Cutting cost of care while improving quality (part one)

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

- Robert Mecklenburg, MD

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

Robert Mecklenburg, MD

Robert Mecklenburg, MD

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

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

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

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

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

Specifically, Dr. Mecklenburg and his colleagues have used:

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

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

  • Patients
  • Purchasers
  • The State of Washington

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

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

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

Ingrid Gerbino, MD

Ingrid Gerbino, MD

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

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

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

Moonshine: Fast, inexpensive way to test ideas

“If we are discharging someone who has had a total knee or hip replacement without them being able to practice how to get in and out of a car, and they twist or turn the wrong way, it could do damage.”

- Debbie Cutchin

Imagine a patient is about to be released from the hospital. She had a total knee replacement and is taken from her room to the hospital front entrance to be picked up. She is then wheeled to within a couple feet of a wide-open car door. Now what?

Yes, she had been working with physical therapy in the hospital on mobility and yes, she knows the rules and guidelines for keeping her knee safe as she recovers from surgery.

But by entering a vehicle, she is about to perform a maneuver – with a new knee – that she has never done before. How should she do this? Could she harm herself by doing this in an awkward manner?

Debbie Cutchin, director, Virginia Mason Kaizen Promotion Office (KPO), makes a crucial point: A patient should be trained on how to get in and out of a vehicle before she has to do so.

Debbie Cutchin

Debbie Cutchin, director, Virginia Mason Kaizen Promotion Office

That brings us to the powerful effects of the moonshine process (sometimes known elsewhere as “skunkworks”). “Moonshine is an inexpensive way to try something out, something new that solves an immediate need,” says Cutchin. “Sometimes, we find that we need something that doesn’t exist in the marketplace or it does exist and is pretty costly. When we have a unique need for a supply or piece of equipment we work through the moonshine process.”

And that is exactly what happened when a Virginia Mason team sought to solve the problem of knee- or hip-surgery patients being released and never having learned how to enter and exit a vehicle.

“If we are discharging someone who has had a total knee or hip replacement without them being able to practice how to get in and out of a car, and they twist or turn the wrong way it could do damage,” says Cutchin.

When teams were helping design a new section of the hospital in the Floyd & Delores Jones Pavilion at Virginia Mason, they aspired to include a practice vehicle for a variety of patients − including those with knee and hip replacements, and those who had suffered a stroke or had other neurological conditions.

There were many challenges for the team constructing the car, including the reality that the space they were allotted was only 52 inches wide. Cutchin and her colleagues came together for a two-day improvement event in 2011. The team included occupational and physical therapists, a patient transporter, a patient care technician and a KPO specialist.

“When the team came together we said, ‘OK, the seat doesn’t have to be able to recline or move because we will always transfer the patient into car with the seat in the reclined position,’” she recalls. “We knew the practice vehicle did not need a roof or a steering wheel, and it doesn’t need a door because the patient will always get in with the door open.”

What the team did need to reproduce was the door angle because it affects the placement of the walker. During the improvement event, the team determined the functional needs for the car: whatever they built had to fit into a defined space; it had to be easily adjustable – preferably having no more than three moving parts; it had to be easy to clean in two minutes or less; and it had to be portable so it could be moved to any part of the hospital, bringing it to patients rather than having patients with serious mobility challenges going to it.

Once the functional attributes were agreed upon, “team members drew pictures of what they envisioned, and then we mocked them up in three dimensions with pipe cleaners, Popsicle sticks and tongue depressors,” says Cutchin. “By the end of the first day of work, we had what the team considered a good basic design. Our next step was to create a life-sized mockup based on our tabletop designs.”

A key aspect of the two-day event was the inclusion of a representative from Creform, a firm that manufactures structural elements – “lightweight components somewhat like an erector set,” Cutchin noted. Creform is devoted to helping clients do rapid mockups in pursuit of “lean manufacturing goals.”

On day two of the improvement event, the team focused on using Creform components to build the new chair.

