Chief of Medicine

Julie Morath joined the Virginia Mason board in January 2009. From the start, she observed the intrinsic motivation that Dr. Lammert and Tachibana describe.

There is alignment but it is not a transactional business model alignment,” she says. “It is alignment to fidelity of purpose; to deep respect for people. There is real clarity of vision and purpose. It’s a highly relational alignment based on common purpose and constancy of purpose – a real passion around that. It is different from a lot of places where alignment works because of incentives. This has a little higher order to it; higher order because people give discretionary energy. They’re not just doing the job. There is always this sense of inquiry − getting better as a way of life. When we look at the Triple Aim* and hospitals under siege, we know patients and families deserve more, society deserves more than we have been delivering in terms of value. Virginia Mason is leading the way.”

Says Dr. Lammert, “I think our people are truly aligned with our mission and vision. We have an opportunity for growth in a culture that allows you to be involved in something significant, something that makes a difference. Our vision is to transform health care. We take that very, very seriously every day. What a wonderful motivator!”

What motivates you and your teams to do the very best work every day?

* The Institute for Healthcare Improvement’s belief that new designs must be developed to simultaneously pursue three dimensions, which it calls the “Triple Aim”: improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Cutting cost of care while improving quality (part two)

“From my perspective, we all have a common purpose, and that is to return healthy and satisfied employees to work faster and more affordably.”

- Robert Mecklenburg, MD

Note: This is the second of a two-part installment looking at the Center for Health Care Solutions at Virginia Mason. This post focuses on how identifying standardized, evidence-based care for common conditions is proving to be beneficial for purchasers and the State of Washington. Part one looked specifically at how patients benefit.

Robert Mecklenburg, MD

Robert Mecklenburg, MD

Virginia Mason believes every patient should receive the best evidence-based care every time. Toward that end, it has identified 10 conditions where standardized, evidence-based care means superb quality at the lowest cost:

  • Abdominal pain
  • Asthma
  • Chest pain
  • Depression/anxiety
  • Diabetes
  • Headache
  • Hyperlipidemia
  • Hypertension
  • Acute respiratory infection
  • Urinary tract infections

For purchasers
Analysis has shown that these 10 conditions also have a negative impact on companies paying for their employees’ health care. Workers suffering from these conditions miss work, which creates an economic disruption for the employer.

Virginia Mason teams led by Robert Mecklenburg, MD, medical director, Center for Health Care Solutions, have worked closely with a variety of companies to define what constitutes quality from an employer’s perspective. This work, which Dr. Mecklenburg has been leading for 10 years, looks at care delivery not only from the patient’s point of view, but also from the perspective of the employer paying for care. The breakthrough here is the alignment of interest − defining quality so the interests of workers and employers are met simultaneously.

“From my perspective, we all have a common purpose, and that is to return healthy and satisfied employees to work faster and more affordably,” says Dr. Mecklenburg. He and his colleagues leverage primary care teams to reliably meet five performance specifications:

  • Appropriate evidence-based care
  • 100 percent patient satisfaction
  • Same-day access
  • Rapid return to function
  • Affordable price for the provider and purchaser

“The goal is to have primary care teams use a systems-based approach to clinical care for frequently seen conditions with zero defects in quality,’’ says Ingrid Gerbino, MD, faculty member, Virginia Mason Institute. “Using the clinical value streams can help restore our patients to fully productive lives in a manner that is patient-centered, efficient and effective.”

Ingrid Gerbino, MD

Ingrid Gerbino, MD

Near the top of every employer’s wish list is the ability to provide quality health care for their employees at an affordable price. Far too often this seems like a futuristic aspiration. But this approach at Virginia Mason has made it a reality, demonstrating to employers throughout the Puget Sound region and beyond that this goal is achievable today.

Another way Virginia Mason provides the finest care at the most affordable price is through its warranty for knee- and hip-replacement surgeries.

