- Sharon Mann

Flow matters in every area of health care, but perhaps no where is it more important than in the Emergency Department (ED) where it can save lives. Virginia Mason’s new ED is the result of years of work aimed at perfecting flow in pursuit of the perfect patient experience.

Sharon Mann

“When patients arrive at the ED in an urgent or crisis situation, we want to make them feel as though we’re expecting them and welcoming them, not that they are an inconvenience or that we are busy and they are a nuisance,” says Sharon Mann, RN, MS, NEA-BC, director, Virginia Mason Emergency Services.

The welcoming environment the VM team has created wouldn’t sustain itself long if the underlying processes within the ED were not so focused on the flow of patients.

A key part of the flow is setting up the system so patients with lower acuity problems never have to penetrate deeply into the ED, but are quickly evaluated in a Rapid Medical Evaluation Area. These patients get diagnosed and treated quickly in a separate area, leaving the bulk of the ED free for higher acuity cases. This one change in flow among many has made a significant difference.

A great example of the advanced flow work that makes a huge impact on the patient experience involves heart attack patients brought into the ED. The old protocol was siloed. But a deep dive using tools of the Virginia Mason Production System (VMPS) broke down the silos and integrated the teams with a laser-like focus on what is best for the patient.

This is where the tools of VMPS really pay dividends for patients. The two teams – ED and cath lab – came together and looked at the entire process from the patient’s point of view. The challenge was how do we work together to create the best possible patient experience?

A key part of the answer proved to be the idea of external setup, an important VMPS concept. It used to be that the ED did ED work and the cath lab did cath lab work, and they did not cross borders. But a breakthrough came when the teams agreed the ED team could do most of the setup work for the cath lab in advance. Thus, heart attack patients in the ED receive an EKG, sign consent, are gowned and ready to roll into the cath lab where the interventionist procedure can be done right away. Flow in the ED is now smoother than ever.

“We had a kaizen event that brought the two teams together to leverage what both teams could do for each other,” says Sharon. “So now, the ED does setup for the cath lab – the prep work – so the patient is already prepped when they arrive in the cath lab and they can start the interventional procedure for the patient right away.”

In fact, the flow process with heart attacks starts before patients arrive in the ED.

“Medics call in from the field and let us know they have a patient with chest pains or, in some cases, they have done the EKG in the field and confirmed the heart attack,” says Karen Gifford, RPh, administrative director, Emergency Services. “We immediately prepare a team and a bed. We have an alert that brings techs, nurses and physicians to meet the patient on arrival and begin working right away.”

Thus, the whole team is in place and ready before the patient arrives.

The Virginia Mason goal is to complete an EKG within five minutes of the patient’s arrival and to get the patient to the cath lab within 15 minutes upon arrival to the ED. When they began the focus on this work a few years ago, the American College of Cardiology and American Heart Association (ACC/AHA) urged hospitals to achieve a door-to-balloon (intervention) time of 90 minutes or less.

But the VM team wanted to do much better. Through the years, VM teams had applied VMPS tools and concepts to a variety of areas and eliminated enormous amounts of waste. Thus, they started their work setting a goal of 60 minutes for door-to-balloon time.

“The flow process works so well now that the current door-to-balloon time at Virginia Mason is 42 minutes – cutting more than half the time recommended by the ACC/AHA,” says Sharon. “This is a great boost to patient experience and to the lifesaving quality of care provided in the ED.”

The flow work in the ED has certainly paid off. The ED patient satisfaction rate is pushing 90 percent (according to Press Ganey), a truly impressive number. It is important to note this has been achieved in a new ED unit with fewer beds than the previous unit, a testament to the relentless kaizen work by the team and a clear confirmation of the power of VMPS to reduce waste and improve efficiency and patient-centeredness.

“We really created that relational shift between the two departments that didn’t exist previously,” says Sharon. “Now, we work as one team for the patient.”

“We created a system that brings services to the patient instead of the patient having to go to the services.”

- Karen Gifford

In 2011, Virginia Mason opened a state-of-the-art Emergency Department that was like few EDs anywhere in the nation. The opening came after years of study and planning in the previous department where VM teams applied a variety of Virginia Mason Production System tools to design a unit that put the needs of patients before all else – and in every way.

The ED’s design offers team members excellent line-of-sight into patient rooms.

The new ED, located in the Floyd & Delores Jones Pavilion, stands as a singular achievement in Virginia Mason’s pursuit of the perfect patient experience. We’ll talk more about this unit in future blogs but today we are focusing on key elements that are foundational to the ED functioning at the highest possible level of quality, safety and access.

For decades, the issue of time has been a bedrock problem in emergency care. Traditionally, patients wait at every turn and it is not uncommon to hear of waits of many hours to be seen by a provider.

The experience at our new ED is totally different. When patients arrive, they are greeted by a nurse who assesses their acuity level. This is done using an Emergency Severity index scale of 1-5* (1 being the most acute). The nurses are so well trained and experienced in emergency medicine that they often make their assessment (based on how the patient presents and his or her chief complaint) in minutes and sometimes seconds.

During the recent years’ improvement work, various kaizen events showed that flow in the ED could be improved significantly (and wait times reduced in a big way) if patients with relatively straightforward conditions were treated in an area set apart from the ED.

Rapid Medical Evaluation Area

Karen Gifford

Virginia Mason created a separate physical area consisting of four rooms where patients in the 4 and 5 categories are treated right away. “One concept from our VMPS work was to not have patients penetrate further into the ED than they needed to,” says Karen Gifford, RPh, administrative director, Emergency Services. “So when patients with lower acuity go through our rapid medical evaluation area, they get seen quickly, get the care they need and leave in a much shorter amount of time.”