“As we went through that process a lot of questions were raised,” says Cutchin. “Can we crank it up to the height of an SUV? Can we crank it low enough for the smallest car?”

The result of this work is a remarkable piece of equipment designed and built by frontline workers who recognized the need to keep patients safe by preparing them for their release form the hospital. (Watch video.) As a Virginia Mason report noted:

The therapy car, which weighs less than 150 pounds, is constructed of lightweight plastic tubing and connectors that allow a variety of configurations to help patients practice mobility. It includes a cushioned car-like passenger seat. The device’s height can be adjusted to correspond with the type of vehicle (i.e., compact, sedan or sports utility vehicle) the patient is likely to get in when he or she leaves the hospital. It also has wheels, allowing therapists to easily move it to meet an individual patient’s post-surgery rehabilitation needs. Most of the time, the car is “parked” in the Virginia Mason Orthopedics Unit therapy gym and used there by patients.

Now, when patients are wheeled out the front door to head home, they are ready to enter and exit any kind of vehicle safely and without fear of damaging their surgical repairs.

The therapy car has been an important advance, but Debbie emphasizes that not all moonshine work is that impactful. “Moonshine doesn’t have to be a mind-blowing experience like the car,” she says. “It can be something as simple as the supply chain needing a stand for an odd-sized printer, so we went through the moonshine steps to build a printer table. The team in sterile processing used moonshine to build racks to hold blue wrap for sterile instruments. If we can avoid spending a lot of money on something and build it ourselves that is where moonshine is really useful.”

What is moonshine?

(aka: bootleg, skunkworks, prototyping)

  • A fast and inexpensive way of testing a concept or trialing an idea before purchasing.
  • A method to create a product to meet a specific need if there is nothing that currently exists on the market.

Key concepts:

  • Try-storming: try it before you buy it.
  • The learning is in the doing: testing, even in simulation, provides so much education and insight before we commit to a solution.
  • Building to fit a need or function rather than adapting a current product.

From concept to construct: getting ideas from paper into a testable product: idea generation small scale mock up large scale mock up test


lighbulb smallmockup largemockup

The MOONSHINE LABORATORY and PATHWAY provide the structure, resources, and space to do this work.

Why moonshine at Virginia Mason?

  • Supports our management method: Virginia Mason Production System (VMPS) is built on principles from the Toyota Production System and lean. Moonshine is a tool used in the application of lean concepts.
  • Supports our vision: To be the Quality Leader and transform health care – we have to be willing to create the right products if they don’t currently exist.
  • Innovative culture: We foster a culture of learning and innovation, this is a pillar on our strategic plan. Looking at better ways of delivering the right care requires innovation or a different way of approaching our work.
  • Utilizing our people resources: Every team member should have the resources to do their job most effectively, generate ideas to improve their work and avenues to act on those ideas.


Road to transforming health care paved by learning

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

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

Craig Blackmore, MD

Craig Blackmore, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

From standardization to customization – greater efficiency and respect for people

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

– Denise Dubuque, RN

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

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

Denise Dubuque

Denise Dubuque

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

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

Sam Luker

Sam Luker

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What are the results of this initiative?

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

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

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

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

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

Deep cultural connection: Respect for people + patient safety

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

Paul O'Neill

Paul O’Neill

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Foundational Behaviors of Respect

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

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


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

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

- Gary S. Kaplan, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Puget Sound High Value Network

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

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

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

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

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

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

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

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

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

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

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

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



Empowering team members to innovate, lead change

“At Virginia Mason, our definition of innovation is directed creativity implemented.”

-Amy Tufano 

Over the course of a lean journey, drivers of change evolve. It is common for improvement initiatives to begin with a consultant, then see that work shift to the organization’s “kaizen specialists,” for example. A defining moment then comes when the impetus for change shifts to the frontline team members who do the work; when each has the knowledge of lean tools and skills to drive innovation every day.

