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 InsuranceThoughtLeadership.com 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?

3P: The power of vision

“For the surveillance 3P, we came up with the phrase: Protect me. That phrase characterized the team’s aspiration to move from a passive data collection and reporting process to proactively protecting our patients, staff and community.”

- Celeste Derheimer, RN

(Editor’s note: This is the first of two installments on the visionary power of 3Ps.)

One of the most important moments in modern health care history came in 1999 when the Institute of Medicine issued its report, To Err is Human: Building a Safer Health System. It shocked the nation with its portrayal of the injuries and deaths patients suffered as a result of medical errors. In the decade and a half since the report was published, health systems nationwide have worked assiduously to reduce harm to patients.

Virginia Mason has been in the forefront of this movement. When Jeremy Hunt, secretary of state for health in the United Kingdom, sought to find the safest methods for protecting patients in his country, he traveled to Seattle to announce that the National Health System would adopt the Virginia Mason approach to patient safety.

“Virginia Mason is one of the safest hospitals in the world and perhaps the safest in the world,” he said.

What sets Virginia Mason apart in terms of safety? An essential element is process; applying the methods and tools of the Virginia Mason Production System to eliminate defects that harm patients. Hundreds of kaizen events have been held through the years to identify and eliminate defects in the system that could lead to patient harm. The Virginia Mason Patient Safety Alert system empowers every employee to “stop the line,” if they believe any patient is in any danger at any time.

A key part of the process is major improvement events, such as 3Ps (Production, Preparation, Process). In fact, 3Ps serve as an instructive window into Virginia Mason’s improvement efforts. A 3P targeting health care associated infections (including catheter-associated urinary tract infections and central line infections) reveals a good deal about the Virginia Mason process.

Derheimer Celeste 12

Celeste Derheimer, RN

Celeste Derheimer, RN, is a faculty member at the Virginia Mason Institute and was a team member for a 3P focused on a “surveillance process for infection prevention.” Celeste notes that the 3P process helps create a vision for sustained improvement in a particular area.

“A 3P helps get all the right people in same room,” she says. In this particular case, it brought together a team of approximately two dozen clinicians, data experts, lab technicians and executives (along with an outside facilitator to help guide the week-long process).

Often, 3Ps are characterized as a way to blow up an existing space or process and create something new. Thus, when teams initially gather to begin the work, there is a sense both of excitement and anxiety; excitement at the prospect of being able to do something great; anxiety in the face of a huge challenge.

A fundamental key to understanding the nature and power of a 3P is recognizing that it is the beginning of an improvement process that will require a series of additional kaizen events to achieve the vision outlined in the original 3P. In fact, an essential part of the 3P Celeste worked on was developing a kaizen plan to provide the structure needed to achieve the vision.

To set the stage for the 3P, a session was first held in April 2011 to create a vision for the work on infections:

Our infection surveillance program will systematically provide easily understood, timely, and actionable information that empowers patients, staff, and the organization to improve safety, quality of care, and outcomes across the continuum.

The 3P event itself began in January 2012 “with the goal of identifying the model for a highly reliable surveillance process and information flow at Virginia Mason and development of a 12-18 month kaizen plan to implement the vision.”

“One of the first things that is standard in a 3P is finding a word or two to signify the rallying cry of the 3P,” she says. “Using the vision we created for what surveillance at Virginia Mason would look like, we came up with the phrase, ‘protect me.’ That characterized the team’s aspiration for this 3P; to move from a passive data collection and reporting process to proactively protecting our patients, staff and community.

“Next, we broke up into three different teams of about eight people on each team, and each team was a mix of physicians, other clinicians and administrators. Each team selected examples from other disciplines that could help guide safety improvements.

“We start out with exercises that push you to think beyond your first few ideas. For example, we said, ‘Think about seven ways in nature how nature protects. [An example might be the way in which emperor penguins identify hazards and work together as portrayed the film, March of the Penguins.] What protective mechanisms in nature might apply to this model? That takes you out of your current way of thinking.”

There is homework after the first day. Each team was asked to gather information on three different industries – weather, computer viruses and air traffic control. Derheimer says, “We asked the teams to think about how the concepts from those industries create a model for a surveillance system. Each team created a model and then we incorporated ideas from the teams into one model.”

“It is a very creative process and the teams came up with imaginative and very exciting models,” she says.

 

Prevent, detect, analyze, respond

The final report for the 3P noted “the breakthrough concept was the 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.”

Surveillance System

Surveillance System

The 3P and subsequent kaizen events focused on finding solutions in concert with workers at the frontlines. For example, the equipment frontline workers use – and the protective clothing they wear – are critical safety factors. The 3P revealed a sense of frustration among nurses and others at the frontlines concerning the use of safety equipment and clothing.

