The power of learning ‘systems thinking’

“We strive to give residents insight into their critical role in system improvement.”
-Brian Owens, MD

The voices of two young physicians speak eloquently about the value of systems thinking in health care.

Residents Camille Johnson, MD, internal medicine, and Carlo Milani, MD, preliminary medicine, find significant value in learning about systems thinking as part of their training. “At Virginia Mason, systems thinking starts with a very different culture,” says Dr. Johnson. “There is a pervasive egalitarian culture that has to be there for process improvement to work. To me, that is one of the bedrocks of process improvement − everyone has to feel safe voicing their perspective.”

Dr. Johnson has dug into learning about systems processing by taking a Virginia Mason Production System for Leaders course, a rigorous initiative required for all leaders within the organization. “The course focuses on lean processes, applying lean tools to a process you are trying to improve,” she says.

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Camille Johnson, MD

“A lot of the principles look really simple, and if you just did the classroom part of it you would come away thinking, ‘this is so obvious.’ But when you try and apply it – that is when the real learning happens because it is messier and more complex than it appears. It’s about change management, and that is a skill you need to practice and get mentored on. You cannot just learn this work in a classroom.”

Dr. Milani said he often hears people say that health care is unique and no comparisons from other industries to health care work are possible. “I don’t buy it,” he says. “Patients aren’t cars, it’s true, but the process by which we care can be standardized and improved upon. And zero mistakes is not too lofty a goal.”

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Carlo Milani, MD

He adds, “Whatever errors occur in a system, that system is perfectly designed to permit those errors in the frequency and manner they occur,” he says. “So with VMPS you have to design things to be error-proof.”

The importance of measurable standards is one of the key lessons he has learned, says Dr. Milani. “If everybody has a different way of doing something, there is no way to tell if we are doing it correctly or to measure how to do it better. When something is systems-based, you can implement standard work so there is alignment throughout the organization.”

Brian Owens, MD, director, Graduate Medical Education, has found that residents consider Virginia Mason “a great place to learn systems thinking. Health care is a complex undertaking in which people, processes and technologies interact, hopefully to the benefit of the patient. Traditionally, health care providers have seen themselves as ‘running’ the system, responsible for system performance, controlling the system. We want providers to accept their role as an integral part of the system that improves care provided to each patient, every time. And that means providers must trust and respect the ability of all components of the system to positively influence care delivery.”

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Brian Owens, MD

Residents learn systems-based practices in a variety of ways. It starts with quality improvement and patient safety systems approaches built into the students’ two-and-a-half-day orientation. There is also a month-long, systems-based practice elective that a sizable number of residents take each year. Classroom work sets the stage for a deeper learning by engaging in an improvement event, such as a Rapid Process Improvement Workshop or other kaizen event.

Two years ago a surgical resident was so enamored of the systems approach that she opted to take a year-long fellowship in quality improvement and patient safety.

“We want every resident who graduates from a core program at Virginia Mason to have participated in kaizen activity before graduation,” says Dr. Owens. “But we are looking for more than resident participation in kaizen. We strive to give residents insight into their critical role in system improvement by providing opportunities for them to work on interdisciplinary teams to improve components of the system that positively influence care delivery and the patient experience. This is the preparation they need to be the next generation of physician health care providers.”

 


Linda Hebish, administrative director, Kaizen Promotion Office, on behaviors that accompany systems thinking: “There are many leadership and staff behaviors we are attempting to refine and develop. But, in essence, the one outcome we are trying to create is coaching and mentoring staff to become problem identifiers and solution generators by asking open ended questions.’’


 

England’s NHS patient safety: getting our inspiration from Virginia Mason

Guest Post by Robin Twyman, Consul (Business and Government Affairs), UK Government Office, Seattle

Virginia Mason Chairman and CEO Gary S. Kaplan, MD, shares information on the organization’s Accountability Wall with British Secretary of State for Health Jeremy Hunt. (Photo courtesy of Robin Twyman.)

Virginia Mason Chairman and CEO Gary S. Kaplan, MD, shares information on the organization’s Accountability Wall with British Secretary of State for Health Jeremy Hunt. (Photo courtesy of Robin Twyman.)

This week, British Secretary of State for Health Jeremy Hunt delivered a major health policy speech at Seattle’s Virginia Mason Hospital, announcing a new challenge for the National Health Service in England. At face value, that seems a bit odd. Why deliver a speech almost 5,000 miles away from those it will affect? Because it’s here that we found the answer to the problem we want to solve in England: better patient safety. 