Here was but one example where the voice of patients – who were involved in the redesign of the ED throughout the process – made a difference. Initially, the triage area was called the “sort area” by clinicians, but patients didn’t think that sounded quite right; it seemed dehumanizing. So the name was changed to better represent what actually took place – the Rapid Medical Evaluation Area.

Bring Services to Patients

During the course of the design process for the new ED, VM teams – working closely with patients – came to understand that a major stress point for patients was leaving the Emergency Department to travel to other areas of the hospital for services.

A CT scanner in the ED means bringing services to patients instead of sending patients to services

“We created a system that brings services to the patient instead of the patient having to go to the services,” says Karen. “We now have a CT scanner located in our ED and expanded our lab services. Before, especially for patients with strokes and high acuity needs requiring a CT, it meant having to leave the department, travel down a hallway, take an elevator ride and often wait. It was stressful for them.”

Quiet Zone for Team

Whether nurses, doctors, technicians or those in any number of other roles, ED team members are exposed to a non-stop flow of urgent, often immensely challenging, medical conditions. They never know what will come through the doors or when. They just know it will be a challenge.

The stress of these positions is considerable. As part of our commitment to putting the patient first, we created a quiet area so team members can get a break and reenergize to take the best possible care of patients.

“This space for the team is separate from the clinical area, and it is a nice quiet zone where they can eat or read or just unwind for a bit,” says Karen. “The team’s reaction has been wonderful. There are big windows with natural light and it is very rejuvenating. They work so hard they need to be able to go somewhere close to the work space but that lets them feel like they are away from it. It is really important that team members have time away from daily stress and mental fatigue.”

Great Results

There are many measures of effectiveness in the ED but among the most important is patient satisfaction. On that score, Virginia Mason’s ED rates a 90-percent-plus satisfaction score through Press Ganey.

 Another measure involves time – how long it takes to discharge patients to home or to admit them to the hospital. (On average, about 70 percent of ED patients are discharged home while about 30 percent are admitted to the hospital.)

As recently as the start of 2013, the average amount of time patients spent in the ED before discharging home was 191 minutes. Through the use of Rapid Process Improvement Workshops and other VMPS techniques, that is now down to 171 minutes. For patients admitted to the hospital, the time at the start of the year was 263 minutes and is now down to 233 minutes.

Virginia Mason has been able to accomplish this with a new ED that has fewer beds – yes fewer beds – than the previous unit. It has done so because the VMPS techniques used – including crucial patient input – has created a much more patient-centered and efficient ED – among the finest anywhere.

*For example, while a heart attack would be a 1, a simple abrasion on the arm would be a 5. A patient presenting with a lot of gastrointestinal pain, nausea and general malaise would be a 3 (and could be sicker than how they appear).

“If everybody is doing something exactly the same each time, you now have reliability and that gives you visibility to see what is and isn’t working.”

- Martha Purrier

In our most recent blog installment, we reported on the use at Virginia Mason of a technique called Training Within Industry (TWI). In essence, TWI is standard work for training where the goal is to train every worker doing the same task in exactly the same way so that the standard work is as precise as possible.

Martha Purrier, RN

One of the leading national experts on TWI in health care is our own Martha Purrier, director of Nursing at Virginia Mason’s Bailey-Boushay House, an inpatient and outpatient center for people living with HIV/AIDS. Martha has a rich mix of experience having served in the Virginia Mason Kaizen Promotion Office and also as an oncology nurse.

A little more than four years ago, Martha took on the assignment of scouting TWI to determine its applicability in health care generally and within the Virginia Mason Production System in particular. At the time, Virginia Mason’s kaizen efforts were producing some dramatic improvement gains.

“It seemed like we had nothing but great ideas and we were really getting some fantastic results,” she says. “The question was how do we keep it going? How do we sustain the gains?”

As she studied TWI, Martha was drawn to the precision of the method. “It’s a really old school method of showing while telling and combining the two because neither is adequate on its own. TWI is a very prescribed way of figuring out the best way to do something and then teaching that by showing and telling the person exactly how to do it.”

Before teaching someone a particular piece of standard work – preparing intravenous medications, for example – the teacher carefully identifies the best practice and then breaks that down into a series of simple steps. Figuring out the design of how best to teach a particular piece of standard work demands precision and accountability from the teacher given that the goal is a defect-free process that can be repeated reliably every time.

“And if everybody is doing something exactly the same each time, you now have reliability and that gives you visibility to see what is and isn’t working,” says Martha. “We value research-based discovery and when you have a large number of people doing something exactly same way it is so revealing.’’

TWI has been introduced in a number of Virginia Mason departments, but by no means across the medical center. “We are still learning how to do the methodology and that takes a lot of practice − breaking down a job and really engineering it well. And it also takes real skill to effectively do the training.”

Martha’s expertise led her to write a book on TWI called Getting to Standard Work in Health Care: Using TWI to Create a Foundation for Quality Care. Martha’s co-author, Patrick Graupp, is an expert on Training Within Industry at the TWI Institute. The collaboration is a powerful one, pairing a leading TWI expert in the world of industry with a leading TWI expert in health care.

“In health care, training is part of your world all the time,” says Martha. “There are always new people and new advancements, so it is something that everybody in health care needs to know how to do well.”

More health care organizations throughout the country are adopting TWI, and Martha and Patrick write about other organizations as well as Virginia Mason. The whole point of the book, says Martha, is to help health care organizations understand and apply TWI.

Essentially, it is a how-to training manual, yet the book is very accessible and easy to read and learn from. (Click here for a free download on the book chapter about hand hygiene.)

“TWI is essentially standard work for training. It helps you train everyone exactly the same way for a particular job.”

- Laurel Brown

What can Rosie the Riveter and her experiences during World War II teach us about improving the quality and safety of health care today? As surprising as it may seem, Rosie actually has quite a lot to teach us.