John Levesque, managing editor at Seattle Business magazine, wrote in November 2014: “Rarely does a medical institution say it will stand behind its work and not charge patients for return visits if something goes wrong.”

Levesque’s article quoted Gary S. Kaplan, MD, Virginia Mason Chairman and CEO: “Under the current reimbursement system in our country, hospitals are often paid more for surgery that does not go well than for surgery that is completely successful. We find this unacceptable and contrary to the needs of patients, employers and insurers paying the bill.”

Levesque commented that “to hear [this] being uttered by the CEO of a hospital is refreshing, rewarding and remarkable.”

For the State of Washington
The approach discussed here works well for patients and employers, and these principles have now been extended to the State of Washington through the work of the Robert Bree Collaborative. This collaborative, established by the state legislature, seeks to ensure “public and private health care stakeholders would have the opportunity to identify specific ways to improve health care quality, outcomes, and affordability.” As explained by the Bree Collaborative:

Each year, our members identify up to three health care services with high variation in the way that care is delivered, that are frequently used but do not lead to better care or patient health, or that have patient safety issues. For most topics, we form an expert workgroup to develop evidence-based recommendations.

Dr. Mecklenburg serves as chair of the work group that has developed bundled payment models and warranties for total joint replacement and lumbar fusion. The work group recently started creating a bundle/warranty for coronary artery bypass graft surgery.

“A warranty provides significant value for purchasers,” says Dr. Mecklenburg. “It means a fixed price for a transparent, standardized patient pathway and builds appropriateness standards into the bundle to avoid unnecessary surgery. Also built in is accountability for nine avoidable complications resulting in readmission to the hospital. The fixed price and warranty mean purchasers are not accountable for paying for avoidable mistakes. Virginia Mason can offer the warranty created by the Bree Collaborative because of our confidence in evidence-based, appropriate care backed up by reliable systems.”

One of the most powerful trends in health care nationwide is toward increased transparency in relation to quality and cost, and the work of the Bree Collaborative is an important step in that direction. Says Dr. Mecklenburg, “What Bree has achieved is a standard for production, purchasing and payment for the State of Washington, a standard in the public domain that is available to any provider group, purchaser or health plan, a standard created by multiple stakeholders and a multitude of contributors.”

Virginia Mason has committed to the quality standards created by the Bree Collaborative. It believes the Bree work over time will result in better, more affordable care for purchasers and patients throughout our state.

How is your organization building in standards that ensure higher quality and lower cost of services?

Cutting cost of care while improving quality (part one)

“As physicians, we are all trained a little differently. But we know that variation in delivering care is inherently wasteful and not quality care.”

- Robert Mecklenburg, MD

Note: This is the first of a two-part installment.

Robert Mecklenburg, MD

Robert Mecklenburg, MD

The Center for Health Care Solutions at Virginia Mason is one of the true innovative gems in health care today. Created 10 years ago, the center seeks “to offer employers, health plans, and policymakers the opportunity to work collaboratively with Virginia Mason providers to reduce unnecessary health care costs.”

It has accomplished that and much more. In fact, the center has blazed a trail that improves quality, access and affordability for patients, for employers struggling with health care costs and for the entire state of Washington.

Far too often in health care, patients do not receive consistent, evidence-based care. In much of Washington state and throughout the country, patients presenting with a variety of common ailments receive markedly varied treatments. Unwarranted variation in care delivery is a major barrier not only to quality, but also to efficiency and affordability. If you go to any number of provider organizations in the Puget Sound area for back pain or migraines, for example, you will find significant treatment variation − variation not only from one hospital or clinic to the next, but even within the same organization.

Working with a variety of employers in the Northwest, Robert Mecklenburg, MD, and his colleagues at the Center for Health Care Solutions have been addressing the most costly medical conditions for companies purchasing care on behalf of their workers.

“As physicians, we are all trained a little differently,” says Dr. Mecklenburg, the center’s medical director. “But we know that variation in delivering care is inherently wasteful and not quality care. We have worked with our physicians to appraise the evidence on what works best for a variety of common conditions that affect very large numbers of people. We have identified a highly standardized evidence-based pathway for each condition fully supported by the evidence.”

