How does standard work lead to better patient safety?

By Eli Quisenberry, Director, Kaizen Promotion Office, Virginia Mason

We’re hurting people in health care more than we think.

Providers and other health care specialists frequently balance the art and the science of medicine. While many clinical studies and evidence of best practices guide our work, we are still dependent on medical specialists and staff to use their best critical thinking, judgment, and knowledge gained through experience to deliver high-quality health care. The challenge is that health care is complex and often chaotic, and people make mistakes. What’s more, variability in our processes leads to variation in patient care—and this is a huge problem. In health care, we know that no mistake or variation should be acceptable if it leads to the potential to harm a patient.

So the question becomes this: What can we do to prevent employees from causing harm to patients? How can we mistake-proof the way we deliver health care? One way that Virginia Mason makes processes safer is the creation of standard work.

Creating standard work

The first thing to realize about standard work is that it’s about efficiency, accuracy and safety and not about making workers into robots. It’s about making sure the patient is first in every part of the health care process—and that takes creativity, teamwork, and testing. It’s about asking at every step, “What is the best way the customer wants me to do this?” It’s about making routine the elements of care that we know will benefit the patient.

With standard work, the employees who are doing the work are key players in developing the standard work process.

That’s why it’s important that health care employees learn to analyze their processes, see waste, and prevent mistakes. And that’s why standard work becomes an opportunity to help employees do a better job. Instead of learning by mistakes, new employees can enter a process and quickly learn to use the best practices of those who developed the standard work.

What is standard work?

Creating standard work involves three parts:

  1. Deciding what the standard is, then creating and testing it. This is where the team analyzes the problem, studies the current work flow, and comes up with a solution that would be better from the patient’s point of view. Then the team uses the PSDA (Plan, Study, Do, Act) method to test and refine it. Remember: this is a learning journey; it’s where the rubber meets the road. This is where you find out if five different employees can use this standard work to produce results with no defects.
  2. Getting the standard work into place, and deploying it. This is where good training, open communication and follow-up with staff are crucial.
  3. Continuously improving the work. With standard work, you never rest on your laurels. You continue to audit the work and make enhancements to make it even safer for patients.

Case study of standard work

Standard work is useful whenever a process is not 100% free of defects. Is this too high a standard? Virginia Mason’s laboratory team didn’t think so.

When team members evaluated the way they labeled specimen tubes, they looked critically at their successive check process, which is completed on the check-in bench in the laboratory’s central processing department. They discovered that in a one-month period, the process failed to catch three mistakes. With more than 30,000 patient orders per month, this meant the process had a 0.01% defect rate. The team determined that the defect rate—though deemed acceptable or even very good in other health care organizations—wasn’t acceptable for Virginia Mason’s patients, who wanted zero mistakes. They knew that a lab mistake could translate to a delay, misdiagnosis or even the wrong treatment in a patient’s care.

So the team analyzed the process, eliminated waste, introduced standard work and used the concept of TWI (Training Within Industry) instruction to ensure that all team members were fully trained in the new standard process. The standard work they developed helped the team achieve zero defects in the next six-month period, and it defined the standard way that all new team members are trained today.

Why was this implementation successful?

The department’s leader, recognizing that creativity is good for employee engagement and skill-building, involved the employees in the investigation of the existing process and the creation and testing of a brand-new process. The leader said to them: “Is there a ‘best way’ for this process? How can our team bring the concept of continuous improvement to the table?” and then encouraged them to speak up with their ideas and made sure they had time to conduct analyses and testing between meetings.

All team members knew that the goal was to make this process more efficient, and therefore, safer and better for patients. They knew that to have a defect-free process, everyone needed to follow the new process, every time, in the same way.

And after the standard work was developed, deployed and refined, the employees were freed up to use creative thinking to investigate other systems and to devise new ways to improve them. Whenever employees developed new standard work, they became more confident and better skilled—really mastering their jobs and growing in their understanding of new aspects of their work every day. And this is because every team member asked, “How can I make this work better for our patients?”

To learn how to create health care processes with zero defects, register for our course Lean Training.

