Virginia Mason Medical Center Applying LEAN Methodology to Lead Quality and Transform Healthcare Learn Serve Lead Association of American Medical Colleges
The AAMC launched the Readiness for Reform (R4R) initiative in 2010 to support members as they implement key elements of health reform. R4R began with a voluntary institution-wide survey to assess members level of preparedness for eight key focus areas of health reform: education, research/comparative effectiveness, payment reform, care delivery reform, community and patient engagement, access, quality, and health information technology (HIT). The AAMC now supports a number of projects aimed at identifying and sharing best practices related to the R4R focus areas in member institutions. More information on the R4R initiative can be found at: www.aamc.org/initiatives/r4r This case study is one in a series that will highlight member success stories in the eight R4R focus areas. AAMC Readiness for Reform Case Study Project Team: Joanne Conroy, M.D. Chief Health Care Officer AAMC Michael Weitekamp, M.D. Robert G. Petersdorf Scholar-in-Residence AAMC Meaghan Quinn Senior Program Specialist AAMC The following people from Virginia Mason Medical Center contributed to this case study: Lynne Chafetz Senior Vice President and General Counsel Virginia Mason Medical Center Dr. Brian Owens Director of Graduate Medical Education Virginia Mason Medical Center Tom Enders Managing Director Manatt Health Solutions Molly Smith Manager Manatt Health Solutions Carl Mankowitz, M.D. Senior Advisor Manatt Health Solutions
Background and Description Virginia Mason Medical Center (Virginia Mason), located in Seattle, Wash., is a nonprofit integrated health care system with a large, multispecialty group practice of more than 450 physicians, a 336- bed acute care hospital, the Benaroya Research Institute, the Bailey Boushay House skilled nursing facility for patients with HIV/AIDS and other complex conditions, and the Virginia Mason Institute, a nonprofit education and training organization dedicated to teaching the Virginia Mason Production System (VMPS) management method to other organizations. Virginia Mason has been the recipient of numerous quality awards. It was named Top Hospital of the Decade at the Leapfrog Group s 10th anniversary gala in Washington, D.C., in 2010 and in 2011 was named a top hospital by the same organization for the sixth consecutive year. Figure 1 shows Virginia Mason s performance on quality and resource use compared to other hospitals graded by Leapfrog. HealthGrades named Virginia Mason a Distinguished Hospital for Clinical Excellence for 2012 and a recipient of America s 100 Best Specialty Excellence Award for Overall Cardiac Care and for Gastrointestinal Care. In 2001, Virginia Mason began a systemwide program to change the way it delivers health care to improve quality and safety. During their search for a reliable management Figure 1: Quality and Resource Use Comparison The Leapfrog Group, 2010 Quality and Resource Group Comparison method to achieve these outcomes, leaders became aware of how Boeing successfully implemented the Toyota Production System (TPS, sometimes also referred to as lean production) to eliminate waste and improve quality in manufacturing airplanes. Virginia Mason recognized that Toyota Production System attributes customer first, highest quality, obsession with safety, high staff satisfaction, and a successful economic enterprise are applicable to health care delivery and are aligned with Virginia Mason s vision to be the Quality Leader and transform health care. Virginia Mason adopted this system and began to train its leaders and to apply the principles of the production system through a series of projects to improve quality and safety and to eliminate waste. In 2001, the senior leadership team traveled to Japan to learn and understand the Toyota Production System firsthand. Virginia Mason adapted the Toyota Production System to health care, 3
naming it the Virginia Mason Production System (VMPS). VMPS is based on the premise that health care consists of a set of complex processes in which waste can be eliminated and quality and safety improved through the application of a proven set of tools and techniques. In practice VMPS is more than a set of quality, safety, and cost techniques it is a system of management in which all employees from senior executives to frontline staff are aligned through a common language, a common way of solving problems, and a common set of cultural values. In this case study, we will describe the VMPS management method and present a selection of projects in which the method, tools, and techniques were applied, to showcase its effectiveness. Management Method The Key to Success In 2001, Virginia Mason adopted a new strategic plan, clearly putting the patient at the top. In addition, Virginia Mason began to develop a new Physician Compact, defining a shared vision for the organization s responsibilities and the physician s responsibilities. At