Reaching this stage takes time and a great deal of work. It involves nothing less than a fundamental cultural change – a shift from top-down improvement to one where change is driven continuously at the frontlines. Having the skills and tools is only part of the equation. The organizational culture must be one in which all employees feel empowered and encouraged to initiate and lead change.

Getting to this point is a significant breakthrough for any organization, but even at that juncture there are challenges: Innovation can be overwhelming – it is an exciting concept. But how do you keep innovation simple and understandable? What do you do to continue to ensure all team members have the ability to make innovation central to their job functions?

Amy Tufano

Amy Tufano

“At Virginia Mason, our definition of innovation is ‘directed creativity implemented,’” says Amy Tufano, faculty member, Virginia Mason Institute. “By direct creativity, we mean having a clear purpose behind the idea generation. Then you implement. Creativity is fun and exciting, and we like to think we are creative, but at the end of the day, if we have 100 idea forms on wall, where does that get us? If you don’t take action it does not benefit patients or staff.”

Obstacles to innovation are everywhere. “We have mental valleys in our thinking, ruts we are stuck in,” says Tufano. “While mental valleys are useful for daily communication, it can get in the way when we need to think differently and see new possibilities. The challenge is how do we escape our current thinking — escape from that valley and see the landscape and horizon?”

Attention, Escape, Movement

One approach to drive positive change is the attention, escape, movement technique. As we noted in a recent blog post on the visionary power of 3Ps, the attention, escape, movement approach* can be summarized this way:

  • Attention involves deep focus on the problem by defining the current state and the defects therein.
  • Escape involves getting out of the current situation and searching outside health care for solutions.
  • Movement is taking action that benefits people – both patients and team members.

Everyday Lean Ideas

Virginia Mason Patient Financial Services team members (from left) Kara Cuzzetto, Michael Williamson, Lisa Ness and Cecilia Lu.

Virginia Mason Patient Financial Services team members (from left) Kara Cuzzetto, Michael Williamson, Lisa Ness and Cecilia Lu.

Another tool that helps ensure team members can drive innovation is Everyday Lean Ideas (ELI). This vibrant initiative enables Virginia Mason team members to identify “rocks in their shoes” and find solutions. ELIs have proven highly valuable among Virginia Mason’s Patient Financial Services (PFS) team members.

“It is a very powerful tool,” says Kara Cuzzetto, manager, Revenue Operations. “It’s not just that I tell my leader an idea and it goes into a black hole where nothing happens. We think of it as a way to remove rocks from your shoes. What is going on around you that drives you crazy, slows you down? And how can we fix those things?”

Generating and implementing ELIs is essential to the success within PFS. In fact, PFS has led all Virginia Mason departments in the number of ELIs generated for four consecutive years.

ELIs are small items that may seem mundane individually but their collective impact is significant. For instance, PFS sends hundreds of faxes each week, most of which go to a fairly small number of payers – both private insurers and government programs, such as Medicare. Previously, team members would punch in the fax numbers and hit send. But a PFS team member suggested loading the numbers into the fax memory. By doing so, they can now hit a single digit that automatically establishes a fax connection to the desired payer.

Yes, this ELI is small. But multiply it by a hundred or a thousand, and the continuous efficiency improvements become clearer.

“The majority of our improvements are staff-driven,” says Cuzzetto. “Improvements through ELIs and huddles to the production board and many of our processes. It is very important that all of these high concepts – creativity, innovation, lean – distill down to simple things, such as attention, escape and movement, as well as daily management.

Daily Management

In addition to attention, escape, movement, another way Virginia Mason teams sustain an innovative culture is through standard work for leaders. Standard work for leaders is derived from daily management (a subset of World Class Management**).

Daily management helps define standard work for leaders throughout the organization. It is designed to identify and fix problems in real time, and it has proved to be a powerful accelerator within the Virginia Mason Production System.

