The Virginia Mason Lean Journey

Steve Schaefer Vice President

Virginia Mason Medical Center

Copyright © 2012 Virginia Mason Medical Center. Al Rights Reserved.

• An integrated healthcare system (primary care with 50+ specialties and sub-specialties) founded in 1920.

• 501(c)3 Not for Profit • 336 bed hospital/24 OR’s • 7 locations with 4 ASC’s • 480 physicians • 5500 employees • Benaroya Research Institute • Virginia Mason Institute • Center for Healthcare Solutions • $900m+ net revenue

Virginia Mason Medical Center

Copyright

Our Strategic Plan

Mental Transformation is the Goal

"Baseball is 90% mental; the other half is physical.”

Yogi Berra

Common Leadership “Mental Paradigm” Problems

• Manage from office • Tell people what to do • Blame • Manage by numbers • Respond to fires • Seek confirming evidence • Delegate • I have the answer

• Go see • Teach people • Improve process • Quantitative + Qualitative • Ask why, why, why… • Seek contrarian views • Participate • Let team do analysis

Same Old Routine Practice New Routine

But Be Prepared………….

…It will be like turning the Queen Mary

Where was Toyota in the 1950s?

Or “Made in Japan” in the 1960’s?

The Paradox

• Daily Sense of Urgency in our Attack on Waste + Daily Shop Floor Orientation = Turning of Queen Mary

• It starts with the tools, but the true power of Kaizen is in its ability to transform a culture over time

“If you want one year of prosperity, grow seeds, If you want ten years of prosperity, grow trees, If you want one hundred years of prosperity, grow people.”

Chinese Proverb From Toyota Talent, Chapter 1

Our story begins on November 9th, 2000

•Our former President Mike Rona flew from Seattle to Atlanta on Delta Airlines flight 706.

•Next to him sat John Black, a Lean consultant who introduced Mike to Lean Production and the Toyota Management Method.

He came back and told our CEO Dr. Gary Kaplan

•They both saw its application to healthcare and how it could give us a systematic method to achieve our Strategic Plan.

• From the very beginning, this effort has been led from the very top.

Kaizen Promotion Office Standup Every Tuesday 7:00-7:30am

2001- The Journey Begins • We had to learn Japanese Terms! - Jidoka - Heijunka -Muda - Kanbans - Takt Time -Kaizen • And the concepts - One-piece-flow -Perfection -Cell Design - Pull -Value Stream -Mistake Proofing • We had resistance: “It’s the latest fad of CQI and TQM dressed up

differently. Trust me: Just ignore it…..it will go away.”

• “We don’t make cars, we provide healthcare for people!”

• Many of us were defensive, and/or went through the grief cycle: Denial…Anger… “Not in my area!”

• And we learned about ‘The Seven Wastes”

Taiichi Ohno's Seven Wastes

Transportation Conveying, transferring, picking up.setting down, piling up and otherwise moving unnecessary items.

Processing Unnecessary processes and operations traditionally accepted as necessary

Overproduction Producing what is unnecessary, when it is unnecessary, and in unnecessary amounts

Time •Waiting for people or services to be provided. •Time when your processes, people and machines are idle.

Inventory •Maintaining excessive amounts of parts, materials, or information for any length of time. •Having more on hand than what is needed and used.

Motion •Unnecessary movement or movement that does not add value. •Movement that is done too quickly or slowly.

Defects •Waste related to costs for inspection of •Defects in materials and processes. •Customer complaints. •Repairs Waste

And we were introduced to the Rapid Process Improvement

Workshop (RPIW) A simple, rigorous and thorough

reengineering process that accelerates improvement, eliminates waste, and gets dramatic, bottom-line reductions in cost and flow time in five days by empowering the people who do the work to make the changes.

At the end of 2001 I was told, “You will be certified.”

• In addition to my regular full-time job!

• Summer of 2002 certification begins: - The Books - The Forms - Lead time Observation Form - Standard work combination sheet - Percent Loading Chart - Standard Work Sheet …and the Value Stream Maps…

My First Value Stream Map

Hospital Late Charge RPIW December 2002

The Beauty of VMPS: Cross Functional Communication and Teamwork

November 2004: The life and death of Mary McClinton and her impact on our

journey

The Life of Mary McClinton

• Born June 28, 1935 in Newport Arkansas • Attended Philander Smith College in Little

Rock • In 1955, left school to help raise her

sisters and brothers after her mother passed away

• Continued as mother to her siblings until they all had graduated from high school

The Life of Mary McClinton • In 1967, moved to Juneau Alaska • Finished college with a degree in social

work • Advocate for the disabled, poor, and

Native Alaskans • Selected by Governor to be on the

Alaskan Women’s Commission • Formed Coalition Against Racism and

Discrimination in Schools (CARDS)

The Life of Mary McClinton

• Counselor/Job Coach for the Juneau Alliance for the Mentally Ill.

• While raising four sons, also foster-parented eight mentally handicapped children

• Adopted by the Tlingit Tribe of Juneau • Named “Jin-Koo-See’e”, or in English:

“Hands That Make Dreams Come True”

The Life of Mary McClinton • Moved to Lynnwood, Washington in the 90’s • Counselor at the Central Area Motivation Project

(homeless shelter and training center for those in need)

• Joined Greater Trinity Missionary Baptist Church in Everett, Washington

• Program Director for the Learning Academy • Active in the Choir, Pastor’s Aide Committee,

and the Mother’s Board • Spearheaded support for a multi-purpose sports

court that would serve the community

What happened on November 4th, 2004?