the same time the chairman and CEO of Virginia Mason, Gary S. Kaplan, M.D., was considering how to deal with significant financial and quality challenges. In 2001 he began searching for a reliable management method for a health care organization. Although he surveyed some of the most prestigious health systems in the country, he could not find a methodology in health care that was successful in bringing about consistent quality and safety. Through discussions with current and former leaders at Boeing and other manufacturing firms using TPS, he realized that while manufacturing may seem very different superficially from health care, the TPS management methodology could bring about reliable results in any process. As Dr. Kaplan realized, not a single principle in auto production could not be applied to health care. The key characteristics of the management method and its key success factors include: A common mission. The common mission of Virginia Mason Medical Center as it evolved was not only to be the quality leader, or to thrive in an era of increasing demands for reduced cost, but fundamentally to transform health care. Over the last decade Virginia Mason not merely has won numerous awards for high quality and low cost, but through its affiliate, Virginia Mason Institute, has become a destination for other health care organizations some from as far away as Japan and Great Britain to learn how to manage using this method. A commitment to put the patient first. Numerous projects over the last decade have demonstrated Virginia Mason s commitment to put the interests and needs of the patient first. For example, when a new cancer center was designed, the patient areas for infusion were located so they had windows, whereas physician offices were located in the interior of the space. By using the tools of VMPS to eliminate waste and remove defects, wait times for many services were reduced or eliminated while the time patients were able to spend with providers increased. Removing unnecessary walking for inpatient nurses eliminated more than 250 hours nurses spent walking miles each day, which increased time at the bedside from about 40 percent to almost 90 percent. 4
Alignment of leadership. The leadership shares a way of identifying and resolving issues, with a common management method. Hence all senior leaders are required to master VMPS, to teach, to coach, to mentor, and to maintain their credentialing in the tools and techniques of the method. Intimate, ongoing involvement of leadership in improvement activities. Leaders strive to be continually present on the genba ( shop floor in Japanese) to understand the current environment and to support staff in addressing issues and engaging in improvement work. Leadership attends weekly stand-up reports, updates to senior executives of the results of current improvement efforts relative to the organization s defined priorities and goals. In addition, a weekly Report Out session every Friday in the medical center s auditorium is open to all employees and is broadcast to all locations. Teams working on that week s improvement projects share their progress with leaders and colleagues, and teams of former projects that have reached their post 60-day point are required to share an update what s working well, what could have gone better. Creating a culture of openness to report mistakes and fix problems. Senior leaders are committed to responding immediately to problems when a staff member initiates Virginia Mason s pioneering Patient Safety Alert (PSA) system. The PSA system literally stops the line for the most serious patient safety concerns until staff and leaders convene to address the problem and find a solution. When Virginia Mason began to implement the Patient Safety Alert system described in more detail below there was a concern, also prevalent in many other health care organizations, that those who reported would be blamed for errors or seen negatively as whistle-blowers. Overcoming this reaction has taken years of leadership encouraging staff to report problems and supporting them without blame. Because staff members who report errors have been supported, all staff are gradually growing to understand that leadership is serious about encouraging the reporting of errors, near-misses, and potential safety issues. Patient Safety Alerts are resolved quickly, and the organization strives to have a member of leadership report the resolution of the issue directly back to the individual or team who called the PSA. Early on in implementation of the PSA system, an incident occurred in which a nurse pointed out to a physician that his order for medication was written without the required testing beforehand. The physician ignored her warning and told her to proceed anyway. The nurse then called a Patient Safety Alert, whereupon the physician became verbally abusive. The department chief intervened to discipline the physician for both his failure to test and his abusive behavior and backed up the nurse. The response sent a clear signal through Virginia Mason that leadership was serious about reporting errors. Engagement of physicians. As Virginia Mason began its journey to change and improve, Dr. Kaplan, the chairman and CEO, realized that success would be dependent in part on engaged and supportive physicians. The organization embarked on the development, with significant input and engagement of all of its physicians, of what was then a very new concept, a Physician Compact, which outlined the mutual responsibilities of Virginia Mason and its physicians. This compact is shown here. 5