The technique that was used during the war to train Rosie – to turn her from novice to an experienced, exacting worker – is helping teams at Virginia Mason significantly improve their ability to achieve the highest levels of standard work.

Training Within Industry (TWI) was used extensively throughout World War II to train inexperienced workers quickly with superior efficiency. TWI was “designed specifically to quickly train industrial supervisors to quickly train neophyte workers … to do the jobs of the workers pressed into service in the armed forces,” observed Steven M. Grossman, Director of the TWI Institute. “In the factories in which warships and planes were produced, supervisors used the techniques taught by TWI trainers to geometrically increase the numbers of workers able to do standard work, thereby maintaining the high levels of production and quality critical to the war effort.”

The application in health care is particularly powerful for the countless repetitive processes that happen hundreds of thousands of times a week within a provider organization.

Sarah Patterson, Virginia Mason’s executive vice president and chief operating officer, said health care organizations typically hire new team members, put them in their job and basically tell them to watch others.

“It can not only be frustrating for new staff members, but it can also be a pretty scary experience for new people,” Sarah said. “It’s not a very respectful way to treat them.”

Sarah noted that it’s critical to ensure new hires have a job that is “doable,” but then “we need to support them, and provide training and resources to ensure they have what they need to do the job well.”

In pursuit of the perfect patient experience – a defect-free patient experience – VM leaders see TWI as a powerful training tool. Its effectiveness comes from the one-on-one nature of the training where an experienced teacher walks a new or existing employee through the essential steps involved in a process.

Roger Woolf

For example, at Virginia Mason, Roger Woolf, director, Pharmacy, and Laurel Brown, manager, Inpatient Pharmacy, led an effort using TWI to train technicians on new standard worked related to the preparation of intravenous medications.

“IV medication preparation happens hundreds of times a day at VM,” says Laurel. “And TWI is perfect for this because teaching standard work effectively is what TWI is all about. TWI is essentially standard work for training. It helps you train everyone exactly the same way for a particular job, such as the IV prep work we did.”

Laurel Brown

Virginia Mason’s Martha Purrier, RN, MN, is a leading authority on TWI and co-author (with Patrick Graupp) of a book called Getting to Standard Work in Health Care: Using TWI to Create a Foundation for Quality Care. (For an excerpt, click here.) Martha says that TWI requires a very specific, prescribed series of steps:

How to get ready to instruct.

1. Make a timetable for training − decide who needs training for what and by when.
2. Break down the job − list the important steps, the key points and the reasons for the key points (this is what Laurel was describing).
3. Get everything ready − round up equipment, tools, materials need to instruct.
4. Arrange the worksite − neatly, as in actual work conditions.

How to Instruct

Step I – Prepare the worker

• Put the person at ease
• State the job
• Find out what they know
• Get the person interested in learning the job
• Place the person in the correct position

Step 2 – Present the Operation

• Tell, show and illustrate one important step at a time
• Do it again stressing key points
• Do it again stressing reasons for key points

Step 3 – Try out performance

• Have the person do the job − correct errors
• Have the person explain each important step to you as they do the job again
• Have the person explain each key point to you as they do the job again
• Have the person explain reasons for key points to you as they do the job again

Step 4 – Follow up

• Put the person on their own
• Designate who the person goes to for help
• Check on the person frequently
• Encourage questions
• Taper off extra coaching and close follow-up

With the IV prep project – as with all other TWI projects – the trainer starts by preparing a job breakdown – dividing the IV prep process into a series of steps. She then gathers the appropriate materials and equipment she will need to instruct the worker.

“The TWI trainer walks the employee through new standard work at least three times, and each time the trainer layers in new information so the employee doesn’t experience information overload,” says Laurel. “And every person learns the job the same way.

“The trainer then does it again with the tech, but this time the trainer goes into deeper detail with each step. A key point about the label is to only work with one label at a time. The key point with supplies is to only collect supplies for one patient at a time.”

And the third time through the trainer explains why each step is necessary and the explanation of the work – the rationale for why it is so exacting – enables the employee to have a broader understanding of the rationale for the work.

“A big aha! for us is that with a lot of standard work you fail to tell the why,” says Roger. “But when we do, it gives the staff member a much better understanding, a greater depth of understanding.”

Roger, Laurel and their colleagues at VM have found TWI helps reduce the amount of time staff members take to learn their jobs well and the technique has applied successfully in areas such as high-risk medication checks, patient rounding and hand washing.

VM long ago learned that significant gains tend to backslide over time. That is why VM teams are so diligent about following up on work in a sustained manner. With TWI, Roger and Laurel do not assume once the tech is trained he will always do the work perfectly. They have built in ongoing support and encouragement and made it clear there is a specific person he can go to for help at any time with any concern or question. This safety valve for the employee is immensely important in providing a sense of confidence and comfort for the worker.

“Applying TWI can sound simple, but one of the things we’ve learned is that breaking down each task is critical to its success, and that can be some of the hardest work to do,” Sarah said. “And it can’t be a top-down activity. We need to ensure teachers and trainers are embedded throughout the workforce.

“We’ve made great strides at VM, but we have a lot more work to do.”

“Experience based design involves being willing to come face-to-face with the emotions our patients are feeling. And that has the potential to be a huge breakthrough. We are good at it, but it is early still and we are not nearly as good as we can be, and we are going to keep getting better at it.”

-          Gary S. Kaplan, MD, Chairman and CEO, Virginia Mason

User-centric design or design thinking is widely used in many industries throughout the world today. A relatively new technique in health care − Experience Based Design (EBD) − draws techniques from user-centric design to improve the overall patient experience.

Paul Plsek

Paul Plsek, an authority on innovation in complex organizations who serves as chair of Innovation at Virginia Mason, played a role in the development of EBD as a consultant to the National Health Service in the United Kingdom. Paul explains EBD this way: Think in terms of three legs to a design stool − Functionality, engineering and aesthetics.