Specifically, Dr. Mecklenburg and his colleagues have used:

  • The tools of evidence-based medicine to ensure quality
  • Reliable systems to limit needless variation
  • Cost accounting to ensure transparency and affordability

Identifying standardized, evidence-based care for common conditions is proving to be beneficial for three stakeholders:

  • Patients
  • Purchasers
  • The State of Washington

For patients
Virginia Mason believes every patient should receive the best evidence-based care every time. Toward that end, it has identified 10 conditions where standardized, evidence-based care means superb quality at the lowest cost:

  • Abdominal pain
  • Asthma
  • Chest pain
  • Depression/anxiety
  • Diabetes
  • Headache
  • Hyperlipidemia
  • Hypertension
  • Acute respiratory infection
  • Urinary tract infections

Working together, Virginia Mason physicians have assembled the latest evidence on all these conditions. After reviewing the literature, the physicians have applied their own knowledge, experience and expertise to agree on the best way to handle each of these conditions. Improvements, based on new evidence and physician consensus among physicians and employers, are built into the process.

Ingrid Gerbino, MD

Ingrid Gerbino, MD

Why target these conditions? Part of the answer is that they affect large numbers of people every day. From a patient perspective, identifying these conditions and receiving the best possible care means we are providing excellent care.

“We have always provided excellent evidence-based medicine in primary care, but these evidence-based tools – these clinical value streams – make the best of what we are doing more available to the primary care teams,” says Dr. Ingrid Gerbino, a faculty member at Virginia Mason Institute.

Next: How identifying standardized, evidence-based care for common conditions is proving to be beneficial for purchasers and the State of Washington

Moonshine: Fast, inexpensive way to test ideas

“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.

Debbie Cutchin

Debbie Cutchin, director, Virginia Mason Kaizen Promotion Office

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.

Key concepts:

  • 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


lighbulb smallmockup largemockup

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.


Road to transforming health care paved by learning

“Our charge is to study the work at Virginia Mason, figure out what is working and share that with the rest of the world through a rigorous peer-reviewed process.”—  Craig Blackmore, MD

How does an organization aspiring “to be the quality leader and transform health care” pursue that mission? What are the day-to-day, on-the-ground practical steps that move toward that enormous ambition?

Craig Blackmore, MD

Craig Blackmore, MD

Virginia Mason does it in a number of ways. First, the Virginia Mason Institute, which was established six years ago, has a stated goal “to advance quality, safety and value by sharing our knowledge and experience.” To achieve that goal, the institute teaches clinicians and administrators from around the world, at its classrooms in Seattle, how Virginia Mason team members continually apply lean principles to health care. Additionally, the institute’s faculty members travel to other organizations to train health care leaders how to use and sustain Virginia Mason Production System techniques at their own facilities.

Second, Virginia Mason provides regular reports on its improvement work in its blog so that health care leaders on a lean health care journey can find assistance and inspiration.

Third, the Center for Health Services Research, established within Virginia Mason in 2012, is making an impact with its publications.

“Transforming health care means sharing what we have learned with others,” says C. Craig Blackmore, MD, director, Center for Health Services Research at Virginia Mason. “At the Center for Health Services Research our charge is to study the quality improvement work we do here at Virginia Mason and share it through peer-reviewed academic literature – sources people trust as a way of understanding our work. Our charge is to dig deeply, figure out what is working and explain it to the rest of the world through a rigorous peer-reviewed process.”

The beauty of this work is that it helps others improve while doing the same within Virginia Mason. “We learn a tremendous amount about ourselves that helps us get even better,” says Dr. Blackmore. “It helps us understand ourselves – figure out where we are succeeding, where we are challenged and why.”

Article topics range from “Effectiveness of Clinical Decision Support in Controlling Inappropriate Imaging” to “A Tool to Improve Mobility in Hospitalized Patients.”