The PFS team uses daily management “throughout our day,” says Cuzzetto. “One of the most useful ways is in the form of a daily huddle where we gather every morning at 7:45 to plan our day. The huddle lasts just 15 minutes, but covers a great deal of territory. Most importantly, it enables the team members to start their day fully in sync.”

The huddles allow teams to identify trends much more quickly than they would be able to do without huddles.

Cuzzetto puts it this way: “Because we are in a heads-down production environment, we might have five folks assigned to one payer group, and they may not individually identify something as a trend. But in huddles, we have those conversations and we can clearly see trends when reported by several different team members.”

When Lisa Ness became a supervisor four years ago, the practice was “to batch issues about payers and discuss them once a month,” she says. “Today, because we talk about these issues in our daily huddle, we resolve them much more quickly.”

The value of the morning huddle is so ingrained in the daily work of the PFS team “even when we are out, the team still huddles without us,” says Michael Williamson, supervisor, Patient Financial Services. “It’s their work, it’s their huddle. When the leaders aren’t there, informal leaders on those teams lead huddles.”

During the huddles, for example, workers who have performed particularly well of late are recognized. Recently identified barriers are described, any new issues with a payer are discussed, and a new ELI might be identified.

Multiple approaches enable Virginia Mason to ensure all team members have the ability to drive positive change every day; to keep innovation simple and understandable; to ensure all team members have the ability and are empowered to make innovation central to their job functions. 

Another key aspect of daily management is the production board. The team has engaged in many kaizen events through the years. One of the more impactful came as early as 2006 (just four years into Virginia Mason’s lean journey) when a Rapid Process Improvement Workshop resulted in a shift from a hand-written production board to a sophisticated Excel document to which all team members have real-time access.

In daily management, the production board is a valuable, visual display of metrics essential to the department’s ability to perform at the highest level. The production board is a critical element of daily management within PFS, says Ness. “We deal with a constant flow of information and the board allows us to make it as transparent as possible so everyone on the team knows where we stand at all times.”

With the production board, team members can see, for example, that there are a number of accounts outstanding, with balances ranging from a few hundred to a few thousand dollars. The board will also show that there is an account where $100,000 is due. With that kind of clarity, team members know in real time which accounts to spend their time working on.

What ways does your organization ensure team members are empowered to drive meaningful change?

*This approach is featured in Paul Plsek’s book, Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience.

**For more on World Class Management see this blog post.

To reduce length of stay, focus on patient experience

 “When you set out to design the optimal stay for patients with pneumonia or hip fracture, for example, you take out huge wait states that patients experience and you embed quality within the process.”

– Robbi Bishop

There is a misperception by some in health care that the lean management approach is applicable to administrative but not clinical or diagnostic issues. In fact, significant progress is possible in a wide variety of clinical value streams, and teams at Virginia Mason have demonstrated meaningful gains during the past year or so.

Teams have demonstrated that when the Virginia Mason Production System (VMPS) is applied to clinical value streams, significant reductions in length of stay – from 10 to 25 percent – are achievable.

Robbi Bishop

Robbi Bishop

“As we looked at length of stay before 2013, we typically looked at specific cycles of work – for example, the admission process, delirium screening process or social worker work flows. Quality improvements were seen, but we didn’t see significant improvements in overall length of stay for our patients,” says Robbi Bishop, administrative director, Kaizen Promotion Office.

In recent years, it seems every hospital in America is focused on reducing length of stay with an obvious focus on just that measure – how long a patient remains hospitalized. But what if you were to approach it differently? What if you were to focus on the perfect patient experience in the stay rather than its length? What if you were to say, as Bishop and his colleagues did, “Let’s design the optimal hospital stay for patients with a variety of diagnoses.”

Turns out that doing so not only improves quality and the patient experience, but flow in the hospital improves, as well, and the length of stay is shortened.

“When you set out to design the optimal stay for patients with pneumonia or hip fracture, for example, you take out huge wait states that patients experience and you embed quality within the process,” Bishop says.