•Two unlabeled containers were presented in the sterile field

•One contained marker dye, and the other contained Chlorexidine

C i ht © 2008 Vi i i M M di l C t All Ri ht R d A f th di t ib ti f th t i l i hibit d

• Mary McClinton was injected with the colorless, toxic antiseptic/cleaning solution

• The solution had recently been changed from a brown iodine based solution

• Had been placed in an unlabeled cup identical to that used to hold the marker dye

• A memo went out to all staff on November 11th communicating what had happened.

November 2004

November 2004

• Over the next 19 days, she suffered great pain

• A stroke • Two cardiac arrests • Amputation of her leg in an attempt to

save her life • She eventually died on November 23,

2004

Virginia Mason Medical Center November 23, 2004

“Investigators: Medical mistake

kills Everett woman”

“Hospital error caused death”

At her memorial service, Pastor Paul A. Stoot Sr. spoke on:

What’s in the Dash?

“This day brings a lot of rearrangement”

November 27,2004

A Turning Point for VMMC

•This event and the decision for full public transparency was a defining moment for the organization.

Patient Safety Alert™

• A healthcare process/system or the action of staff member(s) . . . • Can be the subject of an immediate review to . . . • Assess risk, develop a corrective action plan, implement the plan

and to provide monitoring to . . . • Assure the safety of our patients, visitors, and employees.

A Patient Safety Alert can be a discreet single event not involving complex system issues or an event having more complex quality of care or system issues.

A Patient Safety Alert initiates a process for alerting a response team so that:

Stopping the line

“Stopping the Line” Organization-wide Involvement

• Staff identify and report issues and concerns using the Patient Safety Alert System

• Leadership involvement with investigation and resolution

• Board Quality Committee review and approve closure of high-severity issues (Red PSA’s)

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50

100

150

200

250

300

350

400

2002 2003 2004 2005 2006 2007 2008 2009 2010

# of PSA's

Where is VM Today?

•VMPS is embedded in all that we do…it is our management method.

• It defines who we are and how we think each day.

• It is our foundation in putting the patient first in all that we do

2001-2012 RPIW Example Areas • GI Ambulatory • HR Business Partner • PACU • Radiology • Hospital 3P • Periop Induction Room • Adult Ambulatory Visit Flow • Legal • Ambulatory Specialty

Scheduling • Federal Way Specialty Clinic • Disease State Management • Supply Chain • Skilled Nursing Placements • Specimen Collection Mistake

Proofing

• Payroll • Inpatient Medication • Insurance Contracting • Inpatient Incomplete Chart

Processing • Outpatient Pharmacy • Human Resources • Orthopedics/Sports Medicine • Clinical Research • PM & R • Ambulatory Neurology • Cardiology • Emergency Department

Legal Department Contract Review Process Value Stream Map

HR-Payroll Value Stream Map

Payroll costs represent 65% (approx. $490 million/year) of VM’s total expenses.

Orthopedic Purchasing Value Stream Map

Orthopedics: Kaizen Timeline

Total Hip & Knee Implant Standardization

Focus Focus: • Identification of significant savings opportunities for Virginia Mason if we standardized our implant products for total hip and Knee surgeries.

• Switched from 7 vendors for hip and knee products to

two, resulting in an annual savings of $1.3 million dollars.

• Includes Group Health, Pacific Medical Center and

Virginia Mason physicians

• Involved a number of leaders: • Supply Chain • Richelle Bagdasarian • Steve Graham • Lyle Sorenson, MD • Paul Benca, MD • Clinic & Corporate KPO • Amerinet • VM/ GHC/ PMC Orthopedic Physicians

Results

Feedback Loops Post Implementation PDSA Routinely shared in Integrated, monthly Clinic/

Corporate Kaizen Planning meetings

Results

Dollars Saved

VSM

Flows to the OR RPIW #1, Q1 OR 6 Critical Supply Room

Focus Results • Eliminate Duplicate Products • Establish roles and standards for

ordering, monitoring and safety • Inventory reduction in the OR

• Inventory Reduced by $124k • 5s Agreement produced. Roles and responsibilities

clearly defined. • Productivity Gain of 0.53 FTE • Key learning: Inventory is not location dependent.

Must understand the inventory along the entire VSM.

Flows to the OR RPIW #2, Q2 Focus Results

• Develop dependable communication pathway.

• Develop tools to support Distribution team to meet OR Needs in timely manner.

• Reduce lead time and over-processing related to defects

• Supply Chain and Operating Room Collaboration and teamwork!

• Implementation of the CS Dispatch Model: One Call Does it All

• Productivity Gain: 0.71 FTE • Increased transparency and reporting, leading to

tracking/trending for future Kaizen work.

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Card not picked correctly

Contaminated Package

Large Patient

Restock/not stocked item

Clinical Anticipation

Wrong quantitiy delivered 1st …

Undefined item on Picklist

Flows to the OR, Q4 Focus Results

• RPIW #3, Oct 24-28: Procedure Cards Determine methodology for creating perfect

procedure card, based on utilization of supplies. - - - -

• RPIW #4, Dec 19-23: New Item Set-up Decrease long lead time, make the process

visible, mistake proof flow between info systems

• Creation of agreed upon floor and ceiling return rates for procedure cards.

• Creation of Master Supply Locator for the OR. - - - -

• Creation of Electronic Status Board • Creations of SurgiNet Edit Report • New Item Location on H3

.

The Future? •Respect for People •Intra-company and Inter-community

collaboration and partnership •The problems of healthcare being

resolved via your processes and your people…and not in the halls of Congress alone

•One person…..one process at a time

Key Learnings •Get out of your office •Know how things really work…No

Assumptions •Ask why 5 times •Create a sense of urgency •Horizontal vs. Vertical Orientation… No

process or relational myopia •Great enemy within any Medical Center is

WASTE … Not the Supply Chain…. or IT….or HR…

“In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists.”

Eric Hoffer

“Leaders are Dealers in Hope.”

Napoleon Bonaparte