Paul notes that functionality “refers to whether a design is based on the best knowledge, science or technology available.” Engineering means efficiency, reliability and consistency are built in.

“The element of aesthetics,” he states, “refers to the emotions elicited by the design via the look, feel and experience it presents to the customer or service user.”

So what could this possibly have to do with health care? Shouldn’t science trump all in the realm of health care?

Jennifer Phillips

“We view Experience Based Design as both a philosophy and set of methods focused on understanding people’s experiences so we can design better services together,” says Jennifer Phillips, director, Innovation, at VM. “We have the patient at top of our (strategic plan) pyramid and applying the EBD methods helps us really understand the patient experience in greater depth. We can then take that data and use it while making improvements.”

In the decade-plus that Virginia Mason has been adapting the Toyota Production System to health care in the form of the Virginia Mason Production System, the goal has been the pursuit of a defect-free patient care experience. EBD has become an essential VMPS tool because it enables us to search more deeply to find negative patient experiences – which are, by definition, defects in the care experience.

Susan Haufe

Susan Haufe, administrative director, Patient Relations and Service at VM, says, “With VMPS value is defined by the customer. With EBD methods helping us better understand what matters to customers, we can better deliver on value.”

Paul notes there is “a growing body of evidence showing the positive relationship between aspects of patient experience and clinical quality. Simply put, anxiety and unease impedes communications and delays healing.” [Emphasis added]

For patients and their families, as well as for staff members, being in a medical setting often elicits an array of intense emotions – many positive, many others negative.

Touch Points Key

The key in Experience Based Design, says Paul, “is to view the care process the patient experiences through a series of touch points – moments when the patient or family member experiences an emotion – either positive or negative.”

A touch point is a moment that triggers an emotion. It may come when a nurse or doctor enters a patient room, when a test is being administered, or when the patient is being admitted or discharged. Often, touch points are small – a negative reaction, for example, to a nurse seeming to rush through a series of steps to move on to the next room. However small, touch points pack real power because patients remember them and they impact patient emotions.

EBD research techniques include careful observation, interviews structured to create a deep conversation where emotions can be expressed, focus groups and questionnaires that patients and families complete as they progress through the care process. These techniques reveal patients almost always experience an emotional rollercoaster in a medical setting.

For example, a VM team learned from patient families that when they were in the waiting room during a loved one’s surgery, surgeons handled communication to families differently. Some surgeons would come out to the waiting room and reassure the family all was well. Everyone in the waiting room would hear that. Other surgeons had the family brought to a private room where they would speak privately – usually with reassuring news.

Yet families in the waiting room perceived the private meeting as one where bad news was conveyed, and it raised the overall level of anxiety among other families fearing such a summons. With that knowledge, a VM team altered the process so all family members spoke with surgeons in private.

The VM team also learned patients and families become highly anxious when they witness staff members chit-chatting about personal matters unrelated to the work in the hospital or clinic. It raised worries among patients and families about whether the staff members were paying adequate attention to patients. This called for a very simple change: When staff members wish to talk about subjects other than the work at hand, they do it “off stage” away from patients.

Seeing and Hearing from Patient Perspective

Research revealed, for example, that certain words clinicians routinely relied upon caused stress. When a clinician tells a patient he or she has been “downgraded,” or is moving to a “lower level” of care, the connotation is negative and, to many patients, upsetting.

So improved language was identified, such as using the term graduated instead of downgraded and the phrase transitioning to progressive care rather than to a lower level of care.

“Experience Based Design involves being willing to come face-to-face with the emotions our patients are feeling,” says Virginia Mason Chairman and CEO Gary S. Kaplan, MD. “And that has the potential to be a huge breakthrough. We are good at it, but it is early still and we are not nearly as good as we can be, and we are going to keep getting better at it.”

Often, the EBD methods enable staff to see things from a patient point of view that they might never have seen before. “We make a lot of assumptions in health care about what patients and families want,” says Susan. “But often we do so without a great deal of thought. It’s just human nature to project ourselves into a role and it seems so obviously correct and safe and patient-centered. EBD allows us to pause and let customers tell us what matters most, and we find that often our assumptions were correct, but sometimes they are not.”

For example, the assumption in clinics had been that the VMPS flow system in primary care that had proven so highly efficient was prized by patients, as well. And, for the most part, it is. But when EBD research was conducted it was learned that patients were quite negative about having a conversation with a provider in the hallway after the visit was over. Patients felt as though it was not private enough. And, as Jennifer says, “Of course they’re right! In the hallway, staff were discussing pretty private matters in a setting that wasn’t private at all. When we saw this we thought, ‘of course we shouldn’t have these conversations.’”

Through the use of EBD tools, it was also learned patients in the clinic did not like being weighed in a hallway as part of check-in. The risk of someone else seeing their weight created a negative emotional touch point.

While most of the EBD work thus far has focused on patients and families, research into experiences of staff members is enormously important as well.

Says Susan: “Job performance suffers when staff members are having a negative emotional experience at work. The perfect staff experience is what is going to allow us to consistently deliver on the perfect patient experience.”

There is a sense at VM that they have barely scratched the surfaced with EBD work; that huge learning and insight lies ahead. “There’s a lot of excitement around it,” says Jennifer. “It’s really provoking our thinking as we get deeper and deeper into this.”

“The Kaizen fellowship trains leaders who have a deeper understanding of lean to help keep the organization learning, moving forward … It gives you the deeper learning you need to become a better leader … And it provides a pipeline of lean leaders in the organization.”

- Dan Hanson, MD

Dan Hanson, MD

Virginia Mason is many things, but at its core, it is a learning organization where employees are deeply engaged with learning in pursuit of defect-free care.