In March 2009, the Healthcare Commission published a report into the Mid Staffordshire hospital which revealed cruelty, neglect and serious failures there in patient care from 2005-2008. A subsequent report in 2013 by Robert Francis QC concluded that the Mid-Staffordshire hospital had a culture which focussed on business, not patients; gave more weight to positive results than spotting issues of concern; measured metrics which did not focus on the effect on patients; had too much tolerance of poor standards; and assumptions that performance monitoring was someone else’s responsibility. 

Ten years ago, Virginia Mason experienced its own patient safety tragedy, with the tragic death of Mrs. Mary McClinton. It confronted the challenge and turned things around. Under CEO Dr. Gary Kaplan’s inspired leadership, Virginia Mason is now one of the safest hospitals in the world. So Mr. Hunt wanted to come and see it for himself. He was accompanied by Professor Sir Mike Richards (Chief Inspector of Hospitals, Care Quality Commission) and Mike Durkin (Director of Patient Safety, NHS England), both key senior officials in overseeing patient safety in NHS England. 

Over two days this week, Dr. Kaplan and his team taught us about the Virginia Mason Production System, and the transparency and safety checks which “stop the line.” We visited the Jones Pavilion Orthopedic Unit, the Kaizen Promotion Office Accountability Wall, saw the Med Tele Andon System in operation, and learnt about adopting technology, electronic medical records, and flow to ensure patient safety. Along the way, we witnessed commitment to delivering appropriate and defect-free medical care, and the elimination of waste. And saw “better never stops.”   

This all set the scene for Mr. Hunt’s speech on 26 March at Virginia Mason’s Volney Richmond Auditorium. The speech announced a new ambition for the English NHS to reduce avoidable harm by a half, reduce the costs of harm by one half and in doing so, contribute to saving up to 6,000 lives over the next three years. No one underestimates the challenge of delivering change in 260 hospitals employing 1.3 million people. But it can be done. We have the advantages of a unified, national system, a dedicated NHS staff, and improvements in surgery, hospital infections and the safe use of medicines to build upon. 

Budgets are constantly under pressure, and so the issue of resources comes up. Can we afford to do all this? We believe this is a false argument, both ethically and economically. Safety is not a luxury that we’d like to be able to afford one day. It’s what patients expect now. Mr. Hunt also argued in his speech that unsafe care ends up being more − not less − expensive. Both in terms of litigation and bed days. Our visit to Virginia Mason reinforced our impression that the best hospitals deliver safe care on tight budgets. 

Some of the specific measures that Mr. Hunt announced in his speech include: 

  • an NHS campaign for our hospitals to Sign up to Safety (12 hospitals have already signed up);
  • monitoring by the Chief Inspector of Hospitals;
  • the recruitment of 5,000 safety champions as local safety change experts and evangelists;  
  • encouraging a culture of openness and transparency, empowering staff to “stop the line” when problems occur; and
  • a duty of candour to tell patients if they have been harmed.  

But, as we saw with Virginia Mason’s Accountability Wall, it all needs to be monitored effectively. So NHS England will be developing a new and more reliable system to measure actual harm and allow comparisons. 

Mr. Hunt and UK health officials have been privileged this week to come to Seattle to see one of the world’s safest hospitals. The challenge begins now for us to deliver Mr. Hunt’s vision for the NHS to be the world’s safest health care system.  


 

Robin Twyman

Robin Twyman

Robin Twyman has been the UK’s Consul (Business and Government Affairs) in Seattle since January 2013. He has spent the last 27 years on diplomatic assignments in America, Africa, Europe and the Middle East. His assignments at home and abroad have covered a range of foreign policy, security policy and commercial diplomacy duties. On his London assignments, Robin has managed the UK’s Afghanistan Counter Narcotics programme, led the FCO’s Falkland Islands team, and served as a Foreign Office spokesman.

Terrible tragedy – and powerful legacy – of preventable death

“Our board said that if we cannot insure safety of our patients we shouldn’t be in business.”

-Cathie Furman, RN

 The course of history for Virginia Mason was forever changed Nov. 23, 2004, when Mrs. Mary L. McClinton died due to a preventable medical error. Mrs. McClinton was 69 when she was treated for a brain aneurism at Virginia Mason where she was mistakenly injected with chlorhexidine, an antiseptic. 

How could such an error happen? Confusion over the three identical stainless steel bowls in the procedure room containing clear liquids − chlorhexidine, contrast dye and saline solution. 