To learn more about creating standard work that engages and motivates employees, register for our course Engaging Staff in Daily Improvement.

Rhonda Stewart

Eli Quisenberry, MBA, is director for the Kaizen Promotion Office at the Virginia Mason Medical Center. He partners with leaders, staff, and teams across the medical center, applying the Virginia Mason Production System principles as they work to transform health care and achieve the organization’s vision as the quality leader. Eli has worked in health care administration for over 10 years and is a certified rapid process improvement workshop leader and a Training Within Industry trainer.

“How can my organization use daily management to create a culture that puts the patient first?”

By Rhonda Stewart, Virginia Mason Institute Faculty

Engaging StaffFor leaders who want to make progress in improvements across an organization, the challenge can seem insurmountable. How can you get executives, providers and staff to adopt a mindset of continuous improvement? How do you even get started?

A good place to begin is to reflect on your organization’s culture. What would it take for you to have a culture that puts the patient first? Are you thinking it would be too hard on your organization to make the necessary changes? Are you feeling powerless to bring about a meaningful change that would make a difference? Let’s look at some key aspects of a culture that is truly patient-focused.

  • In patient-centered organizations, staff members speak up about their own near misses. In these organizations self-reporting is essential because it can expose gaps in the process where patient safety might be jeopardized. In fact, leaders encourage self-reporting because it can instigate an investigation of the process and the formation of an improvement event to protect patients.
  • Staff members speak up about others’ mistakes. Staff feel empowered—and eventually compelled—to speak up. This is true for any employee in the organization. Those who speak up for patient safety are met with support, not retribution.
  • Staff members talk to each other to uncover and resolve problems. They don’t point fingers; they don’t say to another team member, for instance, “You always bring me the patient too early.” They say, “When the patient is brought to me, I’m not ready to provide care and then the patient has to wait. What can we do as a team to make this process seamless for the patient?” Leaders support this teamwork.
  • The idea generators in your organization are staff members. In organizations that are not patient-focused, staff members won’t regularly think of ideas—or speak up about them—to improve patient safety or the patient experience. They just do the best they can with the processes they were trained to use. In these organizations, leaders want satisfied patients, but they don’t ask their staff to be a part of improving the system of delivering care. In patient-focused organizations like Virginia Mason, however, leaders ask staff members to come up with ideas to improve patient care, and then the staff members own those ideas and work independently or with a team to test them and bring them to life.
  • Within departments, work processes function similarly for all the department’s providers. In organizations that are not patient-focused, the bigger picture is lost, and medical assistants throughout the organizations say, “My provider does things differently.” Patient-focused organizations are willing to challenge the status quo to make things better for patients across the organization. They know that when variation is reduced, the service becomes not only consistent and more predictable, but also feels safer from the patient perspective.
  • Staff members listen to other perspectives and are willing to integrate them into their own thinking. They’re willing to shadow other staff members and work collaboratively to make the new process function well for the whole team. They know that health care that is truly patient-focused involves collaboration with many staff members involved in the patient visit to make patient care seamless and make it truly safe.
  • Teams make their work visible, transparent. They have production boards showcasing their health care processes so other teams can spot defects that may impact patient satisfaction. Teams know that working well with other teams is essential to an organization that wants to improve the patient care process.

Being patient-focused means that your organization works constantly to do what is best for the patient—to improve patient safety and the patient experience. It means understanding what is not value-added in patient care and working relentlessly to make the patient experience better. To leaders who say, “Where do I begin changing something like culture?” I would say, “Look at one of these key concepts. What can you do to promote this in your organizations?” Small steps in transforming your culture can make a difference—for you, your staff and, most significantly, your patients.

Learn more about leading differently to bring about change in your organization in our course Engaging Staff in Daily Improvement.

Rhonda StewartRhonda Stewart, who is certified in the Virginia Mason Production System, has led improvement events throughout ambulatory, specialty and hospital value streams, including the PACU/Recovery areas. In her former role as Virginia Mason’s director of finance, she led improvement events in accounting, analytics, billing, payroll and supply chain.

“We’re moving to a new space. How do we make things better?”