“The staff kept telling us `we don’t know what to wear when,’” Derheimer recalls.

And no wonder. There were 60 pages of guidelines for protective clothing and equipment. That was condensed to 10 pages, but it was still too confusing – and not available where team members needed them. The innovation was a one page list of precaution principles that actually helped teams clearly understand what was required.

The guidelines got very specific, says Derheimer: “When you have a patient with C-diff you have to be sure to use the right-hand hygiene approach. When you are in this area of a patient room you need to use this equipment. We now have a one page, color-coded guide, hanging outside every patient room that puts the four key items staff need to know (as identified by them) for each type of transmission-based precaution right where they need it; not in some policy book or web page.”

Additionally, the team saw early on that the gowns used had two key defects: People were not tying them in the back and there was a gap between the sleeve of the gown and the glove. “We had a fashion show, and we asked different departments to trial new options that helped us select one self-tie in the back with a thumb-connection that keeps the gown from sliding away from a glove. The staff know what they need to do the work; they voted and we listened – and selected the gown they identified,” Derheimer says.

 

Strong results

A key measure is the number of months where there are zero catheter-associated infections. In 2012, there were no infection-free months. In 2013, however, eight months were infection free. Through May, three months have been infection free in 2014.

Another key measure centers on central line infects. Since December 2012, there have been zero such infections within the hospital.

“We tracked the use of personal protective equipment,” says Derheimer, “and since January 2012 our results have improved from 72 percent compliance among the staff to 93 percent compliance.”

The 3P model (see photo) was represented by puzzle pieces with a frame around it, consisting of prevent/detect/analyze/respond. “The middle is shared ownership with the ‘protect me’ concept right at the center,’’ says Derheimer.

“Our hypothesis out of all this was that the process would be sub-optimized if any piece was missing,” she says. “We were thinking very high level with the 3P. Then, you move from the very theoretical to practical application of the kaizen plan to help you develop the process and discipline needed to implement the vision.”

The power of VMPS specialists

“As a VMPS specialist, I should be driving and accelerating VMPS so much so that a department is functioning on their own and I can move on to another area and do the same thing.”

Cindy Jo Allen, RN

Since Virginia Mason began the process of adapting the Toyota Production System to health care 13 years ago, its Kaizen Promotion Office (KPO) has played a pivotal role in countless improvements throughout the organization.

The purpose of the KPO is to accelerate the impact and application of the Virginia Mason Production System to the operations of Virginia Mason. We focus on service lines that are important to the overall organizational performance and where operational commitment is very strong. These service lines or value streams become the learning labs for the rest of the organization.

In 2008, Orthopedics (specifically total joint patients) became a priority area due to a focused growth plan and identified area of acute length-of-stay reduction opportunities. VMPS specialists and the KPO directors partner with operational leaders to accelerate their VMPS learning cycles. Some specific areas specialists support include developing the current state patient perspective value stream, working with operations to identify a future ideal state patient perspective value stream, and coach to create a kaizen plan to move the current state to the ideal state.

In addition to coaching and educating, the KPO monitors re-measures to assure sustainability. In our total joint patient population, the acute length-of-stay has decreased from a baseline of 86.4 hours to 60.2 hours. Other ways VMPS specialists support the operational work include developing new standard work as the inpatient unit transferred from our Central Pavilion to Jones Pavilion by leading or coaching multiple small kaizen events (one to three days).

Some key principles of VMPS that are apparent in the Jones Pavilion are:

  • Supplies and tools, such as computers, at point of use (5S)
  • Pod assignments that reduce team member walking and keep caregivers at the patient’s bedside, using appropriate layout to reduce the burden of work (5S)
  • “Med Room in Use” signage to eliminate interruptions (visual control)

Because of our commitment to implementing Daily Management (using VMPS as our management system) the team can quickly resolve issues with little coaching from their leaders. For example, nurses were noticing Foley catheters were not being removed according to the protocol. The team started tracking elements such as which patients, at what times, and for what reasons, on a visual board (off-stage area). Their objective was to get to the root cause to understand why the protocol (standard work) was not being followed.

The portfolio of a KPO team member covers the full spectrum of the organization from surgical suites to accounting, from sterile processing to flow in primary care.

Cindy Jo Allen

Cindy Jo Allen, RN

Cindy Jo Allen, RN, for example, has been working with clinic, surgical and hospital teams to improve the experience of patients having total joint replacements. She also supports the general surgery team’s focus on major pancreas and liver surgeries.

“One of the things that makes my job exciting is that there is a real commitment from the surgeons to improve their work,” she says. “On the other hand, one of the challenges for teams can be understanding what KPO’s role is. We support them in improving their own work, as opposed to telling them how to do it. They are the ones who do the work so they have to do the change.