Consider this example from last month. Bishop led a Rapid Process Improvement Workshop (RPIW) focused on patients with hip fractures. “We had an order set in the Emergency Department” where most hip fracture patients enter the hospital, “but nothing for the inpatient stay. For most of these events, we had an order set modified or built,” Bishop says. (In the process, he adds, an RPIW reduced time for building order sets from six months to six weeks!)

The kaizen work noted these patients are mostly older and typically have other chronic medical issues. As a result, the great majority are discharged to a short- or long-term skilled nursing facility.

“We found that while surgery was being done within 24 hours after the patients were admitted, we were waiting until after the surgery to talk with the patient and their family about post-discharge care plans,” Bishop says. “When we moved this discussion from after the surgery to before, we reduced the length of stay from 109 hours to 82 hours.”

This approach enabled clinicians to have a conversation early on to set expectations for the patient. It also gave social workers much more time to work on plans for care after the patient meets all their acute care goals.

Something important happened when the RPIW team focused on total joint replacement: they modified a visual aid for patients to help them clearly understand the pathway ahead.

“Because of the feedback we received from patients, family and our care teams, we decided that we would have a patient-centered visual for every clinical value stream, and that it would be written from the patient perspective,” he says. “We knew we needed to do a better job of integrating patients into the process and to make sure they understood what to expect and were not in any way confused.”

During 2013, Virginia Mason teams conducted 10 RPIWs on clinical value streams and the number this year will reach 17. A recent update on this work made important observations:

In 2013, the clinical pathway/value stream approach was started to address inpatient length of stay opportunities, integrate our patients into their care journey, and address any quality opportunities.  The design included a robust unit leader/physician partnership along with the use of published literature as a way to integrate evidence based care. Early results reveal a median length of stay reduction of 23% for the 10 patient populations addressed in 2013. Patient feedback has been very positive in regards to the patient focused visual, and the events are addressing quality opportunities where appropriate.   

Assessment: Our clinical value stream approach in 2013 has shown significant improvements in length of stay, patient satisfaction and quality. As we plan for the future, we will use feedback from event leaders, sponsors, process owners asking for more standards around the use of literature pulls, event scoping and use of data to help guide the pre-event data collection.  

The update notes that future kaizen work will:

  • Focus on specific patient populations or families of patient populations with similar inpatient care needs
  • Focus on designing the optimal length of stay of our patients as a way of showing respect for their time and the overall cost of providing care.
  • Address quality/safety opportunities when present
  • Provide a patient focused visual that engages the patient and family and summarizes the critical milestones needed for discharge
  • Identify the needed organizational support to implement the clinical value stream. This may include order set changes/creation, upstream or downstream process changes, etc.
  • Incorporate evidence based care processes into the event.
  • Identifies a standard process to conduct clinical value stream improvement events, including a standard metric target sheet.

How are you focusing on the patient experience to improve outcomes?



Leapfrog Leader Praises Virginia Mason’s Transparency Efforts

Leah Binder, president and CEO of The Leapfrog Group, authored a blog post Aug. 13 on titled, “A Hospital That Leads World on Transparency.” In the post, Binder highlights Virginia Mason’s success and commitment to transparency, which is rooted in the application of the Toyota Production System. She also notes how Jeremy Hunt, secretary of state for health in Britain, recently toured Virginia Mason and came away inspired. “Hunt wants doctors and nurses in NHS [the National Health Service] to ‘say sorry’ for mistakes and improve openness among hospitals in disclosing safety events,” Binder writes.

Is your organization committed to transparency?

The visionary power – and joy – of 3Ps

“3Ps are extremely productive, engaging and fun. It creates an environment where you can be very open and innovative.”

- Ellen Noel, MN, RN, CPHQ

Editor’s note: This is the second of two installments on the visionary power of 3Ps. Part I can be found here.