Virginia Mason Medical Center Physician Compact Organization s Responsibilities Foster Excellence Recruit and retain superior physicians and staff Support career development and professional satisfaction Acknowledge contributions to patient care and the organization Create opportunities to participate in or support research Listen and Communicate Share information regarding strategic intent, organizational priorities and business decisions Offer opportunities for constructive dialogue Provide regular, written evaluation and feedback Educate Support and facilitate teaching, GME and CME Provide information and tools necessary to improve practice Reward Provide clear compensation with internal and market consistency, aligned with organizational goals Create an environment that supports teams and individuals Lead Manage and lead organization with integrity and accountability Physician s Responsibilities Focus on Patients Practice state of the art, quality medicine Encourage patient involvement in care and treatment decisions Achieve and maintain optimal patient access Insist on seamless service Collaborate on Care Delivery Include staff, physicians, and management on team Treat all members with respect Demonstrate the highest levels of ethical and professional conduct Behave in a manner consistent with group goals Participate in or support teaching Listen and Communicate Communicate clinical information in clear, timely manner Request information, resources needed to provide care consistent with VM goals Provide and accept feedback Take Ownership Implement VM-accepted clinical standards of care Participate in and support group decisions Focus on the economic aspects of our practice Change Embrace innovation and continuous improvement Participate in necessary organizational change Virginia Mason Medical Center, 2001 The application of this compact over the last 10 years has resulted in higher levels of physician engagement and collaboration. Dissemination of the VMPS method throughout the entire staff with dedicated resources. Medical center staff are trained in the tools and techniques of VMPS. Virginia Mason also committed to establishing an infrastructure and a full-time staff, housed in its Kaizen Promotion Office (KPO), who are dedicated exclusively to leading improvement efforts, disseminating VMPS tools and knowledge across the organization, and tracking results. Figure 2 shows the location of these resources in the Virginia Mason organization. Kaizen means continuous incremental improvement in Japanese. At Virginia Mason, the KPO consists of 25 full-time staff. Leaders regularly rotate into KPO and back into operational management, enhancing the development and spread of VMPS skills and talent in the organization. Staff joining the KPO as VMPS specialists are 6
Gary Kaplan, M.D. Chairman & CEO Sarah Patterson Executive Vice President Chief Operating Officer Andrew Jacobs, M.D. Chief Medical Officer Linda Hebish Administrative Director Kaizen Promotion Office Cathie Furman, R.N. Senior V.P. Quality & Compliance Bob Caplan, M.D. Medical Director Quality Figure 2: Leadership Structure: Kaizen Promotion Office, Quality, and Safety trained to become the future teachers of VMPS. Those who aspire to the management track are encouraged to relocate within Virginia Mason, thereby accelerating the implementation of VMPS as the management method. Selected Outcomes from Applying VMPS 1 Patient Safety Alerts. Early in its journey, Virginia Mason instituted its Patient Safety Alert (PSA) system, requesting all staff members who identify a situation that has harmed (or has the potential to harm) a patient to report a Patient Safety Alert. The most serious PSAs result in stopping the line ceasing the activity and launching a process to understand the root causes of the issue and to correct the problem. Dr. Kaplan and his team had been highly impressed with the ability of any Toyota worker to pull a cord, signaling an abnormal condition, and stop the production line if there was a problem or potential defect; Kaplan insisted that the system be put in place at Virginia Mason. Senior leaders, not middle-level managers, were to be the responders to the most serious patient safety alerts. It sent a message through the medical center about the significance of the new approach. 1 The projects described here are condensed from descriptions on the Virginia Mason Web site (www.vmmc.org) and from Charles Kenney, Transforming Health Care: Virginia Mason s Pursuit of the Perfect Patient Experience (New York: Productivity Press, 2011 by Virginia Mason Medical Center. All rights reserved). 7