“As specialists, we’re not here to do the work for you because it should be the work you are doing on daily basis. Our job is to help you build improvement into your daily work.”

VMPS specialists have a unique view of the work being done at Virginia Mason. They work at the frontlines in a variety of areas and have a strong overall sense of the improvement direction of the organization. And while Virginia Mason has been on its lean journey for well over a decade, VMPS specialists know the challenge of sustaining the commitment to the production system.

“We work to bridge the gap of kaizen and VMPS being viewed as something extra,” says Cindy Jo. “Our ubiquitous dissemination of standard work for leaders helps bridge that gap and make clear the implementation of VMPS is how we do our work. It’s not something we lay on top. It should be embedded.”

May Tanifa 12 (2)

Tanita May, RN

In her work, VMPS specialist Tanita May, RN, routinely sees the power of VMPS. Using the method and tools not only “eases the burden of work on people, but when something is broken we can go in and use the tools to fix it,” she says.

Tanita has a master’s degree in nursing and was drawn to KPO “to learn more about how VMPS can help me increase my skill as a nurse. It’s great to be on a team where you are constantly learning. As a VMPS specialist, my job is pretty multifaceted. It changes week to week.”

Some weeks she might coach others to make sure they are ready for a kaizen event, while the next week she may be teaching VMPS methods to a class.

One of her current projects is working with Evan Coates, MD, Lara Pomernacki, RN, and Christin Gordanier, RN, on the sepsis nurse-initiated protocol. This protocol, called “Sepsis Power Hour,” aims to empower nurses to act quickly to treat patients showing signs of sepsis. Since nurses are always at the bedside, they are more apt to pick up subtle, yet serious, changes in a patient’s condition. This protocol will allow nurses to start treatment for sepsis in the moment they assess for signs and symptoms of sepsis.

If the nurse is able to start the process of treatment while notifying the doctor, then Virginia Mason is using the scope of nurses’ competency to improve patient outcomes.

Tanita’s role is to meet with the team weekly to help determine the production plan for the rollout of Sepsis Power Hour. She provides VMPS expertise to advise the group on change management. The Sepsis Power Hour project is particularly complex in that it involves every department in the hospital.

“Dr. Coates and Christin are a fantastic team, and my job is to help remove barriers and support them while moving the work forward,” Tanita says.

How does your organization ensure the work is always moving forward, continuously improving along the way?

 


 

FlashVirginia Mason Annual Report
We are proud to share the 2013 Virginia Mason Annual Report. Read about our patients, the treatment they received at Virginia Mason and how it has improved their lives.

Leader rounding: Up close and personal on the frontlines of care

 “Genba rounds take conversations out of a conference room and move it to that central area of the practice. As a leader, you are visible there making it clear that we don’t want to merely sit in a conference room and look at a bunch of reports of what’s already happened.”
– Shelly Fagerlund

One of the iconic images of the Toyota Production System involves leaders being physically present on the genba – the shop floor. When Virginia Mason teams make their annual pilgrimage to Japan to study the Toyota method (they have done so for 12 consecutive years), they are constantly reminded that leaders are most effective when present on the front lines. It is where the work happens. It is where coaching and teaching happens. It is where leadership happens.

Leader rounding at Virginia Mason draws from the Toyota tradition. Many leaders throughout the organization at a variety of levels are present at the frontlines throughout the day. These leaders have a specific agenda of leader standard work they follow each day. In general, the closer a leader is to the frontlines, the greater percentage of their work that is standardized.

The power of leader rounding and the benefit of connecting with frontline team members is significant. At Virginia Mason, it has proven to be a key method of team engagement and a successful way of building and strengthening trust at all levels of the organization.

The executives at the top of the organization have the least standardized work, but one important standard element is leading rounding. Every senior executive invests significant time conducting rounds in a wide variety of areas.

Charleen Tachibana

Charleen Tachibana, RN

Virginia Mason’s Charleen Tachibana, RN, hospital administrator and chief nursing officer, conducts rounds in 20 different areas each quarter. When she started rounding years ago she did rounds in 20 areas each month, but the significant increase in standard work throughout the organization has enabled her to round in each area on quarterly basis.

When she first started rounding a number of years ago she found “it made leaders on the floors pretty anxious and uncomfortable. I would go out on the floor with no set agenda and ask what was happening, perhaps make a comment that a particular process didn’t seem to be reliable.”

This was not a particularly pleasant experience for team members on the floors who were working feverishly on a variety of improvement initiatives. Tachibana then changed her approach.

“We began to establish agendas, and we would start with the leader on the floor reporting on successes they had achieved. Then we’d focus on something they found particularly challenging. And then there would be certain elements I would want to observe,” she says.