“A 3P (Production, Preparation, Process) is about enterprise change, about creating vision and process improvements that positively impact our patients’ health care experiences,” says Ellen Noel, RN, who served as director, Quality and Safety, at Virginia Mason until she recently joined the Virginia Mason Institute faculty.

Ellen Noel, RN

Ellen Noel, RN

At Virginia Mason, 3Ps allow for more “revolutionary” change than rapid process improvement workshops, which typically focus on improvements that should be implemented within the event time frame (five days), but no longer than 30 days after the event’s completion. 3Ps are all about developing a future state vision, which would require more than a year to implement.

“It is a high-level, week-long session that produces guiding principles and necessary attributes for process improvement work in the future,” Noel adds. “It enables the team to pay attention to the current state, then escape their habitual way of thinking and move to a new reality to help build quality, patient-centered improvements.”

She defines these essential innovation elements used during the visioning 3P as “attention, escape and movement.” This language was developed as part of Virginia Mason’s work with Paul Plsek to integrate lean and innovation. It is featured in Plsek’s book, Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience.

  • Attention involves focusing on the problem at hand by having 3P leaders invest significant time prior to the week-long event “understanding the current state, understanding our defects and doing a comprehensive review of previous kaizen activity in that area – really drilling down. Sharing this information with the team on day one helps set the stage for new ways of thinking,” Noel says.
  • Escape comes in the form of “innovative exercises that get us out of our skin and include looking outside health care for valuable lessons. Attention and escape help us shape a shared mental model for where we are going,” she notes.
  • The movement phase is the most critical in many ways. Noel says, “It is about harvesting and processing ideas as a team within the structured 3P format.”

What does that mean? A recent 3P focusing on patient safety improvements gathered more than two dozen clinicians, administrators, and Kaizen Promotion Office team members for a weeklong event. On just the first day the group – broken up into smaller teams – generated 231 ideas to improve the process of recognizing and acting on safety concerns.

From that, 35 ideas were harvested, and bits and pieces from those were boiled down to a short list. In group discussion where all voices are heard, a consensus was reached to select one model of safety moving forward.

“Working in small teams of five to seven people allows us to rapidly sort a lot of information and synthesize ideas,” she says. “And because the whole team sorts down to common ideas, we really are producing ideas generated by the team – by the whole.’’

Part of what binds 3P teams together is the creative process that is encouraged early in the week when scores of ideas are generated. “3Ps are extremely fun and engaging,” says Noel. “The directed creativity structure that participants experience during a 3P takes the pressure off and creates an environment where you can be very open and innovative.”

By day three of the event, the team works with pictures, glue, markers and more to put their ideas into a visual format, thus helping to crystallize domains and attributes. As we noted in our first installment on 3Ps, the 3P focused on safety sought to “move from responsibility resting with one department to a shared ownership model at the center with the unifying theme of ‘protect me’ at the heart. Patients, staff, family and community are equal partners in the processes of prevention, detection, analysis and response.”

Under each domain, there are attributes that are essential to achieving the aims of the safety 3P, says Noel. These attributes are categorized under the headings Prevent, Detect, Analyze and Respond.

While the 3P event itself is conducted over a five-day period, the entire 3P process actually takes much longer – many months or even years. (Noel: “Once you have a 3P you have two to three years of work.”) The safety 3P began in April 2011 and, in the ensuing three years, 28 kaizen activities have been held to implement its vision.

Significant time is invested preparing for the event prior to convening the team and a kaizen plan is produced at the end of the workshop. The plan is used to synchronize and sequence improvements to ensure targets are actualized in the future.

“A successful 3P is only as good as the work that is done afterwards,” says Noel. “3P sets the stage for the work ahead. And the five-day workshop helps jumpstart the process. People come out of 3Ps excited and committed. It’s like giving gas to a car and is an effective way to fuel solutions and leverage teams to solve some of the more complex problems in health care.”

How is your organization fueling solutions to solve problems?


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