An article on medication errors is emblematic of the work being published. “Using Lean to Improve Medication Administration Safety: In Search of the ‘Perfect Dose’” appeared in the May 2013 issue of the Joint Commission Journal on Quality and Patient Safety. Authored by Virginia Mason team members Joan Ching, RN; Christina Long, RN; Barbara Williams, PhD; and Dr. Blackmore, the article noted:

Lean interventions were targeted at improving the medication room layout, applying visual controls, and implementing nursing standard work. The interventions were designed to prevent medication administration errors through improving six safe practices: (1) comparing medication with medication administration record, (2) labeling medication, (3) checking two forms of patient identification, (4) explaining medication to patient, (5) charting medication immediately, and (6) protecting the process from distractions/interruptions.

During the course of this work, “trained nurse auditors observed 9,244 doses for 2,139 patients.” The safety results were dramatic:

The number of medication administration errors decreased from 10.3 errors/100 doses at baseline to 2.8 errors/100 doses at final follow-up (absolute risk reduction: 7 violations/100 doses… ). The “perfect dose” score, reflecting compliance with all six safe practices and absence of any of the eight medication administration errors, improved from 37 in compliance/100 doses at baseline to 68 in compliance/100 doses at the final follow-up.

Publishing this research has also significantly increased engagement among Virginia Mason team members.

“We have learned a tremendous amount about how to do research on quality improvement,” says Dr. Blackmore. “People tend to think about research as a creative enterprise, but really it’s like any other process. It is something that can be standardized, and it is a process with a lot of waste. A more standardized research process makes it possible for any team doing improvement to also do research on that subject.”

Dr. Blackmore and his colleagues identified challenges to staff members doing research and then writing about it. A key step was helping research teams figure out exactly what to measure “to understand if what you are doing is effective.”

Dr. Blackmore also worked with many clinicians at Virginia Mason on the best process for writing a research paper. “If you have not done so before, writing for a peer-reviewed journal can be intimidating, and you may not know where to start,” he says. “We created a simple template that helps you start the paper.”

Given the workload clinicians carry, adding research and writing to that can be daunting. Yet the program Dr. Blackmore leads has resulted in a significant increase in the number of research projects and papers being generated at Virginia Mason.

“Our success is attributable to the dedication of the teams doing this work,” he says. “Writing research papers is not usually part of their job description, but because these people are so dedicated they find the time and energy to do some really important papers.”

How are you sharing what you learn with others to transform health care?

From standardization to customization – greater efficiency and respect for people

 “After the analysis was completed, we talked with our OR teams and surgeons, and every person we spoke with acknowledged the tremendous waste in the process.”

– Denise Dubuque, RN

When something is off-kilter in health care, the first to notice the problem – nearly always – are frontline workers. The people who do the work know the work, and recognize when something is askew. That was certainly the case in the Sterile Processing Department.

The pattern repeated itself day after day: Sterile Processing would send carts full of instruments to surgeons for a variety of procedures. And after virtually every procedure, most of the instruments sent to Sterile Processing for cleaning had not been used.

Denise Dubuque

Denise Dubuque

“The team members at the sink decontaminating surgical instruments noticed that a majority of the instruments coming back to us from the ORs had not been used, yet they had to re-clean, decontaminate and sterilize all of those items,” says Denise Dubuque, RN, administrative director, Surgical and Procedural Services.

This struck the workers as a huge waste of time and effort. So they acted. A number of team members proposed Everyday Lean Ideas (ELIs) intended to mitigate the waste of time and work. But the problem was so large and complex that they realized small fixes here and there weren’t going to help very much.

Sam Luker

Sam Luker

Sam Luker, director, Sterile Processing Department, knew his team members had identified a serious challenge, so he and Dubuque initiated a 3P improvement event (which occurred in February 2013). 

“We were on a lean journey and, in our early years, we focused a lot on standardization,” says Dubuque. “We did that because we believed the best product for the surgeon was a standardized set of instruments, so we produced the same set every day for each specialty.”

