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?

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.”


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.”



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.


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.’”


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