“We strive to give residents insight into their critical role in system improvement.”
-Brian Owens, MD
The voices of two young physicians speak eloquently about the value of systems thinking in health care.
Residents Camille Johnson, MD, internal medicine, and Carlo Milani, MD, preliminary medicine, find significant value in learning about systems thinking as part of their training. “At Virginia Mason, systems thinking starts with a very different culture,” says Dr. Johnson. “There is a pervasive egalitarian culture that has to be there for process improvement to work. To me, that is one of the bedrocks of process improvement − everyone has to feel safe voicing their perspective.”
Dr. Johnson has dug into learning about systems processing by taking a Virginia Mason Production System for Leaders course, a rigorous initiative required for all leaders within the organization. “The course focuses on lean processes, applying lean tools to a process you are trying to improve,” she says.
“A lot of the principles look really simple, and if you just did the classroom part of it you would come away thinking, ‘this is so obvious.’ But when you try and apply it – that is when the real learning happens because it is messier and more complex than it appears. It’s about change management, and that is a skill you need to practice and get mentored on. You cannot just learn this work in a classroom.”
Dr. Milani said he often hears people say that health care is unique and no comparisons from other industries to health care work are possible. “I don’t buy it,” he says. “Patients aren’t cars, it’s true, but the process by which we care can be standardized and improved upon. And zero mistakes is not too lofty a goal.”
He adds, “Whatever errors occur in a system, that system is perfectly designed to permit those errors in the frequency and manner they occur,” he says. “So with VMPS you have to design things to be error-proof.”
The importance of measurable standards is one of the key lessons he has learned, says Dr. Milani. “If everybody has a different way of doing something, there is no way to tell if we are doing it correctly or to measure how to do it better. When something is systems-based, you can implement standard work so there is alignment throughout the organization.”
Brian Owens, MD, director, Graduate Medical Education, has found that residents consider Virginia Mason “a great place to learn systems thinking. Health care is a complex undertaking in which people, processes and technologies interact, hopefully to the benefit of the patient. Traditionally, health care providers have seen themselves as ‘running’ the system, responsible for system performance, controlling the system. We want providers to accept their role as an integral part of the system that improves care provided to each patient, every time. And that means providers must trust and respect the ability of all components of the system to positively influence care delivery.”
Residents learn systems-based practices in a variety of ways. It starts with quality improvement and patient safety systems approaches built into the students’ two-and-a-half-day orientation. There is also a month-long, systems-based practice elective that a sizable number of residents take each year. Classroom work sets the stage for a deeper learning by engaging in an improvement event, such as a Rapid Process Improvement Workshop or other kaizen event.
Two years ago a surgical resident was so enamored of the systems approach that she opted to take a year-long fellowship in quality improvement and patient safety.
“We want every resident who graduates from a core program at Virginia Mason to have participated in kaizen activity before graduation,” says Dr. Owens. “But we are looking for more than resident participation in kaizen. We strive to give residents insight into their critical role in system improvement by providing opportunities for them to work on interdisciplinary teams to improve components of the system that positively influence care delivery and the patient experience. This is the preparation they need to be the next generation of physician health care providers.”
Linda Hebish, administrative director, Kaizen Promotion Office, on behaviors that accompany systems thinking: “There are many leadership and staff behaviors we are attempting to refine and develop. But, in essence, the one outcome we are trying to create is coaching and mentoring staff to become problem identifiers and solution generators by asking open ended questions.’’