But the essential question raised during the 3P was how could the team shift from standardization to customization? How could they give each surgical team just the instruments they needed – no more, no less – for a particular case?

The answer proved to be a build-to-order approach for surgical instrument cases. The initiative started with good data collection – asking scrub techs in the operating room to list every instrument a surgeon used during a particular procedure. Techs did this by checking a box on the instrument list that accompanies each set of surgical instruments.

This process would be repeated five times for each surgeon performing a particular procedure. Once the data had been collected and analyzed, the problem emerged in striking numbers:

  • On an average day, Virginia Mason conducted 70 to 75 surgical procedures.
  • For each procedure, the Sterile Processing team created 13 instrument sets.
  • Each of the 13 sets contained 53 instruments.
  • This amounted to 52,721 individual instruments scrubbed and sterilized per day.

And the analysis showed that 70 percent of these instruments were returned to Sterile Processing unused.

“After the analysis was completed, we talked with our OR teams and surgeons, and every person we spoke with acknowledged the tremendous waste in the process,” says Dubuque.

Armed with new data, the Sterile Processing team assembled new sets of instruments for each surgeon conducting a particular procedure. This was inherently complex since multiple surgeons on a number of different service lines all had their individual preferences for what instruments to use. They had been able to select their preferences from the large, standardized instrument carts, but the goal now was to provide them only with the instruments they needed – no more, no less.

And that is what the teams constructed – instrument sets tailored to the needs of a particular surgeon performing a particular procedure.

“In a lot of these cases, there were 70 percent fewer items going up to the OR,” Dubuque says. “It was really a great process that eliminated so much waste.”

From the start, everyone was concerned about a what-if scenario – what if something goes wrong in the OR and the customized set of instruments does not contain what is needed for unforeseen circumstances?

“Everyone shared the same concern – surgeons, techs, nurses, the Sterile Processing team,” says Dubuque. “Everybody wanted to make sure that every patient had the instruments needed for their operation. We needed to ensure that our surgical team had what they needed.”

The solution was a backup cart containing a full, original set of instruments – everything a surgeon might need in the most challenging situation.

“We created contingency plans to allow redundancy and still support the OR,” says Luker. “So if something is dropped on the floor, the surgeon just calls for the backup cart, which is in the OR on standby.”

The backup has not been used much. But over time the customized sets have been modified. “If the OR team sees a need for a certain item, they let us know and we add it back to the set. We can add and delete items as we go.”

What are the results of this initiative?

Greater efficiency, of course. “Previously, they had to set up so many instruments in the OR suite it was taking 24 minutes just for setup,” says Luker. “With the new build-to-order sets, setup now takes two minutes and 30 seconds. We are decontaminating many fewer instruments, assembling fewer sets, storing less, lifting less and transporting less.”

The average assembly time for a neuro instrument set decreased from 34 minutes to 22 minutes. The average number of instrument sets/case carts decreased from 13 to three (while the average number of instruments in each set increased from 53 to 60).

But something else was achieved with this initiative – perhaps less tangible than the efficiency gains, but just as meaningful. And that involved the issue of respect for people. When Dubuque first recognized the unnecessary burden of work on the Sterile Processing team, she saw it as deeply disrespectful to the workforce.

“We believe that the build-to-order initiative is about respect for people,” she says. “I have passion to come to work every day as a leader, saying: How can I help this team be successful? Because every day that goes on that we’re not getting to that goal of build-to-order we’re disrespecting the team.”

What work on your team could be done differently to improve respect for people?

Deep cultural connection: Respect for people + patient safety

Having served as CEO of one of the world’s largest corporations (Alcoa), and as Secretary of the Treasury of the United States, Paul O’Neill knows something about leadership. A while back, O’Neill was asked to write something about leadership, and he took the assignment quite seriously.

Paul O'Neill

Paul O’Neill

“I spent a lot of time thinking about what I had done for the previous 60 years and how to capture the essential ingredients of real leadership,” he says. O’Neill came up with three clear points focused not on the C-suite, but on what workers within an organization say about their work.