This shift in approach proved quite effective. When teams are able to start the rounding reporting on progress, it set an entirely different tone to the rounding process. “It was much more balanced and didn’t seem so negative,” Tachibana says.

The process has evolved even further so that when Charleen does her rounds now the agenda is set by teams on the floor. “They tell me what they want to focus on or what they think is relevant. The nursing directors actually set the agenda.”

The continuing evolution of executive rounding can be seen in the standard agenda template below. This came as a result of a kaizen event involving executives from the hospital, clinics and corporate sectors of Virginia Mason. The idea was to identify best practices and to standardize rounding to maximize its effectiveness.

Initially, Tachibana conducted rounds monthly. But through the years, so much work on the units has been standardized that she now rounds on a quarterly basis. With a clear agenda she finds that 30 minutes is usually sufficient for a productive visit.

“Part of what I do in rounds now is connect on their RPIWs (rapid process improvement workshops),” she says. “If they are facing barriers, I will follow up. For example, if there are challenges with a support department I can get more involved. I can do some coaching, maybe call someone in another department and connect them together.”

Systems issues are more visible when she rounds. “When I am rounding, I can see things that are common floor to floor and can see that the problem is a bigger issue than on just one floor. It allows me to see the system issues that they cannot see when they are not going floor to floor,” Tachibana says.

Through the years, she has found that attitudes of teams on the floor toward rounding have changed significantly. “I do it with the director and assistant nurse manager, and they seem very happy to have us there to showcase their work and talk about challenges. I make sure the administrative director for the area is with me in case things come up that require follow-up.”

Fagerlund,-Shelly-12

Shelly Fagerlund

Shelly Fagerlund, vice president, clinic operations, starts her genba rounds at the production board in the clinic to ask, “‘What do we know about the health of the business today?’ We have business analytics where we look at our business weekly and monthly, but by the time we see the reports the data is old. We’re looking in the rear-view mirror by that point.”

Fagerlund says the value of going to the production board is that it answers questions such as: What is true right now? How busy are we today? What openings do we have today to meet anticipated patient needs? What is our phone service level for our patients and referring providers?

“In clinic practices, our phones are the portal of entry in most cases,” she says. “In addition, when you see a snapshot of what is the health of the business today it helps you assess a leader’s ability to manage the business.”

Fagerlund did a series of genba rounds focused exclusively on the most recent value stream mapping done in various practices. “An updated value stream map shows me leaders are using tools of VMPS (Virginia Mason Production System) to run their business,” she says. “It is a way to frame the opportunities they see for improvement.”

Shelly adds, “Genba rounds get you up close and personal. The location the leader has identified for the production board is typically in the center of the clinic. Genba rounds take conversations out of a conference room and move it to that central area of the practice. As a leader, you are visible there making it clear that we don’t want to merely sit in a conference room and look at a bunch of reports of what’s already happened.”

blogtable

 

Why Midwest health system went to Virginia Mason for help

“The fact that Virginia Mason is driven by the same purpose we are – serving patients and communities – helped them understand us better than consulting companies could.”

- Andy Hillig, Wheaton Franciscan Healthcare

Increasingly, high-quality health care organizations around the country are turning to the Virginia Mason Institute (VMI) for guidance and coaching on improvement. Virginia Mason’s 13-plus years of experience adapting the Toyota Production System and tools to health care has given it a reputation as a highly effective teaching partner and demand for coaching from VMI team members is rapidly growing.

Why VMI? There are, after all, hundreds of companies out there that provide consulting, coaching, guiding services in health care. In fact, there are many companies that specialize in lean consulting.

hillig

Andy Hillig

Perhaps the reason provider organizations come to Virginia Mason is defined by Andy Hillig, vice president of Operational Excellence for Wheaton Franciscan Healthcare in Wisconsin, Iowa, and Illinois.

“Virginia Mason has successfully adapted a management approach that has had sustained impact for the health care system and has led to a culture of continuous improvement,” Hillig says. “They have lived it, felt the challenge of change and transition, and have maintained the commitment and discipline. The fact that Virginia Mason is driven by the same purpose we are – serving patients and communities – helped them understand us better than consulting companies could.”

That is why leaders at Wheaton reached out to VMI for help. “As an organization, we knew we had an opportunity to establish the leadership discipline and incorporate the necessary tools to carry it out to achieve a culture of continuous improvement,” says Hillig. “We partnered with the Virginia Mason Institute because it offered us an opportunity to learn an approach they had field-tested and proven effective.”

Susan Boland, president of Wheaton Franciscan Healthcare-All Saints in Racine, Wis., credits the organization’s vice president of operations as the impetus behind contracting with VMI. Connie Slomczewski “raised the bar for what continuous quality improvement could look like. Her ability to create a pilot for All Saints was really valuable.”

