Seeking Perfection in Healthcare: Applying the Toyota Production System

to Medicine

Association of University Programs in Health Administration

J. Michael Rona, PresidentVirginia Mason Medical Center

June 25, 2006

“If you are dreaming about it…you can do it.”

Chihiro Nakao, Chairman and CEO

Shingijutsu International

November 4, 2003

Virginia Mason Medical Center Strategic Plan

What is the problem?

Poor QualityImpact on individualsCost of poor qualityCost of healthcare to those who payAccessMorale of workers

3% defect rate100% defectBillions of dollarsUnaffordable ………..Millions Unreliable systems

Virginia Mason Medical CenterNovember 23, 2004

Investigators: Medical mistake kills Everett woman

Hospital error caused death

Mary L. McClinton

Strategic Issues for BusinessQualitySafetyMoraleCost Margin

Profit

Selling Price

Selling Price

Cost

(1) (2)

Profit = Selling price - Cost

For an increase in profit:(1) Increase the selling price. This is determined by the market.(2) Lower the cost. This is achieved by Kaizen.

Virginia Mason Medical Center Strategic Plan

Overview

Taiichi Ohno – Father of the Toyota Production System

“You should submit wisdom to the company.

If you don’t have any wisdom to contribute, submit sweat.

If nothing else, work hard and don’t sleep.

Or resign.”

Taiichi Ohno’s Seven Wastes

MUDA

Time on Hand(Waiting)

Transportation

DefectiveProducts

Processing

Movement

Stock on Hand(Inventory)

Overproduction

The Impact of TPS: Half is Waste

½ the human effort½ the space½ the equipment½ the inventory½ the investment½ the engineering hours½ the new product development time

The Virginia Mason Production System

Virginia Mason Production System

To Make things in the Right Way

Virginia Mason Production System

To Make things in the Right Way

JUST IN TIME

Operate with the minimum resource required to consistently deliver

• Just what is needed.• In just the required

amount.• Just where it is

needed.• Just when it is

needed.

MaterialsMaterials

Machines

People

AndonOperational Availability

Standard Work in Process

Kanban

StandardWork

Pull System Production

One Piece Flow Production

Supermarket System

Takt TimeProduction

JidokaOne-by-one confirmation to detect abnormalities.Stop and respond to every abnormality.Separate machine work from human work. Enable machines to detect abnormalities and stopautonomously.

Leveled Production (Heijunka)

Cost Reduction Through The Elimination of Muda (Waste)

Seeing with our Hands…Japan 2002

Summary

How are air conditioners, cars, looms and airplanes like health care?

• Every manufacturing element is a production processes

• Healthcare is a combination of complex production processes: admitting a patient, having a clinic visit, going to surgery or a procedure and sending out a bill

• These products involve thousands of processes—many of them very complex

• All of these products, involve the concepts of quality, safety, customer satisfaction, staff satisfaction and cost effectiveness

• These products, if they fail, can cause fatality

The VMPS Plan - 2002

1. “Patient First”

2. The Virginia Mason Production System

3. “No Layoff Policy”

4. “The Patient Safety Alert System”

5. Innovation

6. Economic prosperity through the elimination of waste

7. Leadership Accountability

The Virginia Mason Production System is our

Method

Quality is our Business Strategy

The VMMC Quality Equation

Q: QualityA: AppropriatenessO: OutcomesS: Service W: Waste

Q = A × (O + S)W

WASTE

VMPS Tools Action

Patient Safety Alert SystemValue Stream DevelopmentRPIW (Rapid Process Improvement Workshop)5-S (Sort, simplify, standardize, sweep, self-discipline)3-P (Production Preparation Process)Daily work life – Everyday Lean Idea System (ELI)

Global Enterprise Value Stream

• Identify value stream

• Make value flow

• Pull value through from supplier’s supplier to customer’s customer

• Remove waste

• Pursue perfection

Steps

Health Care EnterpriseHealth Care Enterprise

HospitalHospital

OROR

Overview

Right Size Equipment

3P

3P

VSM Mapping

VSM

VSM

Kaizen

Kaizen

Kaizen

Kaizen

Kanban

Kanban

Kanban StandardWork: SW

SW

SW SW SW SW SW

VMPS Tools

Patient Safety Alert SystemValue Stream DevelopmentRPIW (Rapid Process Improvement Workshop)5-S (Sort, simplify, standardize, sweep, self-discipline)3-P (Production Preparation Process)Super FlowDaily work life – Everyday Lean Idea System

Stopping the line

Stopping the Line™

Virginia Mason’s Patient Safety Alert System™

Stopping the Line™Safety Intervention Concepts

Safety hazards are process defects

Process defects are leastharmful and easiest to fix at the time they arise

Process defects are moreharmful and harder to fix as they go downstream

Everyone is an inspector

Everyone can stop defects

If the process cannot be stopped from making defects, the process must stop

Average Monthly Declared PSAs

3 10 17

251

0

100

200

300

2002 2003 2004 2005

Num

ber

Distribution of Declared PSA’s

41%

19%5%

34%

1%

Systems

Medication Errors

Diagnosis & Treatment

Facilities & Equipment

Professional Conduct

VMPS Tools

Patient Safety Alert SystemValue Stream DevelopmentRPIW (Rapid Process Improvement Workshop)5-S (Sort, simplify, standardize, sweep, self-discipline)3-P (Production Preparation Process)Super FlowDaily work life – Everyday Lean Idea System (ELI)

GI / Endoscopy 2001-200512 RPIW’sFocus

StandardizationTravelTurnoverSet UpSchedulingResult ReportingInventorySupplies

Net Margin Per Room +48% Net Margin Increase per year: $ 2.1 MillionNo Additional Procedure Rooms (est. savings $2,000,000)GI Clinic Access Improved 50%

$620,000$755,783

$916,375

0

200000

400000

600000

800000

1000000

Net Margin Per Room

2001 2003 2005 (est.)