There is no greater tragedy within a medical center than when a patient dies due to a preventable error. The terrible truth is that such deaths are not uncommon. The Institute of Medicine report, To Err Is Human (1999), estimated that as many as 98,000 Americans die each year from preventable errors. 

The death of Mrs. McClinton was first and foremost a terrible tragedy for her family and community. She was a beloved, widely respected figure. 

But her death was also the most severe test a medical center can face, for the question becomes, what do you do? What is your response to this unthinkable event? 

Virginia Mason promptly disclosed the fact that a mistake had been made in Mrs. McClinton’s case that caused her death. It is a sad understatement to say that this level of transparency was – and for the most part, remains – rare in the world of health care. The disclosure ran directly counter to the cultures of secrecy in which many provider organizations have cloaked themselves. 

Virginia Mason then took a radical step: It set aside its dozen or so organizational goals and declared that, going forward, it would have a single goal: To insure the safety of our patients through the elimination of avoidable death and injury. 

Cathie Furman

Cathie Furman, RN

“Her death galvanized us,” says Cathie Furman, RN, senior vice president, Quality and Compliance. “Our board said that if we cannot insure safety of our patients we shouldn’t be in business.” 

Safety remained the single annual organizational goal for three years after Mrs. McClinton’s death. During that time, Virginia Mason made quantum leaps forward in creating a safer environment. This work was and remains guided and inspired by the memory of Mrs. McClinton. 

“On the one-year anniversary of her death, we came together as an organization to memorialize her,” says Furman. “Her family joined us that day, and we committed then to setting aside a day every year to reflect on improvement of the past year in her memory and honor. It is the single most important day of the year at Virginia Mason.” 

The Mary L. McClinton Patient Safety Award is now the most coveted accolade at Virginia Mason. Teams compete for it each year by submitting a rigorous application describing their safety-related work. There is a set of explicit criteria and scoring legend that a multidisciplinary selection committee uses to score each application. The award goes to the team that demonstrates its safety work is patient-centered, has applied the Virginia Mason Production system, has spread beyond a single work unit, has been sustained over time, and been published or presented at regional or national conferences. 

For all the improvement that has resulted from Mrs. McClinton’s death, there is a profoundly disturbing postscript that speaks to the culture of secrecy in so much of health care. 

A month after Mrs. McClinton died, Furman received a call from a state health regulator. “She said every single hospital that they had surveyed in the month subsequent to Mrs. McClinton’s death told her they had had the exact same situation in the procedure room and changed their process as a result of the tragedy,” she says. “And, we learned that another hospital had a similar error two years earlier and did not have the courage to be transparent about it. Just imagine if they had disclosed the error and we had been able to change our process back then.” 

What does transparency at your organization look like when it comes to patient safety?

Finding innovation, using lean integration improves patient experience

Implementing learnings from conferences, literature key to improvement

The process of identifying innovative ways of improving the patient experience, then using lean methods to integrate those findings into our daily work is an important part of Virginia Mason’s vision of being a learning organization.

In health care, complacency too often stalls progress. Organizations focused within their own silos remain clueless about innovations elsewhere that could improve the quality and safety of care. Unfortunately, this sort of complacency is far from uncommon.

In contrast, providers that consider themselves learning organizations continuously search outside their own walls for ideas that can improve care for patients. In the complex, often turbulent world of health care, an insatiable sense of curiosity is no longer optional – it is essential. 

This installment takes a closer look at Virginia Mason team members who have taken innovative approaches learned outside the organization and integrated those learnings as part of our efforts to improve the patient experience. 

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Barry Aaronson, MD

Barry Aaronson, MD
Barry Aaronson, MD, found gold in work being done by a team at Emory Healthcare in Atlanta on venous thromboembolisms (VTE), a dangerous condition where blood clots in the leg sometimes migrate to the patient’s lungs and become fatal. It is among the leading causes of death for hospital patients, taking tens of thousands of lives each year. 

Dr. Aaronson, hospitalist and associate medical director, Clinical Informatics, was searching for a way to make sure clinicians and Virginia Mason were compliant with standard recommended practices for preventing the formation of these dangerous venous clots that could embolize to the lungs and cause grave damage.  

 This was an area where Virginia Mason was not performing to expectations. “We were getting it right 93 percent of the time,” says Dr. Aaronson, `”and that is not even in the top 10 percent of the country. 