That pilot expanded into a broader improvement effort now being rolled out throughout the Wheaton system. As with any attempt to fundamentally alter a management approach and, in the process, alter culture, there are bumps in the road to be expected. But leaders at Wheaton say they have hit surprisingly few. So far, there has been strong engagement from team members and physicians.

Originally, the work started as an initiative between Virginia Mason and Wheaton Franciscan Healthcare-All Saints in Racine, but it soon broadened to the Wheaton umbrella. “We needed a true partner that had successfully utilized lean principles and focused on patients,” says Slomczewski. “A number of organizations and companies teach lean, but not all center on the patient the way Virginia Mason does.”

The Wheaton team wanted guidance but also wanted to learn how to do lean management on their own, says Slomczewski, adding, “We wanted an organization to teach us and allow us to grow and develop our own platform, and we found that Virginia Mason fit that bill. They are a quality driven organization focused on the patient.”

One of the most powerful effects of the work, says Boland, is seeing the engagement of frontline team members “who participated very well early on because they saw the true value of what these changes could mean for quality care and service.”

A real plus has been the reaction of physicians to the work. At some organizations, physicians are suspicious of lean – and sometimes resistant. Overall at Wheaton, many physicians see the power of the lean approach.

“We are light years beyond where we were a year ago,” says Boland. “We have strong engagement from physicians and staff, and we have had some very good early adopters.”

Diane Miller

Diane Miller

Two years into the lean journey, Hillig says he hears feedback from frontline team members saying, “We can never ‘go back.’ We expected some growing pains. We’re delighted with the progress we’re making.”

As is Diane Miller, executive director, Virginia Mason Institute. Miller notes that not only is there great satisfaction in being able to help an excellent organization such as Wheaton Franciscan Healthcare, but “the work there and elsewhere is a tangible commitment to Virginia Mason’s vision to ‘transform health care.’”

Powerful vision of ‘outside eyes’

“When you are familiar with your surroundings and your process and routine, you often do not see things with fresh eyes.”
– Steve Schaefer

Have you invited teams from other provider organizations into your clinic or hospital to conduct improvement events? Does that sound too invasive? Transparency gone overboard?

If you haven’t done it, you might reconsider: The power of outside eyes should not be underestimated.

Yes, there is something unnerving about inviting an outside team to see the reality of your value streams; to see the current state when your swamp is drained. But it can also be exhilarating and insightful.

That was the experience at Virginia Mason when a team from Florida Hospital Zephyrhills traveled across country to Seattle to conduct improvement events in a couple of different departments.

Zephyrhills had been coached by lean expert John Black, who also helped Virginia Mason start down the lean path 14 years ago. John had suggested that Zephyrhills teams visit Virginia Mason for a genba kaizen tour. The notion was that organizations such as Zephyrhills could learn from an organization much further along the lean journey – in much the same way that Virginia Mason conducts an annual genba kaizen tour in Japan.

On its lean journey, Zephyrhills had retained the Virginia Mason Institute (VMI) as a coach and guide. This involved Zephyrhills coming to Virginia Mason to learn the Virginia Mason Production System (VMPS) tools and techniques while conducting rapid process improvement workshops (RPIWs). Doing so at Virginia Mason was essential for it is a culture that understands how to identify and eliminate waste. For Zephyrhills, seeing the Virginia Mason culture up close suggested what their own future might look like.

The other side of the learning coin was that Virginia Mason teams received strong reinforcement about the power of outside eyes.

Cote, Jim 09 color

Jim Cote

“The best way to get somebody to see the power of lean is to have them immersed in an organization that is doing the improvement work,” says Jim Cote, senior vice president and Clinic Administrator. “They can come in here and relate to the work just like the work they do, and immediately take lessons learned back to their organizations.”

Virginia Mason was having some difficulty in tissue and transfusion support areas in the laboratory, says Cote. “The work flows were not working well for our team,” he says

Thus, Zephyrhills was invited into conduct an RPIW. Virginia Mason teams had done hundreds of RPIWs and thousands of kaizen events, occasionally with some outside eyes, though never an entire team. The Zephyrhills team proved how truly valuable a fresh set of eyes can be.

“They completely transformed the space and changed the work flow,” says Cote. “They really streamlined it so there is much better flow out of that space to the operating rooms. It transformed the way the work is done there. They could see where all the defects and inefficiencies were. It was amazing.”

In another part of the organization, Zephyrhills teams focused their improvement efforts on the process used at Virginia Mason when patients arrived for an appointment and on the process used for the release of medical information.