But VM is also a teaching organization. Much of the teaching done by VM staff is within the organization, of course. But VM team members also teach other organizations, as well. Until now, they’ve exclusively been teaching the Virginia Mason Production System (VMPS) to other health care organizations. But now, VM is helping various departments within the Washington state government on their lean journey by coaching them during their events.

Gillian Abshire, director, Graduate Medical Education at VM, has been coaching state government IT workers to build value streams that enable teams to eliminate waste in various processes to improve quality and efficiency.

Imagine teams at a medical center assisting IT professionals in government about management methodology!

This relationship is possible because Virginia Mason has committed for more than a decade to being an organization where continuous learning and improvement is woven throughout its DNA. Through the years, continuous learning has worked its way into the very nature of VM.

There are huge benefits to this, but by far the greatest benefit goes to patients cared for in an organization striving every day to create a defect-free experience for all patients all the time.

When we push upstream we find a series of learning steps within VM and the PhD level a program called Kaizen Fellows. This is an elite program where a handful of carefully selected professionals take a deep dive into VMPS and emerge enriched as never before.

“With the Kaizen Fellows program we are looking for particularly talented people,” says Linda Hebish, administrative director, Kaizen Promotion Office. “It is part of our succession planning – a way for us not only to identify great leaders but also to provide them with a rigorous, advanced program in VMPS so they become true experts.”

The program started in fall 2004 and, thus far, including a class on the cusp of graduating, 34 fellows have graduated.

 Leaders who have completed VMPS Certification – preceded by VMPS for Leaders – are eligible for the program and the competition for the few slots is intense. The program accepts five to six people every other year and all applicants require an executive sponsor. Applicants for the fellowship are carefully screened and, ultimately, Linda and the most senior leadership at VM make the selections.

While quite prestigious, the fellowship is also a lengthy period of hard work – which fellows do in addition to their “regular jobs.”

“It’s a huge commitment because you do it on top of your regular work,” says Dan Hanson, MD, who is about to complete his Kaizen fellowship. “But truly worthwhile things aren’t usually easy and this certainly isn’t. But it is so worth it.”

Features of the program include a study group where fellows do a great deal of reading and discussion, and have classroom work under the tutelage of Linda Hebish and other senior leaders. The classroom work includes value stream mapping, root-cause analysis, level loading, product-quality analysis and much more. In all, there are 12 study group classroom sessions and a trip to Japan, all over the 16-month period of the fellowship.

“The trip to Japan is focused on the fellows experiencing the spectrum of kaizen,” says Dan. “We went to a variety of factory floors to observe and analyze what we saw. We would go to some places that had only recently adopted the principles of the Toyota Production System, and you could see clearly that their processes were very primitive. We saw places like that all the way up to Toyota and everything in between.”

Says Dan, “The kaizen fellowship trains leaders who have a deeper understanding of lean to help keep the organization learning, moving forward, becoming even better at what we do. It gives you the deeper learning you need to become a better leader, better at your job. And it provides a pipeline of lean leaders in the organization.”

It has also been a great help to Dan in the critical work he and his colleagues are doing related to transitions from hospital to home. Lessons from the fellowship have helped Dan significantly improve hospital discharge instructions. They have developed an electronic tool that facilitates a team-oriented approach to discharge instructions that ensures all the key players – doctors, nurses, social workers, physical therapists and more, are directly involved in building discharge instructions that give the patient a crystal clear explanation of what is required in the transfer from hospital to home.

The beauty of the kaizen fellowship program is that not only do the fellows greatly enhance their knowledge, they also develop close bonds with the other fellows with whom they have spent so much time in such an intense experience.

Applicants for fellowships tend to be highly motivated and passionate about VMPS. They emerge from the program with more knowledge, determination and passion. As part of their post fellowship obligation, they are asked to teach new leaders through the VMPS Certification program, giving the new leader a front-row seat of what applying VMPS to your value stream really looks and feels like. Thus, the teaching Gillian and others at VM are doing both internally and now with the Washington state government.

Dr. Kim Pittenger, who has played an important role working with other team members on dramatic improvements in primary care flow at VM, is an example of a fellow “who lives and breathes VMPS,” says Linda Hebish.

Kim was energized by the intense study and close collaboration among the fellows. During his fellowship, “the team was cross functional with an attorney, RN, finance person, managers and an MD,” Kim says. “And we all shared applications and ideas – a kind of transference from one discipline to another. If it works in one fellow’s trial in her arena, then we try it in another. As we worked on our projects we would get stuck. No way out but to help each other get unstuck. Fellows have a strong bond. I learned a ton about mistake proofing and P-Q analysis, which we have applied to our difficulties in primary care, ER and hospitalist work.’’

Gillian has an insightful view of what the kaizen fellows program does for VM: “It helps build on the collective body of knowledge that serves continuous improvement. It also builds a collective wisdom about what we at VM can do to make our system even better.”

The wisdom earned through the fellowship enables VM leaders to ask challenging questions of themselves and their organization: Why are we doing it this way? Is this the most effective way to apply TPS to VM and health care? Can we improve on our improvement method?

What a wonderfully demanding and challenging question: Can we improve on our improvement method?

“The kaizen fellowship program builds its own set of senseis who continue improvement and question whether we have waste within our own improvement processes,” Gillian says. “It helps make the application of lean even more dynamic.’’

Joan Ching, RN VMPS mastery — humility, hard work and patience For Joanie Ching, RN, the kaizen fellowship was magnificent yet humbling. “I had been at VM for three years, and when I started the fellowship I was so out of my league,” says Joanie. “My understanding of lean was shallow compared to the other fellows – and Linda of course. I was frustrated because they could see things on a moving line that I couldn’t see. I remember in the Nissan factory they showed us automobiles being painted with four to five layers of primer, paint and top-coating. And I think when one starts down a lean path you can’t wish yourself a top coat with a glossy finish. It takes study, exposure, practice and experience with VMPS to get further along.”