“It is a difficult issue because we are admitting the patient for a disease or condition, so prevention of an embolism is not what they are here for. Integrating work to prevent embolisms is difficult because clinicians are focused on dealing with the disease that caused the patient’s hospitalization. 

“At a conference, Dr. Jason Stein from Emory talked about software he had developed to help identify defects in care process. It focuses on real-time feedback, telling clinicians in real time that you are not doing something you want to do. Without technology, defects have traditionally been identified retrospectively. But if we can get information to clinicians in real time we can head off serious problems.”

Dr. Aaronson and his team made the approach consistent with the Virginia Mason Production System by creating a clinical andon board − a signal updated in real time indicating when a patient was not getting needed therapy. 

“It is basically a red light, a visual cue, that the patient is not getting the therapy they need,” he says. “We also placed a monitor on the wall of the Critical Care Unit (CCU) so everybody on the care team would be getting real-time feedback. It’s group situational awareness so that everyone on the unit can see that the patient is not getting what we as an organization decided to do.” 

Dr. Aaronson believes humans can only improve care systems to a certain level and that “the only way to deliver mistake-proof care is with the help of machines.” 

The clinical team studied the workflow to understand the current state and how best to integrate the new andon into the care process. The result was standard work where the charge nurse, a pharmacist and clinicians would monitor the board throughout the day. 

And here is the great news: six months after this protocol was implemented in the CCU, there had been zero defects. “How does that translate into patient outcomes?” asks Dr. Aaronson. “We know patients would have died from VTE if we hadn’t done it.” 

Once the VTE pilot is complete, the plan is to add other clinical quality measures to the andon board, and improved glycemic control is the next target. If the care team can be provided with real-time group situational awareness about patients who do not appear to be getting the care they need, the care delivery process can be mistake-proofed for those patients too. Ultimately, the hope is to monitor up to about 20 care processes with this technology, which should help Virginia Mason with its vision of becoming the Quality Leader. 

Shirley Sherman, RN
“Ten years ago, I had the opportunity to participate in the Institute for Healthcare Improvement (IHI) Critical Care domain conference in Boston on improving critical care,” says Shirley Sherman, RN, nursing director, Critical Care. “I went with the CCU travel team, headed by (critical care medicine specialist) Mike Westley, MD. Attending the conference not only opened my eyes about the national improvement work and the networking prospects with colleagues around the country, but also the ability and value of getting on a plane and going out on a learning journey. It is quite amazing and extraordinary to network with my own organization’s peers in another state without getting paged, and the ability to compare and contrast what we are doing and benchmark with others.” 

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Shirley Sherman, RN

Sherman has been part of Virginia Mason teams that have implemented evidence-based bundles from IHI for ventilator-associated pneumonia prevention, glycemic control and central-line insertion, along with care improvement for delirium identification and early mobility for the critical care patient. She had read about the research and changing culture around early mobility at Intermountain-LDS Hospital and it sounded promising. 

“To start mobilizing patients early in their stay in CCU can alleviate a host of complications, including delirium and weakness, prolonged time on the ventilator and extended stay in the critical care unit and the hospital,” says Sherman, who learned that Intermountain teams got their patients up and moving as soon as possible. When implemented at Virginia Mason, “critical care patients were walking the halls while still on the ventilator and even out to the roof garden and shower,” she adds. 

While attending another IHI conference, a CCU team of nurses, respiratory therapists and physicians learned about work being done at Vanderbilt Medical Center in Nashville, Tenn. “We’ve taken this and other innovations to the local leadership level within Virginia Mason, and we look to make sure they are being done correctly. Are they understood by the staff? What are the barriers and how can we help solve those?” 

Janine Wentworth, RN
Janine Wentworth, RN, administrative director, Hospital Patient Care Services, has been guided through the years by National Patient Safety Goals issued annually by The Joint Commission, as well as by goals from the Institute of Medicine (IOM), the Agency for Health Care Research and Quality (AHRQ), and from IHI. 

Janine Wentworth, RN

Janine Wentworth, RN

Staying abreast of the latest ideas from these and other organizations is a direct benefit to patients, she says. “We have gotten ideas from all these organizations about improvements to our organization in a wide array of areas, including fall prevention, medication administration safety, and much more. And we always use lean principles to determine how best to make these innovations apply here.” 

Information from the literature and conferences makes clear there is real danger when nurses are interrupted in the course of administering high-risk medications to patients. 