Steve Schaefer

Steve Schaefer

“These are very repeatable processes for them that enable them (Zephyrhills) to get better with the tools,” says Steve Schaefer, vice president, Finance. “It was a great opportunity for us to have these outside eyes to come in and provide evaluation.”

For some years now, Virginia Mason has been the teacher and Zephyrhills the student. But the ability of the Zephyrhills teams to come to Seattle and, with faculty from VMI serving as workshop leader, the team would run an effective kaizen event. It also advances their knowledge – knowledge they can take back to Florida with them and apply right away.

“They arrive Sunday and show up first thing Monday morning ready to go, and they want to learn as much as they can that week,” says Cote. “Their goal really is to learn as much as they can about VMPS. And they learn a lot. But we learn a lot also.”

Both Cote and Schaefer expressed admiration for how the Zephyrhills teams handled themselves. “It’s a real challenge and can be disorienting to go to a new place. You are out of your comfort zone,” says Schaefer. “They worked very well, and they are able to bring real value and improve our processes.”

Diane Miller

Diane Miller

VMI Executive Director Diane Miller facilitates these opportunities and expressed great admiration for the Virginia Mason teams who embraced the visitors and their ideas for changes. “It speaks to the culture of openness and engagement of our teams that we’ve been working toward,” she says. “It pushes us to be even better every day.”
Why are outside eyes so powerful?

“Because when you are familiar with your surroundings and your process and routine, sometimes you do not see things with fresh eyes,” says Schaefer. “You sometimes don’t see it through the lens of VMPS. You see waste much better when you are in an unfamiliar environment because in familiar settings a lot of time we get blind to waste.”

Sarah Patterson

Sarah Patterson

Nonetheless, there has been an effort at Virginia Mason to create “outside eyes” within the organization. “We have had discussions about what is it that allows Zephyrhills to see things clearly that we aren’t seeing,” says Sarah Patterson, executive vice president and chief operating officer. “What we have observed is that they use the tools with a lot of rigor, they use the data, they make observations. We have a tendency to think we know what is going on and not use the tools with as much rigor. I think the challenge for every organization needs to be how you create ‘outside eyes’ inside.”

It should also be noted that working with organizations such as Zephyrhills – helping them advance in their lean journey – “is very consistent with Virginia Mason’s vision to transform health care,” says Schaefer. In fact, the Virginia Mason Institute was created for exactly this purpose.

Organizations that invite outside teams to conduct improvement events are rare. The process can be time consuming for the home team, and time spent on improvement events is obviously precious.

Kaizen events run by internal teams are clearly the preferred method. But a regular effort to reach out and have skilled teams come in and see things you and your teams don’t see, can really pay off.

In an upcoming post, we’ll report on the perspective from the Zephyrhills team on their work.

Do you have examples of using “outside eyes” you can share?

Lessons from Japan: Value of deep dive into TPS

“It was a life changing experience. It was one of the most interesting things I have done in my 37 years in this business.”  – Bob Norton

On the surface, it is a challenging idea: That if you work in health care in the United States you can learn a lot about improving quality and safety by traveling to Japan and working in a factory.

And yet every year for the past dozen years, Gary S. Kaplan, MD, chairman and CEO, Virginia Mason, has led a delegation of Virginia Mason team members to Japan to do just that. In recent years, people from other organizations have been invited on the trip, as well.

Here are two particularly illuminating examples from those who have made the Japan pilgrimage: one who currently works at Virginia Mason (but did not when she went on the trip), and the other who is CEO of a prestigious provider organization in Massachusetts.

Lisa Mukavitz, Administrative Director, Ambulatory Services

Mukavitz, Lisa 2013

Lisa Mukavitz

“When I went to Japan – before I even started working at Virginia Mason − I really didn’t know what to expect going into the trip,” says Lisa Mukavitz, administrative director, Ambulatory Services. “I went blindly, having no idea what the trip would be like.”

She quickly discovered the essence of the trip is seeing the Toyota Production System (TPS) method and tools in action, seeing improvement and reduction of waste right before your eyes, and participating as a worker on the floor, identifying possible improvements and opportunities to reduce waste.

As a Virginia Mason outsider at the time (she was working for a different health care organization), Mukavitz was “struck by the unbelievable transparency of the Virginia Mason team,” she recalls. “There was another organization from the UK on the trip, so you had teams from two organizations outside Virginia Mason, and the transparency displayed by Virginia Mason with us outsiders in the room was incredible. To me, that really highlighted that their journey was truly focused on improvement and not on looking good.”

When the Virginia Mason team members wanted to discuss a particularly sticky problem they were experiencing in Seattle, they did not go off and huddle by themselves out of earshot of Mukavitz and others, they discussed the matter openly and sought the opinion of everyone in the room.