PSAs are categorized as red, orange, or yellow. Red events are the most serious, for example, lifethreatening never events, and anything else that could pose potential serious harm to a patient. Red events also include actual or near-misses, wrong-site surgery, security issues, disruptive behavior by staff or physicians, falls with injuries, and serious pressure ulcers. Orange events are less severe and typically involve more than one department. Yellow alerts are mistakes or latent errors. Of the errors reported, 1 percent of all alerts are red, 8 percent are orange, and the rest are yellow. Several culture-changing events occurred early in the program. A major event was the death of a patient who was inadvertently injected with an antiseptic during an interventional radiology procedure. The antiseptic was one of three clear liquids in bowls on the surgical tray, the others being contrast solution and saline. The antiseptic was mistaken for saline. The death was reported in the Seattle press; Virginia Mason made public apologies. Virginia Mason then mistake-proofed the process by purchasing swabs with solution already on them. The event was a watershed it helped accelerate making inspection of one s own work, the inspection of colleagues work, and the calling out of errors and defects part of the culture. This event also caused other hospitals to change their processes and caused the Joint Commission to issue a sentinel event alert based on this type of error. Many hospitals are reluctant to be so public with their errors, fearing an increase in liability claims. Virginia Mason s experience has been the opposite: Malpractice claims dropped 26 percent from 2007 to 2008 and an additional 12 percent the next year. In a state without tort reform or damage limits, Virginia Mason s premiums for professional liability insurance have dropped nearly 60 percent over the last six years. Insurance carriers are asking Virginia Mason to teach other medical centers its approach to risk mitigation. Designing a New Cancer Center. In 2001, Virginia Mason designed a new cancer center using a VMPS tool called 3P (for Production, Preparation, Process ). The first step was to create a cardboard model of the existing cancer center and the ancillary departments that served it. Blue yarn was used to track the distance traveled by a typical cancer patient through the medical center to receive all the services required. Because the laboratory, the radiology department, the outpatient clinic, and the infusion center were all on different floors, the typical infusion patient would spend most of the day navigating this maze. The blue yarn was a graphic indicator of a deeply flawed system. It was an aha! experience for the nurse and physician leaders of the cancer center. The redesign team included all the stakeholders in the cancer center both those who provided services and cancer patients. Over a five-day period, the team developed a fishbone diagram of all the processes. The diagram revealed many duplicative and overlapping processes, which in VMPS terms is waste, and also that communication among caregivers was poor, requiring wasteful rechecking, interruption, and rework. Flows of patients, providers, families, medication, supplies, and equipment were all mapped. A separate flow diagram for the delivery of chemotherapeutic agents was also included. 8
The team approach to redesign began to have an impact: Patient concerns about privacy and comfort were taken into account. The goal of the redesign was to bring everything to the patient, rather than have the patient travel around the medical center. In the course of the 3P, the team realized that the vacant space designated for the new cancer center was not the best fit for the new flow and that another space, already taken, would work much better. The CEO agreed and, after considering this and other factors, freed up the space the design team had identified. About a year later, after the designated space had been made available, a second 3P design team convened. This team, with many of the same players, was more experienced with the tools of redesign. The team focused on the different types of patient who came to the cancer center, and identified different categories with very different needs: patients who came for a simple injection and were in and out in a few minutes; patients who came for infusion, who might be there for hours; and patients who came to be seen by a physician. The team designed different work flows for these different groups of patients. Because the patients on the design team placed a high value on privacy, private rooms for infusions were included in the design. In keeping with the patient-first approach, more attractive, windowed rooms were designed for the patients while the physicians