“High-risk medication check is a nursing National Patient Safety Goal, and we used lean to come up with process for medication delivery,” says Wentworth. “We wanted to understand at what point in the medication delivery process nurses were most at risk of making errors.” 

One thing Wentworth and her colleagues noticed was that pharmacists were delivering medications to the dispensing machine in the middle of times that were among the busiest for nurses dispensing medications. “It was built-in system disruption,” she says. “We talked with pharmacy to move their times of delivering medication, and it made a real difference. Ten years ago, it would have been very difficult for pharmacy to understand our need and for the nursing unit to understand pharmacy. But with our cultural transformation we were able to do it in a conversation.” 

Standard work for high-risk medication distribution now requires Virginia Mason nurses to retrieve and dispense medication for one patient at a time, significantly decreasing the chances of a mix-up. 

Wentworth and her colleagues have attended any number of conference sessions focused on preventing falls in the hospital. They have reviewed the latest literature and the bottom line is that while some organizations have made progress, no one has yet cracked the code. 

“No one has been able to sustain improvement for very long, so we’ve had to figure it out on our own, and it is both extremely complex and nuanced,” Wentworth says. “Our goal is to get to zero injuries. We may still have patients fall with assistance and they aren’t injured. There is a balance here. It is very important to mobilize patients. If we protected them so there was no chance of falling, we would restrict beneficial mobilization.” 

There remains much work to be done, but the encouraging news is that during the past four years, overall fall rates and falls with injury rates (per 1,000 patient days) have declined year over year. 

What have you learned outside your organization that improved processes within your organization?

Virginia Mason Production System: Draws clinicians seeking patient-focused practice

“I have been in leadership in health care for about eight years, most of that in Connecticut. And in my position at Virginia Mason I have learned more in one year about being a true leader than I had in all seven years before this.”

- Rea Berg, RN

A few years ago, the number of U.S. provider organizations adapting the Toyota Production System (TPS) as their management method was miniscule. There are many more now, but the approach is still very much the exception rather than the rule. 

The idea of using a management method that enables providers to reduce waste, offer greater access, and better quality and affordability is a powerful draw for a growing number of clinicians. 

Michael Ingraham

Michael Ingraham, MD

Michael Ingraham, MD, a hospitalist who also works as part of the Graduate Medical Education faculty for internal medicine at Virginia Mason, has seen some green shoots in this area. 

“I’ve been doing interviews with applicants for our residency program and it’s amazing that a number of these young men and women seek us out because of our reputation with lean management,” Dr. Ingraham says. “They have a deep interest in quality improvement.’’ 

Some of these applicants have a business background and possess familiarity with the power of TPS in many different industries. “These are applicants drawn here based on the fact that we have developed the Virginia Mason Production System (VMPS), and they are looking to gain experience as a result of their training here,” Dr. Ingraham says. “They don’t have hands-on lean experience and they are looking for that here.” 

These residents make the conscious decision not to go to a large academic medical center where, as Dr. Ingraham puts it, “they may have quality improvement or safety activities but many don’t have a methodology other than very rudimentary things like PDSA (Plan-Do-Study-Act). And they definitely don’t have lean.” (At Virginia Mason, lean can be defined as having the resources needed when they are needed, in just the right quantity, and at just the right time, to achieve 100 percent quality and service expectations the first time.)

Catherine Potts

Catherine Potts, MD

Catherine Potts, MD, Chief of Primary Care at Virginia Mason, puts it this way: “When I am interviewing doctors for positions here, I talk about how our management method has made our patients so safe and that really resonates with doctors. Nobody wants to make a mistake, ever. Mistakes are so devastating for patients clearly, but also for physicians. So with our management method, it doesn’t take very long before people realize how much safer everything is. And that is a real help for me in recruiting the best people because it’s hard to sell change without compelling proof that it really works.” 

And there are people who seek an interview with Dr. Potts who say, “I have read all about you guys and I want to come here because of what you are doing with lean health care.” 

Rea Berg

Rea Berg, RN

When Rea Berg, RN, relocated from Connecticut to Seattle a little more than a year ago, her extensive health care experience made her an attractive job candidate. She looked into positions at a variety of provider organizations but decided on Virginia mason because of VMPS. 

“It is the management method and all it enables us to do that attracted me here,” she says. “I had to make a decision on where to go, and the VMPS process helped me make my decision. It was not a difficult decision.” 

Berg serves manager of nursing resources, a job in which she juggles a variety of supervisory challenges. The complexity and demands of the job have been made easier because she has been through the VMPS for Leaders program, a rigorous course studying lean tools and methods.