“They talked constantly about challenges and issues back home,” she recalls. “How can we make things better? There was a sense of raw truth. Every time we were in a conference room and had to present a component of our value stream, they were all having conversations exposing challenges and opportunities.”

Mukavitz adds, “There was no fear among the Virginia Mason group about talking truthfully about what their challenges were. They were having very candid, open debate among themselves and with us about various issues. The conversations were completely transparent. And their willingness to accept those of us from outside, encouraging us to participate in conversation − allowing outside eyes, not just as observers but as participants.’’

For years, Virginia Mason team members have come back from Japan with important insights into how to improve the lean process to serve patients. This requires, as Mukavitz puts it, “when you go on the trip you have to be open to what you don’t know and to learning what you don’t expect to learn. You have to be open to learning in a completely different way because it takes you way out of your comfort zone.”

It is an arduous journey, and while it is frequently transformative, there are some who believe a trip to the Virginia Mason Institute in Seattle to learn about lean application is just as valuable – and more convenient – than the Japan trip.

For Mukavitz, it was “an indescribable experience. I came back from Japan with a refined sense of urgency to make a difference in health care. This was about how we collectively, as an industry, accelerate improvement. That was the big picture for me when I came home.’’

Bob Norton, CEO, North Shore Medical Center

Bob Norton

Bob Norton

The North Shore Physicians Group near Boston had been working closely with the team from the Virginia Mason Institute to adapt the Virginia Mason Production System as the group’s management method. The effort had been quite successful.

At the time, Bob Norton, CEO, North Shore Medical Center, was closely observing the work among the physicians group. I watched the physician group’s journey in parallel to the hospital journey,” he says. “We had a much more eclectic approach at the hospital.”

But the question was whether two distinctly different improvement approaches – one for the physician’s group and another for the hospital – made sense?

“We had a good deal of debate in the hospital about whether a common methodology could help us reach our improvement goals more quickly,” says Norton. “There was not a total consensus but more people did (think it could help) than didn’t.”

Norton and his hospital leadership team engaged in discussions with Diane Miller and Henry Otero, MD, from the Virginia Mason Institute. One of the suggestions Miller and Dr. Otero made was for Norton and several colleagues to join the next delegation traveling to Japan.

The question for Norton, after nearly four decades in health care, was this: Would he travel nearly 7,000 miles to work in a Hitachi air conditioning plant to learn how to improve quality at his hospital and physician group on Boston’s North Shore?

Norton went all in. At Hitachi, he and his colleagues were part of teams that worked on the production line with the goal of reducing waste and identifying improvements in their processes.

“We were seeing the science of the Toyota Production System applied to a vastly different production line than health care, but we were seeing that the principles and concepts are exactly the same,” says Norton. “It opened everybody’s eyes. There is this myth we have been living under that our business is totally different than all other businesses, but we could see that it was just that, a myth.

“There is something about seeing it in action in the presence of a language barrier that forces you to look for universality.

“It was a life changing experience,” adds Norton. “It was one of the most interesting things I have done in my 37 years in this business. We were benefiting both from the expertise of the Virginia Mason folks but also from the expertise of lean trained leaders at a Hitachi factory as well.”

How far would you travel to change the course of history at your organization?

Is Toyota Production System a fad?

Is the Toyota approach in health care a fad? What does it mean exactly when we say that we use the Virginia Mason Production System (VMPS) as our management method? How do we use VMPS to run and improve our business? Here are some insights from around Virginia Mason.

Joan Ching Fellow VMPS

Joan Ching, RN

Joanie Ching, RN
Administrative Director, Hospital Quality and Safety
At a conference in Washington, D.C., I was really distressed by the responses I heard about applying lean principles and tools in health care. A large group of health care leaders and industrial engineers were very negative about using VMPS as a management method, much less as an improvement tool. The sentiment was that lean doesn’t take humans into account. I explained our Respect for People approach, but I walked away with the realization that lean as Virginia Mason knows it is definitely not mainstream, and that negative reactions are largely based upon the limited experiences people have with lean consultants or are a consequence of organizations giving up because “it’s too hard.”

One of the ways Virginia Mason demonstrates VMPS as our management method is our commitment to “go look.” Resilience engineers refer to this as “work as imagined vs. work as done.” “Go look” involves observing the challenges our frontline workers face trying to do their jobs while simultaneously accepting the notion that humans tend to drift into failure. It takes a partnership between engaged workers and committed leaders to close the gap between work-as-imagined vs. work-as-done at every level of the organization and in every location. I believe that our regard for the genba is foundational to our management method.