“Virginia Mason is a learning organization in pursuit of zero defects.”

- Linda Hebish

Linda Hebish, Administrative Director, KPO

Virginia Mason Medical Center is many things: A nationally known hospital, a network of superb clinics and centers of excellence in a wide variety of clinical specialties. But perhaps as much as anything else, Virginia Mason is an active, engaged learning organization. The idea that leaders at VM would ever remain static in their knowledge base is contrary to the very essence of the Virginia Mason Production System – the adaptation of the Toyota Production System to health care.

The learning at VM is not simply for learning’s sake. It is in pursuit of a very clear goal:

Zero defects throughout all Virginia Mason operations.

“Virginia Mason is a learning organization in pursuit of zero defects,” says Linda Hebish, administrative director of VM’s Kaizen Promotion Office.

All VM staff members really have two responsibilities that are intertwined: Their day-to-day job and the responsibility to improve processes essential to their work. That requires an intense, sustained level of learning for employees at all levels, but particularly for those in leadership positions.

In fact, every leader at VM is required to complete a rigorous course called VMPS for Leaders within a year of hire or promotion to a leadership role. Since leaders work their way through the seven modules of VMPS for Leaders at their own pace – over and above their normal job – it generally takes about a year to complete all the classroom and workplace aspects of the curriculum.

To date, 272 VM leaders have graduated from the course with an additional 240 leaders currently working their way through it.

“In the VMPS for Leaders course, we teach the essential concepts and tools of the Virginia Mason Production System, including change management, innovation, value stream creation, identifying waste and leading a significant kaizen event within their own value stream,” says Linda.

Leaders in the course learn about standard work where every step in every task is defined on the basis of best practice. They learn about Toyota Production System concepts, such as kanban and andon – simple tools, such as status boards, that convey clear visual information about how well a process is moving forward. They learn the crucial concept of takt time – the pace at which a task must be completed to meet demand (where the process is powered by customer “pull” rather than producer “push”). They learn how to organize the workplace using 5S (Sort, Simplify, Sweep, Standardize, Self-discipline), making sure the workplace is cleared of any furniture, material or equipment that is not absolutely necessary to providing efficient, high quality care.

“Many new leaders join VM because they know we are trying to transform health care. They are drawn to VMPS, and thus eagerly complete the VMPS for Leaders course,” says Linda. “If they don’t complete it within the 12-month timeframe, then this becomes a performance issue.”

This insistence on all leaders completing the course is somewhat unusual in health care. At major provider organizations, training is often perceived as optional. It is not unusual for training classes to be viewed as an annoying waste of time. This is a bedrock difference at VM and it goes directly to the soul of the organization –  its culture.

Culture may be the most overused word in health care these days but at VM the culture is visible in the actions of the caregivers. While VMPS for Leaders has evolved into an excellent curriculum over the years, what makes it so valuable is the culture embraces such learning. All leaders at VM engage eagerly in learning because they are aligned with the mission that constant improvement – and the pursuit of zero defects – requires deeper knowledge every day.

Curriculum can be introduced at any organization, but without the cultural foundation – the eagerness to learn and improve – it has little impact. Culture at VM is staff members taking a rigorous course that is over and above the work they must do each day; culture is staff members recognizing and passionately embracing the idea that being a learning organization honors their commitment to put patients first in everything they do; and culture at VM is recognizing that when staff members learn, patients benefit in multiple ways.

The educational pathway that is the framework of VM as a learning organization looks like this –

All staff members may take three different courses:

-          Introduction to VMPS

-          VMPS General Education (focused on tools and methods)

-          Everyday Lean Ideas (see our Jan. 30 post)

Supervisors and managers take two additional courses:

-          VMPS for Leaders and

-          Standard Work for Leaders

And directors, executives and physician leaders take courses for

-          VMPS Certification

-          Standard Work for Leaders

Note all leaders are learning the concepts and applying Standard Work for Leaders. What is this exactly? It is a management approach which makes clear the specific actions leaders are responsible for taking to focus on the processes within his or her areas of responsibility.

Standard Work for Leaders enables leaders to get the maximum out of the VMPS management method. It also allows the Kaizen Promotion Office to work with leaders to be more standardized in their work across the three KPO divisions – hospital, clinic and corporate. (Implementing Standard Work for Leaders is a continuing KPO priority for 2013, and we will go into greater detail in a few weeks on this program at VM.)

So here’s a pretty straightforward question: Is your organization a learning organization in pursuit of zero defects? If not, why not?

“The KPO team works relentlessly to accelerate the improvement of the Virginia Mason Production System as our management method – our guiding beacon.”

- Linda Hebish

In our last post, we focused on Standup at Virginia Mason, characterized as “the state of the union every Tuesday morning.” This time, we continue the theme of the work of VM’s Kaizen Promotion Office with a focus on the mission, structure and function of that department.

Health care professionals frequently ask how they can replicate the Virginia Mason work from the past 11 years. We encourage them to adapt the tools of the Virginia Mason Production System and, in fact, through the Virginia Mason Institute, we teach the tools and methodology.

We explain an essential component of the engine that powers the improvement process at VM is our Kaizen Promotion Office (KPO). Surprisingly, very few other health care organizations in the country that we are aware of have a comparable KPO.

KPO is derived from the Toyota Production System, and TPS guidelines recommend between 1 to 5 percent of an organization’s non-management FTEs should be dedicated to the KPO function. At VM we are nowhere near that. Our number is 0.6 percent (28 FTE). Nonetheless, the impact of the KPO team is felt throughout our organization.

“The KPO team works relentlessly to accelerate the improvement of VMPS as our management method – our guiding beacon,” says Linda Hebish, administrative director of VM’s Kaizen Promotion Office

In a sense, the heart of the KPO staff members’ work is focused on value streams.

