“The fellowship was transformative for me”
- Dr. Alvin Calderon
Perhaps as much as anything else, Virginia Mason can be described as a learning organization. We hear this term used frequently in health care but what does it mean?
In the case of Virginia Mason, it means a relentless search to learn new ways – within the organization as well as outside it – to improve patient care. At the core of the Virginia Mason approach is a management method – the Virginia Mason Production System — that provides the method and tools for continuous learning and improvement.
One of the most robust and challenging learning opportunities within Virginia Mason is the Kaizen Fellowship. The Kaizen Fellowship program provides current and future leaders deep training in the management method. The program typically includes six fellowship candidates in an 18-month training period. It is exceptionally rigorous, requiring fellows continue their “normal jobs” while simultaneously carrying a fellowship workload.
The program was developed internally and is an important element of Virginia Mason’s journey as a learning organization. (Note: a subsequent post will take a closer look at how the program works.) For all the program’s demands, however, fellows say that the experience is one of the most important they have had at Virginia Mason.
“For me, the fellowship was an incredible opportunity,” says Ingrid Gerbino, MD, an internal medicine physician at Virginia Mason Lynnwood who also serves on the faculty of the Virginia Mason Institute and as deputy chief for the Department of Primary Care. “So much of the value of the fellowship was the relationships I built with my co-workers who were fellows with me. Your professional relationships are nurturing, but you also definitely want to perform better for your colleagues and make them proud.
“Through the fellowship, the organization invested a lot in me and because of that I want to give a lot back to the organization. The fellowship immensely deepened my knowledge and understanding of the principles of the Toyota Production System. Seeing the principles performed to perfection confirmed for me that we have been settling for less than we are capable of at Virginia Mason, and heightened my expectations of myself and my colleagues.’’
Alvin Calderon, MD, hospitalist and director of the Virginia Mason Internal Medicine Residency program, says, “The fellowship was like going to night school for an MBA. We were doing improvement work in our day jobs anyway, and we used examples of our work for fellowship projects and homework – the same thing we do for the VMPS for Leaders program. But this was much more in-depth. It was a group of people holding each other accountable for results – pushing each other, challenging each other, asking one hard question after another.”
Japan Trip: Key to Fellowship
One of the foundational learning experiences for fellows happens during a two-week trip every fellow takes to study in Japan.
“The Japan trip is an essential part of the fellowship,” says Henry Otero, MD, oncologist and faculty member with the Virginia Mason Institute. “It allows us to look at things at a deeper level. We had gone on the genba kaizen tour in Japan, but as a fellow I went on a flow tour learning to think more deeply about the concept of flow. It was like going from a 100-level course to a 500-level course.
“The fellowship was very influential for me. The concept I pulled out most from my fellowship was the concept of the flows of medicine. The fellowship experience was very influential for me in that respect. We went back to Japan as part of program, and did the flow tour at a mattress factory, and I am thinking ‘how are we going to extract anything out of this experience?’
“But I am watching and there is a guy stuffing foam into a mattress, and you can see on the visual display board production is falling behind and all of a sudden a supervisor comes to the bottleneck and works with the workers stuffing foam, and very quickly they bring production back up to pace. I sat there and said, ‘wow, health care just tells you you’re behind but there’s no mechanism to make sure you catch up quickly.’’’
The process and learning Dr. Otero experienced in Japan has been adapted to improve primary care at Virginia Mason. When a primary care team is out of flow, there is help from others, including leaders, to get back on track.
Dr. Gerbino had a similarly valuable experience in Japan. “We were at a factory and the sensei pointed out one particular screw in a piece of machinery on the assembly line. He asked us to follow that one piece all the way through the line. That was difficult because all along the line different things were happening and often quickly.”
But for Dr. Gerbino the point was clear. In health care, she had to take one patient and “flow” that one patient all the way through the process to ensure they received the integrated, quality care needed. It informed her work on improving the flow of care for patients with diabetes. It helped her think about flow in planned diabetes care: How to pull patients into the system who need care but who are not actively seeking care.
“Following the flow enables us to see a big gap in care from the time the patient leaves the primary care physician’s office with instructions,” Dr. Gerbino says. “Why is the patient not meeting goals? Maybe it is a lack of understanding, or maybe the patient is overwhelmed with how many meds they take, so we loop in a pharmacist to work with them on medication.
“The fellowship renewed my sense of urgency that we can do better in providing care for our patients with diabetes. We have so many team members with strengths that we were underutilizing.”
The fellowship started Dr. Gerbino on a deep dive into the flow of planned diabetes care, and she has carried it through her work in the years since.
“At Toyota we read, ‘Action for the future is taking place at this moment.’ We need to use the tools to leverage our team to relentlessly pursue the perfect patient experience,” she says.
Dr. Calderon also appreciated the Japan trip and its focus on flow. He says it helped him think about the in-depth work he was doing to improve the work flow of residents and hospital wards.
“We went to Japan to learn by observing what flow looks like in museums and factories,” he says. “By really studying it.”
More to Fellowship than Japan
But there is much more to the fellowship than the Japan trip. For Dr. Otero, his intensive fellowship study and work led him to the clear realization that, as a leader, it was not incumbent upon him to solve a problem, but rather to be a “problem framer.”
“I had to create the sense of urgency framing a problem from the patient’s viewpoint and then work with the people who are actually doing the work to find the solution,” he says. “The answer doesn’t lie with me. It lies with the people doing the work.”
All three physicians have progressed significantly in the time since their fellowships, and all three credit the fellowship with enabling them to take a deeper dive into understanding VMPS methodology, as well as the tools to foster improvement.
Dr. Gerbino says that in her work with planned diabetes care, moving the metrics is a significant challenge. But by sharing the care of patients with the appropriate professional – nurse, pharmacist or another physician − the planned diabetes care has improved noticeably.
“Through all of this work, the primary care physician now can spend less time with a patient with chronic illness, enabling the doctor to have more access to new and more complex patients,” she says. “At the same time, the patients are exceptionally well served by pharmacists and nurses. Sitting one-on-one with each patient, our nurses do a phenomenal job of coaching and empowering our patients to meet their health goals. Our pharmacists are most skilled at medication adjustment, and partnering with our patients to help improve compliance and outcomes.”
For Dr. Calderon, there was a significant breakthrough in improving the flow of interns rounding on patients.
“The fellowship helped me get a theoretical design and conviction that a change in rounding by interns was the right thing to do,” he says. “Operationalizing it took more time.”
Now, rather than interns rounding in a way that is similar to batch processing – which leads to forgetfulness and errors – they focus on one patient at a time all the way through the round. It’s the same as Dr. Gerbino following that screw all the way down the assembly line, and how she seeks one-piece flow all the way through planned diabetes care.
“The fellowship was transformative for me,” says Dr. Calderon, “in that I could look at medical education and see the flow of interns from a completely different perspective and that helped me solve a lot of problems.”
Dr. Otero sums it up this way: “As I was approaching the concept of zero defects in my fellowship mistake-proofing module, I reflected on any quality statements that our profession embraces. And there it was all along, ‘First, do no harm.’ The Hippocratic Oath predated Shingo, Taiichi Ohno and Toyota. If ‘do no’ equates to zero and ‘harm’ equates to defects, then even the ancients knew that respecting the patient meant ‘First, Zero Defects.’”
How is your organization a “learning organization?”