 “I have been in leadership in health care for about eight years, most of that in Connecticut,” she says. “And in my position at Virginia Mason I have learned more in one year about being a true leader than I had in all seven years before this.” 

She says the team-based nature of working at Virginia Mason aligns everyone around the same set of goals and keeps the focus on patients. “And there is a huge difference between other places I have worked and here where you get the kind of support you need as a leader to ensure that our patient care is excellent” 

“At Virginia Mason there is a real sense of teamwork,” Berg says. “What is really great is you never feel you are doing anything alone.”

 How does your organization use lean as a draw to get the best talent?

Successful lean management requires leaders to be ‘all in’ every day

“You’ve got to live this every day and if you think it’s just an another initiative that you can kick off and then step back and have the consultants or the team underneath you lead it, you’re wrong.”

- Sarah Patterson 

During the past dozen years, Virginia Mason has become one of the world leaders in adapting the Toyota Production System to health care, and Sarah Patterson, executive vice president and chief operating officer, has been a leader there every step of the way. 

Sarah Patterson-Virginia Mason

Sarah Patterson

Her reflections on the lean management system are particularly insightful. Among the countless essential lessons she has learned through the years is that as a leader you must be engaged in the improvement work every day. 

“As a leader, you’ve got to live this every day,” she says, “because what you are doing is changing the culture of the organization by changing the behaviors of the leaders. If you think you can stop leading the weekly report-outs on improvement work or stop doing genba walks to see what is going on in the organization or say that executives don’t have to be certified lean leaders anymore because they are too busy, and because we’ve come so far, you’re wrong. If you start backing down, if you acquiesce on important commitments you have made as leaders − which really make up the structure and discipline of the management system and require that leaders be coaching and mentoring on the front lines of the organization − you’ve lost.’’ 

Early on, Patterson learned that many health care team members suffered from a kind of improvement fatigue. They had seen a variety of improvement projects or methods tried and abandoned – derided as improvement project “flavors of the month” − and had no real belief that the adaptation of the Toyota Production System would be any different. 

“They didn’t know what a management system really was and even we, the leaders, didn’t know what it was but we knew enough to know we would be more able to execute on our vision and strategy with one,” she says. 

Some skeptics were loud and difficult, while others were more subtle. Patterson recalls, “People would tell me they were waiting to see if we would blink and if you did, they’d say, ‘OK, we knew you weren’t serious about it.’ Staff members would tell me that they were waiting us out. One person told me, ‘I’ll give you two or three years, Sarah, and then if we’re still doing this, I’ll believe it and I’ll get on board.’” 

A dozen years later, just about everybody at Virginia Mason is on board. That has created an alignment throughout the organization that enables continuous improvement. In many organizations it is common for department heads to fight for resources for their team, to focus on the work of their department with little thought to overall organizational goals. 

It is different at Virginia Mason. “Starting years ago we had conversations about how we as a leadership team need to be aligned around this management method and around our goals,” says Patterson, “and how this wasn’t about each of us individually deciding we like this or not; we are one team working together on the entire body of work and that is what we do and over the years we have refined that.” 

“At Virginia Mason all the executives are responsible for all the goals,” she emphasizes. “I’m not just responsible for the goals in the areas that report to me. All leaders are responsible for all our goals, and our compensation is based not on how we perform individually but how we perform as a team on our overall organizational goals. 

“Every Tuesday when we go to standup we’re looking at each other and saying, ‘what are we doing to keep this work moving?’ And if the status is that it’s not on track, ‘OK, what do we need to do? Who needs to be engaged?’” 

This is where having a World Class Management system comes into play, for it is the processes and procedures that ensures an organization can accomplish its goals. World Class Management has three components:

  • Management by Policy, which means having focus, direction and alignment within the organization through a goal-setting process that engages everyone;
  • Cross Functional Management, which calls out work that goes across the organization and aligns everyone toward full customer satisfaction; and
  • Daily Management, which is essentially standard work for leaders, the daily routines and behaviors of leaders from a frontline supervisor to an executive that create the environment and ensure reliability of processes day in and day out.

Daily Management has become a particularly important strategy at Virginia Mason. In practice, this approach means “leaders have two important jobs – running their business and improving their business, and they are right there side-by-side with staff doing the work,” says Patterson. “It’s about working with people in a respectful way so they have the opportunity to identify the problems we need to fix through root-cause analysis. Then, for me as a leader to be right there asking questions, helping to be sure there are the resources to fix them. It isn’t the leaders that are deciding what to work on, it’s the people who do the work because they know what’s getting in the way of providing great care to our patients.” 