He says organizations with the best leadership – “with the potential for greatness” – are those where every employee can say yes without reservation to three questions:

  • Can I say every day I am treated with dignity and respect by everyone I encounter without respect to my pay grade, or my title, or my race, or ethnicity or religious beliefs or gender?
  • Am I given the things I need − education, training, tools and encouragement – to develop my full potential so I can make a contribution to the organization that gives meaning to my life?
  • Am I recognized and appreciated for the work I do?’’

O’Neill’s questions go directly to a foundational element of the Toyota Production System. While the Toyota approach is commonly viewed as lean management methods and tools, there is more to it than that. A broader view of the Toyota system recognizes that true lean management must embrace “respect for people” principles, as well.

For much of the Virginia Mason journey in adapting the Toyota Production System to health care, the focus had been on the implementation of lean methods and tools. In this work, the teams achieved a significant level of expertise. But there was an aspiration to grow stronger on the people side of the ledger. Part of the reason for this was the belief that greater respect for people within the organization would lead to a safer environment for patients and accelerate this important work.

What does respect for people have to do with patient safety? Consider the culture within a Toyota vehicle assembly plant where every worker is empowered to stop the line if he or she sees a defect in a vehicle. Defects are corrected in the moment, and workers are encouraged and celebrated for identifying and correcting defects.

Virginia Mason leaders adapted the Toyota approach and instituted a Patient Safety Alert system in which every team member is encouraged and empowered to “stop the line” and call in a Patient Safety Alert whenever they see any possible threat to the safety of a patient.

The system worked well for a number of years – Virginia Mason is one of the safest health care organizations in the world − but leaders knew it could be more effective if everyone in the organization truly felt comfortable stopping the line.

In 2011, Virginia Mason leaders invited Boston surgeon Lucian Leape, MD, to visit Seattle and work with them on the respect issue. Dr. Leape is internationally known for his expertise on patient safety, and one of his core beliefs is that Paul O’Neill’s three questions are essential to the kind of culture where patient safety thrives.

Respect and safety, Dr. Leape told the Virginia Mason teams, are joined at the hip. Both are cultural issues. Do workers at all levels feel comfortable speaking up or is there reluctance for fear that management won’t have their backs? Did some workers see the Patient Safety Alert system as punitive? Did they fear getting colleagues into trouble?

Leape made it clear that when doctors, nurses, technicians, pharmacists and many others are reluctant to speak up, patients are at risk. He emphasized several points from his articles in Academic Medicine where he argued that “a substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect. Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.”

Lynne Chafetz, Virginia Mason senior vice president and general counsel, considered Dr. Leape’s visit and the themes he enunciated to be nothing less than “a seminal moment in our journey.”

A sustained effort at Virginia Mason to embed respect more deeply in the culture has had an impact. Catherine Potts, MD, chief, Primary Care, says she sees a greater willingness among team members to speak up when they perceive something might be off kilter. “People now realize that they can speak up freely without fear of retribution; that there will not be anything like a shaming event.”

Engaging team members in improvement work is a key part of demonstrating that respect for people is real and not lip service. Virginia Mason’s Everyday Lean Idea system, in which team members are encouraged to make improvements in their work, is one such method. Another is the commitment to daily management, where leaders are present on the genba, where the work is done – teaching, guiding and coaching – and working with team members to improve daily work by reducing waste.

Charleen Tachibana, RN, hospital administrator and chief nursing officer, adds that the best interests of the patient are paramount “when you create a culture where people can feel safe to say what needs to be said, to be transparent, to call out issues, to bring forth problems, to challenge peoples’ thinking in respectful ways.”

When O’Neill reflects on the power of his three questions, he notes that they derived naturally “from my years of watching the behavior of colleagues, subordinates and bosses and trying to distill what is most likely to release the human energy in an organization.”