offices were located in the interior of the space. Although some physicians objected, the Physician Compact supported the decision to move forward with a final design with windows for the patients. Both before and after the cancer center opened, the team employed more than a dozen Rapid Process Improvement Workshops (RPIWs) to improve cancer center processes. An RPIW is a five-day workshop during which a team examines the components of a process, identifies and eliminates non value-added steps (waste), and re-engineers the process to eliminate quality defects and to reduce wait times, transportation, unnecessary motion, and other wastes, thus reducing costs. Prior to the start of an RPIW, leaders meet to define the goals and metrics for the workshop. The length of a typical chemotherapy visit was reduced from 10 hours to 2 hours, creating additional capacity and increasing patient satisfaction from 70 percent to 90 percent. Evidence-based care standards were brought to the cancer center. Treatments for various common cancers were standardized; all oncologists deliver the same treatment for similar patients. National professional society standards were chosen and applied uniformly. The early success with the cancer center established the value of the Virginia Mason Production System, and the relevance of the Toyota Production System to health care. Inpatient Nursing Care. Over a period of several years starting in 2005, inpatient nursing care was redesigned using a series of RPIWs. Virginia Mason s inpatient floors are long corridors, and nurses spent a lot of time going back and forth from nursing stations to patient rooms, and to get supplies required to deliver patient care. Nursing assignments were redesigned into small, geographically proximate patient group clusters to reduce walk time. These geographic cells also improved coordination with patient care technicians (nursing assistants). A centrally located supply room entailed many back and forth trips. A subsequent RPIW identified a set of high-use supplies, and a customized box was installed in each patient room with those supplies, which are replenished on a regular basis, dramatically reducing walk time to the central supply location. 9
These small changes have led to dramatic results: A reduction in the average number of steps per day by each nurse from more than 10,000 (five miles) to 1,200 (0.6 mile), for a savings of 250 hours. That previously wasted time nurses spent walking is now spent at the bedside providing nursing care. From a productivity perspective, it is the daily equivalent of 21 nurses each working a 12-hour shift. Conservatively, it amounts to more than $4 million in productivity gains every year. The chief nursing officer noticed that handoffs at the transition between shifts consumed at least an hour at the beginning and the end of each shift, reducing patient contact time by at least a quarter. Another RPIW resulted in the report being given at the patient s bedside. Reporting at the bedside reduces the overall time of report; it enables patients and families to add useful information that influences the plan of care; and it enables incoming nurses to see the patient s status firsthand as soon as they start their shifts. Charting documentation pulled nurses away from the bedside, so workstations on wheels were instituted, enabling nurses to document care in flow, as they are providing it, both improving the accuracy of the chart and increasing time spent at the bedside. Supplies were placed at point of use and those supplies not in the rooms were given a designated storage room, reducing nurses time spent hunting for these items. A visual electronic control board showing the status of all beds in the hospital was put in place. The control board is refreshed every 15 minutes. Knowledge of available beds streamlined critical transfers from floor to ICU and back, and from postoperative recovery to floor. Call lights were considered a defect to be eliminated through active engagement with patients. Virginia Mason nurses began to perform standardized hourly rounds on patients to anticipate problems rather than react to them. These hourly rounds enable nurses to track clinical status at regular intervals and to be in a position to meet patient needs before a call light is activated. Nurses may help patients to the bathroom, rather than letting them try it alone and risk falling; nurses and patient care technicians make sure that everything a patient needs is within reach; and patients are asked direct questions to elicit their needs and concerns. All of these changes in how work is done ran against the solo model of nursing. Gradually, however, the culture changed so working in teams is now the rule, not the exception. Staffing plans tied to anticipated volumes help make the workplace more stable and predictable. The cumulative effect of the changes has resulted in shorter lengths of stay and a dramatic increase in nursing time at the bedside from 40 percent to almost 90 percent. 10