Using teams to create a new patient experience

By Chris Backous, MHA, Virginia Mason Institute faculty

A team encouraged to test ideas can create entirely new ways to improve patient care.

A team encouraged to test ideas can create entirely new ways to improve patient care.

You just found out your health care team has the opportunity to move to a new space. How do you make it work? Is it possible to make it better?

If you’re like many health care teams, being told you’re moving to a new space creates a challenge. Your current space works because you’ve made it work—because you’ve had to make it work. And for most health care employees on the team, the space was inherited, along with some processes, too. In many ways, it’s not a very functional space, and for years patients have been waiting in the waiting room for longer than they want to—longer than you want them to, even on the best of days—and there hasn’t been anything you could do about it.

“Furniture is what people buy. Flow is what people create and what adds value to your organization.”

– Chris Backous, MHA

But now you get to start over in a new space. It could be a brand-new space; it could be a repurposed space with a different shape, and a different look and feel. How can you make this space an opportunity to change the way you and your team work together and to change the way you all work with patients?

  1. First, and most important, challenge yourself to think differently. Imagine what it would be like to really change things with breakthrough ideas.
  1. Then ask, how does the current space function from the patient perspective? What are the opportunities for improvement in the new space? What are the unnecessary wastes and processes? Should health care workers be doing different types of work, or the same work in new and different ways? What if, for instance, medical assistants had more responsibility so that physicians could spend more time with their patients?
  1. Use the 3P method—production preparation process—to allow you to invest your time wisely and think differently.
  1. As a team, identify and eliminate waste. Ask, “What wastes should we focus on first?” or “Where are the biggest rocks in our shoes?”
  1. Involve your team and get them excited. Help people move from their usual ways of doing things to inventing something new. For example, if you know that patients wait a long time in waiting rooms, talk about what you can do to change your process. What if your organization didn’t have waiting rooms at all? What if it was illegal to make patients wait? How could your team create a process in which “no need for waiting rooms” became a reality? Once the team can imagine this, then they have a new process to reinvent, and it becomes exciting. Without imaginative thinking, the best you might hope for is just a smaller waiting room in the new space. Your team can do better.

    When I work with organizations using the 3P method, at first the team struggles to come up with one or two ideas. It can be hard to come up with original thinking and say these ideas out loud. People worry, What if my colleagues think my ideas are ridiculous? But every time, as the class progresses and the confidence builds, the team develops a ton of ideas. Before long, they’re testing out their new ideas within minutes using Legos and they’re doing simulations. It’s amazing!

  1. Look at other spaces for ideas. Borrow shamelessly, but make it your own. Health care leaders and providers from around the world tour Virginia Mason week after week, every year, to find out how we’ve transformed our space to improve patient safety and the patient experience. We encourage them to get inspired by our use of space for our patients, and we want them to do the same for their unique patient populations. We want their space to be as great for them as ours is for us.
  1. Give your team time for out-of-the-box thinking. It’s not natural or easy. It takes work; it takes practice; it takes time.

Remember, designing a new space is not about new furniture that pleases your staff and patients. Furniture is what people buy. Flow is what people create and what adds value to your organization. If you can’t design for new flow processes, your new design becomes just a different—but not better—patient experience. You can do better for your patients and your staff. You can create a design that works for your patients, your staff and you, one that your team owns and values, one that enhances everyone’s experience. I encourage you to make it happen!

Do your teams struggle to break out of current thinking about space? What helps?

Learn more about creating a patient-centered design in our Lean Facility Design Seminar.

Learn more about improving flow in our course Creating Flow in the Ambulatory Setting.

Chris Backous, MHA

Chris Backous, MHA

Chris Backous, MHA, is certified in the Virginia Mason Production System and 3P facilitation. Before joining the Virginia Mason Institute, Chris was a member of the Virginia Mason Kaizen Promotion Office, where he led numerous improvement activities on facility design. Chris has influenced and inspired individuals, organizations, and national health care systems to integrate lean processes into their improvement and transformation efforts, to engage teams to use innovative thinking and to create new processes and spaces.

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?


Get every new post delivered to your Inbox.

Join 5,991 other followers