“We’re trying to help people throughout the organization understand how to build their value streams,” says Linda, “to improve their opportunities for process improvement. Our KPO team is in there working with frontline managers and staff side-by-side to learn and implement changes and figure out what improvements work and what don’t work.”

Value stream maps help drain the swamp of activity around any process and reveal the reality of the current state. Value-stream mapping is an essential VMPS tool because it allows VM teams to identify a variety of types of waste in any process – waste of waiting (time), materials, motion, etc. When the value stream is completed, VM team members work to create a new process that eliminates all waste and focuses on steps in the process that add value.

“Everybody at VM should have a value stream going in their area,” says Linda. “Every leader, every department. Certainly every department that sees patients should have value stream for their patient flow. That’s when you start to see the opportunities for improvement.”

Resistance in Early Days
In the early years of the Kaizen Promotion Office at VM – from 2005 to 2006 – the assistance of KPO staffers was not always welcomed by leaders or front-line staff.

Says Linda, “There was a feeling KPO was intrusive then and a feeling among people that ‘we don’t need your help.’ It was seen as more intrusive than a working partnership.”

But that has changed fundamentally through the years as KPO staff members have played a vital role in helping to improve processes throughout the organization. The work KPO staffers have done is so effective and the acceptance of KPO’s role throughout the organization is such that Linda says she frequently hears people say, “When can you get to our department? We need you!”

Also contributing to the organization’s improved perspective was decentralizing KPO into hospital, clinic and corporate groups that reported to the operational vice presidents for those areas. That helped ensure KPO’s work was aligned with operational work.

KPO focuses on high impact, high growth areas – the areas that are most impactful to the VM mission. Some departments are on the KPO priority list for a year. Others – such as Primary Care and the Emergency Department – have been on the list for five or more years.

But that does not mean work in those areas is a failure. Far from it.

Says Linda, “You stay on the target sheet until we know foundational components are in place and leaders can move work forward without help of KPO. When the foundational components are in place – that is, when every leader in that area understands the basic tools of VMPS and every leader has a value stream for their process – then it is self-sustaining.”

One example of the work in Primary Care is an intensive focus of the KPO team and frontline staff to reduce waste and improve the patient experience. A result of the partnership work is a significant change in how primary care is delivered. The new model has medical assistants and others doing setup so when doctors enter the exam room all of the non-doctor work is completed. This enables all team members to work at the top of their license – creating the right skill-task alignment – thus freeing doctors to do what they are best at: one-to-one visits with patients where they diagnose and treat complex conditions.

Other work in primary care helped result in dramatically improved flow processes throughout the clinic, including a flow station where physicians work side-by side with medical assistants who serve as flow managers. This model has spread throughout VM primary care and resulted in greater productivity, as well as increased patient and provider satisfaction.

In fact, the flow manager concept has been so successful it has been adapted within the hospital for hospitalists and is being used by some specialty groups, as well.

Years of such work, says Linda, means “we have better understanding of our current state, we’re better at planning and connecting organizational goals and initiatives to our KPO priorities. We communicate much better and more effectively throughout the organization at all levels, and our sustainment rate has improved dramatically. We are definitely getting further along every day – but we’re not there yet.”

“It helps us become a stronger organization. We learn about exactly what is working and what’s not working.”

- Linda Hebish

Standup occurs every Tuesday at Virginia Mason.

Every Tuesday at 7 a.m. sharp, the senior leadership team at Virginia Mason Medical Center gathers in a hall directly in front of a wall of charts tracking various VM improvement initiatives.

Welcome to Standup, perhaps the most intense 30 minutes at Virginia Mason on any given week. The meeting is designed to do nothing less than measure where Virginia Mason stands in its now 11-year improvement journey. An executive once termed it VM’s “State of the Union every Tuesday morning.”

A few minutes before 7 a.m., Chairman and CEO Gary S. Kaplan, MD, Executive Vice President and Chief Operating Officer Sarah Patterson, and their

leadership team assemble in the hallway directly in front of the accountability wall that tracks the key metrics teams are working on. Everything is out there, clear and transparent. This is serious business.

Accountability matters: KPO leaders present progress on kaizen activity.

At 7 a.m. precisely, leaders from the Kaizen Promotion Office (KPO) report the progress (or lack thereof) of their projects for the week and look ahead to the coming week. Standup meetings keep close track of dozens of kaizen events under way throughout the organization – Rapid Process Improvement Workshops, 3Ps (Production, Preparation, Process workshops) – any initiative where team members are working through a value stream in an effort to eliminate waste and improve efficiency, safety and quality.

“The three divisional KPO leaders [hospital, clinic, and corporate] have seven minutes each to present what activities occurred last week and what the results were,” says Linda Hebish, administrative director of VM’s Kaizen Promotion Office. “Sometimes they report on a longer period – maybe a 30-, 60- or 90-day update.”

After the three presentations, nine minutes remain in Standup. That’s when Dr. Kaplan, Sarah Patterson and other senior leaders question, probe, teach and coach.

Says Linda: “The real richness of Standup is the nine-minute discussion that follows the three presentations. We celebrate wins, but we also talk about the challenges of getting to root causes, of ensuring we’re solving the problem we want to solve. It’s an opportunity to look for gaps in our strategy to change the culture.”

In essence, Standup is a snapshot of how well VM is doing in its mission to provide the perfect patient experience. It is a weekly measurement of what projects are succeeding and what are not and why.

“The people presenting can be anxious,” says Linda. “They are presenting to the entire executive leadership team and their colleagues, and it is very nerve-wracking. Everyone wants to report successes but obviously not every project is succeeding.”

The session is about accountability; it is about the organization’s most senior leaders understanding – really knowing – what is happening on the front lines of care. It is about what works and what doesn’t; about getting straight answers if an improvement initiative is not advancing.