Foundational Behaviors of Respect

With widespread feedback and thoughts from workers throughout Virginia Mason, the organization identified 10 foundational behaviors of respect:

  1. Listen to understand. Good listening means giving the speaker your full attention. Nonverbal cues like eye contact and nodding let others know you are paying attention and are fully present for the conversation. Avoid interrupting or cutting others off when they are speaking.
  2. Keep your promises. When you keep your word you show you are honest and you let others know you value them. Follow through on commitments and if you run into problems, let others know. Be reliable and expect reliability from others.
  3. Be encouraging. Giving encouragement shows you care about others and their success. It is essential that everyone at Virginia Mason understand their contributions have value. Encourage your co-workers to share their ideas, opinions and perspectives.
  4. Connect with others. Notice those around you and smile. This acknowledgement, combined with a few sincere words of greeting, creates a powerful connection. Practice courtesy and kindness in all interactions.
  5. Express gratitude. A heartfelt “thank you” can often make a person’s day and shows you notice and appreciate their work. Use the Virginia Mason Applause system (an internal recognition program), a handwritten note, verbal praise, or share a story of “going above and beyond” at your next team meeting.
  6. Share information. When people know what is going on, they feel valued and included. Be sure everyone has the information they need to do their work and know about things that affect their work environment. Sharing information and communicating openly signals you trust and respect others.
  7. Speak up. It is our responsibility to ensure a safe environment for everyone at Virginia Mason; not just physical safety but also mental and emotional safety. Create an environment where we all feel comfortable to speak up if we see something unsafe or feel unsafe. 
  8. Walk in their shoes. Empathize with others; understand their point of view, and their contributions. Be considerate of their time, job responsibilities and workload. Ask before you assume your priorities are their priorities.
  9. Grow and develop. Value your own potential by committing to continuous learning. Take advantage of opportunities to gain knowledge and learn new skills. Share your knowledge and expertise with others. Ask for and be open to feedback to grow both personally and professionally. 
  10. Be a team player. Great teams are great because team members support each other. Create a work environment where help is happily offered, asked for and received. Trust that teammates have good intentions. Anticipate other team members’ needs, and clearly communicate priorities and expectations to be sure the work load is level loaded.


Network brings quality, value employers need for better care at lower cost

“The Puget Sound High Value Network … gives employers the value they seek – high quality, cost-effective care at a reduced unit cost to businesses.”

- Gary S. Kaplan, MD

PSHVNThere are countless lessons from the Virginia Mason experience during the past dozen or so years, but the lesson that transcends all is always putting the patient first. When the patient is always the center of attention, the quality of care, access, and affordability all improve.

The patient-first mantra extends well beyond the exam room and the hospital all the way to decisions about selecting partner organizations with whom to affiliate. That is why the creation of the Puget Sound High Value Network is one of the most important breakthroughs in the Washington marketplace. Virginia Mason is a founding member of this new network that includes a highly select group of provider organizations that have made the cultural leap forward to put patients first in all things at all times.

This patient-focused approach is very different from organizations where the major driver is market dominance and the bottom line.

“The Puget Sound High Value Network is game-changing,” says Virginia Mason Chairman and CEO Gary S. Kaplan, MD. “The network gives employers the value they seek – high quality, cost-effective care at a reduced unit cost to businesses.”

Every member of the network has significantly reduced contract rates with First Choice Health, thus providing the value that companies are seeking in this challenging new health care environment.

Dr. Kaplan says that a fundamental question “is not ‘how big do we need to be?’ but ‘how good can we be?’” For patients and their families there is a profoundly important shift from simply accumulating or rewarding scale to aligning philosophies and operating with shared systems, values and priorities.

“The Puget Sound High Value Network is an example of how to enable geographic coverage and a full breadth of services by knitting together a group of like-minded providers, gaining the advantages of scale without the concentration of providers that, in the end, has proved so detrimental in other markets.” 

While the health care marketplace is experiencing turbulent times, it becomes increasingly clear each day that the future is about value; value defined as the highest quality care at the lowest cost. That is what employers want and that is precisely what the new network is designed to deliver.