 

Katerie Chapman, Vice President, Administration

Katerie Chapman

Katerie Chapman
Vice President, Perioperative and Support Services
VMPS is the way we lead. It is the way we do our work. You have principles and values you live by in your personal life, and applying them takes you no more time or effort to make your decision or do what you do to live consistently with those. Leading with VMPS is equivalent in that regard. We lead with a set of principles. As your knowledge, skill and comfort increase you apply them more seamlessly to your work. Earlier in the journey there is certainly a learning curve, especially for leaders who have been the successful “capes” in their organizations. With time, commitment and the rigor of systems and leadership reinforcing, VMPS evolves to a more natural state and soon becomes your framework.

 

Roger Woolf

Roger Woolf

Roger Woolf
Administrative Director, Pharmaceutical Services
For me, the revelation came when I realized that VMPS or lean was not something you did on top of everything else you are doing but instead it’s an integral part of your work every day. VMPS is used not just when leading a week-long kaizen event, it is a method you apply to everything you do.

As VMPS becomes part of your management method, it becomes the way you see things. You look at a process and clearly see the waste present. Your perspective changes and you challenge yourself to understand the process. This may require pulling a small group together to flow map a process and identify where the opportunities are present. The shared understanding of the current process provides the starting point to apply lean tools for improvement. One of my first learnings from the sensei in Japan was that “40 percent today is better than 100 percent sometime way off in the future.” To me, this translates into understanding a process, selecting the most appropriate lean improvement tools and then testing it real time in a PDSA (Plan-Do-Study-Act) manner. Try the improvement now, test it and try again, don’t wait for the perfect solution. This has become the way our teams improve the work we do.

 

Gerbino,Ingrid06color

Ingrid Gerbino, MD

Ingrid Gerbino, MD
Deputy Chief, Department of Primary Care
VMPS is our management method:

  • It is ingrained in everything we do.
  • It is how we run our business.
  • It is how we improve our business.

Using VMPS as a scientific method to study how we currently deliver care from the perspective of the patient allows us to study any implemented change to ensure the change is meaningful. This assures leaders and sponsors of our improvement work that we are focusing on the right efforts.

Because everyone in the organization is trained in VMPS we all speak the same language. Our leaders are all aligned in our vision and strategic plan, and are all highly trained in VMPS to help deliver on our promise to provide exceptional care for our patients. We use the tools and methods of VMPS to help set up each member of the team to deliver what they do best with the goal of delivering to our patients just what they need, when and how they need it.

VMPS allows us to identify waste, and remove it from our processes, thereby adding value to the patient experience, and freeing up capacity in team members to provide more value-added care for our patients.

Our strategic plan places the patient at the top of the pyramid, and VMPS provides the foundation to ensure all of our processes are centered around the patient.

The tools and methods of VMPS allow us to relieve the burden of work – making the work more meaningful to team members, and valuable to our patients. Because a key element of VMPS is having the workers who do the work improve the work, waste and non-value added care is driven out of the processes.

VMPS helps to mistake proof our processes through inspection, visual controls, devices and standard work. With these methods we increase our respect for people (having team members work in safe processes), and it allows us to achieve our mission to improve the health and well-being of the patients we serve.

 

Kim Pittenger, MD

Kim Pittenger, MD

Kim Pittenger, MD
Director, Quality and Innovation, Primary Care

  • Everybody should strive to understand and achieve 5S, standard work and flow
  • Everyone should have standard work defined and follow it, retooling standard work as needed to fit the realities of complexity
  • The cost of poor quality is our No. 1 enemy
  • Evidence based medicine is the 5S method for clinical practice patterns

5S is the foundation of VMPS. It is basic.

  • SORT necessary from unnecessary “stuff”
  • SIMPLIFY how you store “stuff” and how much you stock
  • STANDARDIZE it across all exam rooms, across the team
  • Label it so you can SWEEP your vision across the work area and locate “stuff” at a glance
  • SUSTAIN the 5S with self-discipline, using 5S agreements across the team, so no one improvises or changes the “stuff” without the team agreeing

Stock less, rummage less, buy less, invest the savings in kaizen Standard work is built on 5S. The team is becoming more disciplined after 5S and accepts that savings are good and no real autonomy has been lost. Use measurements, such as timings, to test different ways of operating. The winning time or the most mistake-free operation becomes the new standard work. Train people in the standard work. Audit their consistency. Flow is now enabled. The group’s choreography is defined. The group sets each other up to flow:

  • Appropriate vital signs taken plus visual controls to cue elevated blood pressure re-measurement, for example
  • Shoes and socks off for patients with diabetes
  • PHQ-9 depression scaling tool done and entered in EMR before PCP enters
  • Flow manager gives directions, like “do two messages and then go to next patient” or “let’s huddle since we’re 30 minutes behind and we have to plan how we might catch up”

Has lean become ingrained into your organization? If not, what is keeping it from becoming the way you manage your work?

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