Daily Management is critical to strengthening standard work and reducing variability in day-to-day processes. A huge part of leadership at Virginia Mason is making sure standard work is developed and being followed consistently for the benefit of patients. 

“This is what most organizations struggle with the most: how to ensure the improvements they have made are sustained,” Patterson says. “Without leaders regularly checking to see if they are still in place and signaling that it is important to follow the new standards, it is easy for things to drift back to everybody doing it their own way.” 

When Patterson is on the genba seeing the reality of the current state in the hospital or clinics, “I’m looking to see if I can see the standard work in place,” she says. “The idea is not just to get a report from the person who reports to you, but to literally be there on the genba watching and looking, coaching, teaching. As an executive leader, I should not be just relying on my team to tell me what’s going on but I should go out and see for myself.” 

Daily Management means that not only are leaders following their standard work, but that the notion of sticking to standard work is cascading down to all levels of leadership. Managers, for example, may be checking on standard work at least weekly and perhaps even daily. And Patterson says that at a supervisor level, “supervisors check in with their frontline staff on an hourly basis in some cases. Supervisors may round three or four times a shift, and they are continuously pitching in guiding, responding to questions and concerns.” 

Ideally, if Daily Management is in place and all leaders are doing their jobs, then Patterson says you should be able to see what any work unit does, whether it is on schedule, and more. “This is really how the culture shifts from those days of heroic action in health care – I call it management by superheroes, which is a dangerous way to provide care – to reliability and calm and providing great care every day,” she says. “Leaders often get to where they are by being good crisis managers, and now we are saying that a crisis is really a failure of leadership.” 

A great deal of progress has been made through the years, but Patterson and many of her leadership colleagues have a mantra of sorts when they are asked about the progress. Yes, she acknowledges, there has been progress, “But I know we have huge potential to do better. All I have to do is go talk to our team members and they will tell me all of the opportunities we have to make things even better. The great thing is that they aren’t waiting for me to make the improvements, they know how to do it themselves.” 

As a leader, how do you show your team that you are “all in, everyday?”

Pathway to superb primary care: highly coordinated and skilled teams

 “The fact that patients have a person they know who is readily available to them is hugely important.”
  – Lisa Freeman 

Physicians clearly play a central role in the delivery of quality primary care, but it is the strength of the primary care team that serves patients best. Great doctors are the first step, but there are other essential elements to great primary care teams. Today, we’d like to focus on the critical roles of two other key team members: registered nurses and medical assistants. 

Lisa Freeman

Lisa Freeman

Lisa Freeman, RN
Lisa Freeman, RN, works at a busy Virginia Mason clinic in downtown Seattle where she devotes much of her time working on what is known at Virginia Mason as an “intensive primary care program.” 

“This is a great team effort where patients with multiple chronic conditions work with a doctor, nurse and other care team members to make sure all the patients’ needs are met,” says Lisa. “The patient, doctor and I work out a care program, and then I stay closely connected to the patient to help make it work.” 

Lisa works with each patient to make sure all their tests and screenings are up to date. She regularly monitors blood pressure, blood glucose level and more. While the medical aspects of the care are foundational, there is more to Lisa’s work. 

Because Lisa comes to know the patients quite well, a trusting relationship is developed making patients feel more comfortable sharing information with Lisa. The fact that patients have access to Lisa by telephone, email and in-person adds to the connectivity and trust.

“The fact that patients have a person they know readily who is available to them is hugely important,” she says. “For example, we might work with a patient with diabetes whose blood sugars are elevated. Because of our close, trusting relationship, the patient shares her personal challenge that she is overwhelmed and exhausted caring for her elderly parent. This issue is affecting every aspect of her daily life. She tells me her most important goal at this time is to obtain care giving help for her parent. An important part of my role is to connect her with our team social worker to discuss available resources. It’s crucial to know a patient’s day-to-day reality, not just his or her test results.”

Another patient with diabetes having difficulty managing her disease might reveal to Lisa – because of their close, trusting relationship – that she has been eating many meals at fast food restaurants. 

“She’ll tell me she is pressed for time with her child and long hours at work, and she chooses fast food because it is convenient and cheap,” says Lisa. “So we try to come up with a care plan that gradually moves her in a healthier direction. How about bringing your lunch to work? How about when you do go to a fast food place that you try a salad? Or another lower calorie and carb option?” 