One way to define value is the Triple Aim, a construct of the Institute for Healthcare Improvement, defined as:

  • High quality individual care
  • High quality care for populations of patients
  • Reducing costs

This definition of value is the Holy Grail for the Puget Sound High Value Network.

During a recent broker symposium in which the network was officially announced, Curtis Taylor, chief marketing officer, First Choice Health, which administers the program, said, “The Puget Sound High Value Network collaborative is a group of unaffiliated industry-leading hospital and medical group professionals forging a ground-breaking relationship to serve community employers and their employees. This is an ACO (Accountable Care Organization) for employers.”

“The future is now!” added Jonathan Hensley, President, Capital Benefit Services. “With the market deployment of the Puget Sound High Value Network, the future is now defined by providers and health care organizations that deliver sustainable value, which I define as quality care plus superior patient experience plus lower total cost of care.”

During the past couple of years, both Virginia Mason and EvergreenHealth have implemented the Puget Sound High Value Network approach with their employees. Says Hensley, “While the data is too immature to declare absolute success, the early results for EvergreenHealth and Virginia Mason’s employee benefits program are incredibly promising. They’re setting the example that I expect many employers to follow.”


Puget Sound High Value Network

Joining Virginia Mason in the new network are EvergreenHealth, Franciscan Health System, Lakeshore Clinic, Overlake Medical Center, Edmonds Family Medicine and The Everett Clinic. All participants are aligned philosophically and share a commitment to collaborate on ongoing clinical initiatives focused on delivering quality, efficiency, value and coordinated care to patients.

The scope of the network’s footprint supports employers by reducing their health care costs while enhancing the health and well-being of employees and their families where they live and where they work.

The network stretches from Tacoma to Everett, across eight hospitals, 164 clinics, 23 ancillary provider locations, and through 2,835 specialty and primary care providers.

Why are health care organizations turning to networks like this?
In response to changes in the nation’s health care system, providers and organizations are aligning to develop ongoing clinical initiatives focused on delivering quality, efficiency, value and coordinated care. In these models, participating health care organizations and providers manage care across specialties and develop contracts with payers to improve quality while controlling costs. 

How is PSHVN different from other health care networks or benefits plans?
Participating providers and health care organizations are selected for demonstrated commitment to quality, and offer cost savings to employers between 10 to 13 percent over competing options. 

Who benefits from this network?
Employers benefit from increased access to a comprehensive network of care providers at a reduced cost, and participating providers can better coordinate patient care with a broad network of specialists who share a commitment to quality. PSHVN providers are selected for demonstrated quality outcomes and a commitment to reducing costs, and for providing patients access to the participating providers’ hallmark high-quality, patient-centered care, but at a lower cost.

How does PSHVN achieve cost savings?
Network members are committed to achieving lower costs through more seamless coordination of care, and are able to achieve other economies by working together to manage care. 

Will employees and their dependents have to travel a greater distance to see specialists in the PSHVN network?
No. The network reaches from Olympia to Everett and includes more than eight hospitals, 163 clinics, 24 ancillary providers and 2,875 specialty and primary care providers, so employees in the Puget Sound region will find participating providers near where they live and work. 

What providers are included in the PSHVN network?
Participating organizations include CHI Franciscan Health, Edmonds Family Medicine, The Everett Clinic, EvergreenHealth Partners, Lakeshore Clinic, Overlake Medical Center and Virginia Mason.

Who oversees PSHVN?
First Choice Health is the network administrator and offers benefit administration and support for employers and employees through customer service, online member and employer portals and more. 

What organizations can offer PSHVN to employees?
PSHVN is available to self-insured organizations with 50 or more employees through First Choice Health, the plan administrator. 

Can coverage be customized?
First Choice Health will work with larger self-insured organizations to customize network offerings. For smaller groups, First Choice Health offers a comprehensive standard offering that connects employers and employees to PSHVN.




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