And, of course, it is about accountability, about the leaders – Dr. Kaplan and Sarah Patterson standing there week after week – and placing each initiative under a microscope. With the senior executive team present every Tuesday to review the work in detail, it sends the message that the kaizen work throughout the institution – all of it – is incredibly important and the senior leaders want to know it, understand it and guide it.

The most awkward moment during the session – and there are invariably awkward moments – comes when the KPO leaders finish their presentations by reporting on barriers they face.

“Nobody likes to talk about the barriers,” says Linda. “It is very difficult to bring up the barriers without sounding like you’re throwing someone under the bus – someone who might be standing 10 feet away from you. You have to have finesse to deliver the barrier without damaging relationships.”

Linda says there is a tendency for those reporting to say they faced no barriers. This invariably brings a response from the CEO or another senior executive: “Well, if there are no barriers then why haven’t we reached the target?”

At VM, the commitment to doing Standup every Tuesday morning is ironclad. Standup happens 52 times each year – never missing a week. In 2012, when Christmas and New Year’s Day fell on Tuesdays, Standup was the following morning at 7.

This depth of commitment – never missing a week, always having the CEO and COO or at least one of the two present if the other is traveling – sends a clear signal throughout the organization of how critically important the improvement work is.

“If we start to slide for one or two things maybe we’ll start to slide for other things,” says Linda. “And once you slide from the standard, how do you hold everyone else to that standard? It’s walking the talk. It helps us become a stronger organization.”

How do you ensure accountability in your organization’s improvement efforts?

The most common types of Everyday Lean Ideas involve shaving time off a process. “And when you think about the cost in health care one of our most valuable resources is time.”

- Jennifer Phillips

What if employees on the front lines of your organization not only did great work on their assigned job, but simultaneously generated simple ideas to increase efficiency and reduce waste?

That’s the idea behind a program at Virginia Mason called Everyday Lean Ideas (ELI). The program encourages all employees to identify opportunitities to make small scale improvements that are within their control. In other words, improvements where the worker identifies a problem, does the testing and provides the solution – without the need of other resources.

These improvements are the embodiment of the continuous incremental improvement that defines kaizen, the essential element of the Toyota Production System (VM has adapted TPS to health care in the form of the Virginia Mason Production System). At any given moment at VM, there are hundreds of small improvement ideas in the pipeline. Not all of those ideas are successful, of course, but even ideas that don’t pan out often provide a useful learning experience to staff.

Jennifer Phillips, innovation director in Virginia Mason’s Kaizen Promotion Office, says the Everyday Lean Ideas system “works best when departments incorporate it into their regular processes, such as staff meetings or huddles. So we know that it is really working well when identifying kaizen opportunities is part of the natural department process.”

When a staff member identifies a problem – say for example, excessive and wasteful paperwork – Jennifer and her team stress that the person working on the problem “pick one simple metric. We stress that they work on ideas that are as simple as possible and not get caught up in complicated metrics. A simple metric that answers basic questions: How do you know your idea worked? How do you know it solved the problem?”

Let’s look at an example. A staff member in the Patient Financial Services department − Raquel C. Pagaduan – believed there was too much paperwork related to clinical referrals. “We seldom need to go back to this paperwork,” Raquel wrote in her report. “It takes up space and it takes time to copy and file this paperwork.” She reported further –

Key metric to improve: Reduce inventory, see how often we actually need to go back to the paperwork, reduce time going through old paperwork.

She proposed scanning the referrals then shredding the documents. “In the current state work comes in batched and queued. It goes from one box to another, then to another, and then to another … Work should be processed as soon as it is received … By holding the work and not faxing it to the respective VM department it delays patient care. It should be one-piece flow.”

Specific results: We no longer keep any paper records. We fax the information to the clinic sections, wait for the fax success confirmation and then shred the chart notes. This saves approximately 30 minutes a day for the initial preparation that was being done to save the documents and then another two hours per week going through to “clean out” old files.

The results of this simple fix reduced six types of waste: inventory, motion, over-production, processing, time and transportation. The source of this idea, as is the case with the great majority of improvement ideas in the ELI program, was “personal experiences/observation.”

Jennifer says the most common types of Everyday Lean Ideas involve shaving time off a process. “And when you think about the cost in health care,” she says, “one of our most valuable resources is time.”

The ELI program is significantly dependent upon where the organization is in the evolution of what Jennifer terms “our overall kaizen culture. And we’re pretty far along when comes to philosophy and identifying waste and having ideas but we are still building the more technical skills of kaizen − how do I test my idea? How do I measure? We’re still building PDSA (Plan-Do-Study-Act) skills in the organization.”

Jennifer seeks to measure cultural alignment with Everyday Lean Ideas by posing several questions on the VM staff engagement survey:

• My manager gives me time to work on promising new ideas
• My manager makes it clear new ideas are desirable
• My manager recognizes my ideas

When managers recognize the staff members who generate Everyday Lean Ideas, there is “huge leverage in staff satisfaction,” says Jennifer. “Staff take a lot of pride in their ideas and when they are recognized by managers at a staff huddle and thanked for their ideas and their work they feel a great sense of pride.”

She hastens to add, “support from coworkers is just as important as support from your leader.”

In the right culture, Everyday Lean Ideas can flourish – but getting there is not a simple matter. VM started the initiative with small pilot groups in 2005 and 2006, then slowly and carefully rolled it out throughout the organization.

Even after all that time and a great deal of work, Jennifer says VM still does not have “the level of organizational traction we would like. We’d like to see more widespread participation.” This is particularly true in clinical areas where clinical staff say they like the concept but lack the time to take on such projects.

Nonetheless, during the seven years the ELI program has been in place literally thousands of simple staff ideas have given Virginia Mason tremendous momentum in its mission to eliminate waste and add value for patients.

What lean ideas have you implemented in your everyday work?