Responding to Payers. Virginia Mason faced the issue of continued inclusion in major insurers networks. While quality was high, the cost was expensive and most of Virginia Mason s focus was on the care of acutely ill patients. While employers and insurers also are concerned about the quality of inpatient care, much of their cost resulted from the treatment of high-volume acute and chronic conditions. One of Seattle s major employers, Starbucks, had an ongoing issue with store personnel who had chronic back pain. Employees were frequently absent, and when present were not fully productive. The aggregate costs of treating back pain were high, and long delays for patients to receive an appointment at Virginia Mason led to longer absenteeism. Starbucks through its insurance company called on Virginia Mason to redesign how the medical center cared for patients with back pain. Virginia Mason collaborated with Starbucks, the insurance company, and several other major employers to establish five governing principles: 1. Focus on customers highest costs, 2. Adopt the customers definition of quality, 3. Create evidence-based value streams, 4. Employ systems engineering to remove waste, 5. Use a cost-reduction business model. Virginia Mason then mapped the value stream, revealing multiple areas of waste: too long for the spine clinic to answer the phone, too long a wait for the initial appointment, further long waits for MRIs, additional waits to see the physician again, and then another wait time to begin treatment. The chief of physical medicine and rehabilitation at Virginia Mason decided that patients should be sorted into complicated and uncomplicated cases. The uncomplicated cases generally did not need an MRI or to wait to see an orthopedic surgeon and could begin treatment right away with a physical therapist. In order to eliminate waiting time, the clinic converted to a system of sameday appointments. Patients were evaluated by a team of a physical therapist and a physician. The physical therapist would see the patient first, take a history, and conduct a physical exam. The physician then would join the therapist and hear the history; if pain medications or imaging studies were needed, the physician would order them. Physical therapy would commence at the first visit. Physical therapists had considerable patient-relationship skills and became a key component of the redesign s success. Reducing the use of MRIs was far more difficult to implement than the other changes. Many physicians initially ignored the new evidence-based guidelines. Then an initial stopgap step (a screen) was put in place that required physicians to check off an evidence-based indication for the MRI. MRI use dropped 31 percent almost immediately. This screen is an application of the VMPS concept of mistake-proofing: not allowing the process to continue without deliberate consideration. 11
Lessons Learned Cultural transformation and adoption of the Virginia Mason Production System is an ongoing process, requiring continuous leadership perseverance and courage. Leaders must understand the philosophy, tools, and methods of the system so they can serve as coaches and teachers. Leaders must learn to see differently and focus relentlessly on putting the patient first. For example, a common mental model for health care is that some level of error and poor quality is inevitable. The production system philosophy is based on the concept that zero defects is the only acceptable state and that perfection is possible. By reimagining what is possible, leaders can create a vision for change and transformation. A core principle of the production system is that the frontline staff the workers directly involved in the process are in the best position to understand the work and identify opportunities for improvement. Frontline staff are best able to generate and implement the ideas necessary to reduce waste, improve quality and the patients experience, and increase staff engagement and satisfaction. Management s role must change from a traditional top-down approach to one of empowering frontline staff and equipping them with the resources and tools to change and improve. By respecting the role and knowledge of frontline staff, leaders can ensure that continuous improvement becomes embedded in daily work, transforming the culture and ultimately transforming the health care system. 12
Resources Virginia Mason Medical Center Web site. Available at: www.vmmc.org. Describes the scope and services of Virginia Mason Medical Center, awards, and selected VMPS projects. Virginia Mason Institute Web site. Available at: www.virginiamasoninstitute.org. Describes training and education in the Virginia Mason Production System for other health care organizations. Kenney, C. Transforming Health Care: Virginia Mason Medical Center s Pursuit of the Perfect Patient Experience. New York: Productivity Press; 2011 Virginia Mason Medical Center. 13
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