The intensive primary care program, says Lisa, “is really working very well. Patient satisfaction is great because patients have developed a trusting relationship and rapport with the nurse, and we are frequently able to address topics because of that relationship and trust that the patient may have been embarrassed about before.” 

With some patients, says Lisa, the management of their complex care requires a significant investment of time, but she says it definitely pays off. With particularly complex patients, there is a 45-minute appointment where Lisa spends the first 15 minutes working with the patient on all aspects of their condition – the latest labs, medication concerns or adjustments and more. Then, a physician joins them for the next 15 minutes and together they decide upon a care management plan going forward. For the final 15 minutes of the visit, Lisa makes sure she and the patient are aligned about the care plan and next steps. 

“Our patient care teams at Virginia Mason are a well-oiled machine,” says Lisa. “All of us – doctors, RNs, medical assistants, pharmacy, clinical support staff, front desk – everybody works closely together to provide the best care for patients at all times and each team member brings particular talents and expertise that is highly valuable.” 

tiffany

Tiffany Bierbrauer

Tiffany Bierbrauer, Medical Assistant/Flow Manager
Medical assistants at Virginia Mason who serve as “flow managers” in primary care clinics do a superb job. Tiffany Bierbrauer works as an MA at Virginia Mason Kirkland Medical Center, and she thrives in the intense, fast-paced primary care world. 

“When you work as an MA in primary care at Virginia Mason, you work in a team – it’s all about teamwork,” she says. “We start the day with a team huddle where we review the schedule and identify any external setup we can do for any of our patients. We know we’ll have an EKG for Mrs. Smith, for example, so everything is ready for that before she arrives. 

“We’ll go through each patient and discuss how we can make the visit great so, for example, we might have someone coming in having issues with blood pressure meds so we’ll say let’s have the pharmacist see this person first. Or sometimes a nurse will see a patient first to guide them on their diabetes. The huddle is only about 15 minutes but we cover a lot.” 

When patients arrive, Tiffany will room them and when she does so she will get work done that, previously, was left to the doctor. For example, she will look at the health maintenance module on the electronic record to see whether the patient needs tests or screenings, do detailed agenda setting to make sure all of the patient’s concerns are addressed, and use an appropriate template to gather key pieces of the history from the patient. 

“All the preventive care shows on the screen and I will go through that schedule. I review their medications and then I will ask them what their main issue is that brought them in. The visit note template in the medical record is great for this because it prompts us to ask a quick series of questions based on the patient’s responses.” 

The information the medical assistant gathers is then front and center on the computer screen when the provider enters the room. “So the agenda is set for him when he comes in the room, but it’s not always cut and dried,” she says. 

Tiffany closely monitors the clock throughout the day knowing that falling behind by more than a few minutes can interrupt the flow that makes the system work its best. “When the physician has been in the exam room with the patient for 18 minutes, I page him because any longer than that and we will fall off schedule and run behind – which isn’t fair to all the other patients coming in. It’s really key that we manage our time well throughout the day to stay on time or to be able to catch up quickly if we are running behind.” 

The flow manager also helps set up the provider in their email and paper work that needs to be done between patient visits. By doing this, providers have more flexibility to be able to spend more time with their patients in the exam room.  

“While the doctor is in the room with the patient I am at the flow station in the hallway looking at the indirect work. Some I can take care of myself very quickly — an email message or call. Some I know should go right to a nurse or pharmacist. We work hard to make sure that only the indirect work that really must go to the doctor does so. So you’re a flow manager at the flow station and you are a medical assistant in the room. It’s very rewarding work.” 

What steps are you taking in your daily work flows to help ensure your customer receives the best experience possible?

Authentic teamwork means smooth flow in primary care

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

- Ingrid Gerbino, MD 

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

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

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

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

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

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Ingrid Gerbino, MD

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

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

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

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

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

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

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

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

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

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

Roger Woolf

Roger Woolf

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

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Catherine Potts, MD

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

 

Patients depend on us to be a great learning organization

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

- Diane Miller 

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

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

Diane Miller

Diane Miller

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

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

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

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

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

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

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

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

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

Foster learning or fall behind

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

- Cindy Rockfeld

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

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

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

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

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

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

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

Roger Woolf

Roger Woolf

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

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

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

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

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

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

Cindy Rockfeld

Cindy Rockfeld

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

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

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

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

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

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

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

Sampling of books Kaizen fellows read during their studies

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