Primary Care – Flow Stations

CHARGESLIP

$

DOCUMENT VISIT

$

CERNER MESSAGE

URGENT

PAPER MAIL

RESULT REPORT

Lean Concepts of a Flow Station

•Waste of motion (walking)•Continuous flow•Visual control (Kanbans)•External setup•Water strider•U-Shaped Cell

Creating MD Flow Reduces Patient Wait Times

Flow Stations

“Less nursing time provided to patients is associated with higher rates of infection, GI bleeding, pneumonia, cardiac arrest and death.”

Keeping Patients Safe: Transforming the Work Environment of Nurses~ Institute of Medicine 2004

Nursing Cells – The “ideas”

Nursing “Cells”

Nursing Cells

Organize work of RN and patient care technician (PCT) in a geographic grouping of rooms (cell)Supplies at point of useOne piece flow – documentationIn room handoff with patientsStandardize work for PCT and RN from 7AM –11 AM (First cycle of day)Increase nursing surveillance of our patients—make care safer

Nursing Cells – Results after 90 daysBefore AfterRN # of steps = 5,818PCT # of steps = 2,664Time to the complete am cycle of work = 240’Patients dissatisfaction = 21%RN time spent in indirect care = 68%PCT time spent in indirect care = 30%Call light on from 7a-11a = 5.5%Time spent gathering supplies = 20’

8461256126’0% 10%16%0%11’

Measuring our results: 2002-2005

77 FTE’s freed up!

A reduction of702 Days!!!

A reduction of70 miles!!

A reduction of34 miles!!

Mary L. McClinton

“This Day brings a lot of Rearrangement”

Pastor McNutt, Jr.November 27,2004

Executive Leadership Goal – 2005

Ensure the Safety of our Patients:Eliminate Avoidable Death and Injury

1. Zero avoidable “Codes”

2. Zero failures to follow specified critical safety policies:

Patient ID; Procedural Pause; Solutions/Medication Labeling; MD Response to calls; Patient Summary List;

3. 100% conformance with Clinical Care “bundles”:

Acute Myocardial Infarction (heart attack) “AMI”; Congestive Heart Failure “CHF”; Central Line “CL”; Ventilator Associated Pneumonia “VAP”; Surgical Site Infection “SSI”;

4. Zero Preventable Adverse Drug Events

Safe Medication Ordering; Medication Reconciliation

Quality & Standard Work:Gold Standard

VAPMETAvoidable CodesMedication and Solution LabelingPatient Summary ListAMI BundleSafe Medication Ordering

Quality and Cost: Standard WorkImplementing the Ventilator Acquired Pneumonia Bundle

40

28

22

14

53

0

5

10

15

20

25

30

35

40

Cases

200020012002200320042005

1.6

1.1

0.88

0.6

0.20.1

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Estimated Cost in Millions

200020012002200320042005

Mortality Rate: 14% rate

VAP Cases Cost in Millions

*Data complete through September 2005

Medical Emergency Team Calls

MET Team Utilization

0

20

40

60

80

100

Nov-04

Dec-04

Jan-0

5

Feb-05

Mar-05

Apr-05

May-05

Jun-0

5

Jul-0

5

Aug-05

Sep-05

Oct-05

Avoidable Codes

Percent Avoidable Codes

0

1

2

3

4

5

6

7

8

9

10

Nov-04

Dec-04

Jan-05

Feb-05

Mar-05

Apr-05

May-05

Jun-05

Jul-05

Aug-05

Sep-05

Oct-05

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AvoidableCodes

VM Goal

PercentAvoidable

Medication & Solution Identification

Compliance with Medication and Solution Labeling

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

May-05

Jun-0

5

Jul-0

5

Aug-05

Sep-05

Oct-05

Nov-05

Dec-05

Jan-0

6

Feb-06

Mar-06

Apr-06

Patient Summary List

Percent Compliance with Patient Summary List

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Jan-05

Feb-05

Mar-05

Apr-05

May-05

Jun-05

Jul-05

Aug-05

Sep-05

Oct-05

Nov-05

Dec-05

AMI Bundle

AMI: Zero-Defect AMI Bundle Performance

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nov-04

Dec-04

Jan-0

5

Feb-05

Mar-05

Apr-05

May-05

Jun-05

Jul-0

5

Aug-05

Sep-05

Oct-05

Safe Medication Ordering

Defect Rate in Medication Orders

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nov-04

Dec-04

Jan-0

5

Feb-05

Mar-05

Apr-05

May-05

Jun-0

5

Jul-0

5

Aug-05

Sep-05

Oct-05

Leapfrog

Hospital Name City CPOE ICU High Risk Treatments

SafePractices

ScoreResults

Submitted

Updated:9-20-05

Business Validation

External ValidationVIRGINIA MASON IS RECOGNIZED BY U.S. NEWS & WORLD REPORT IN

‘AMERICA’S BEST HOSPITALS’ RANKINGVM Ranks in the Top 50 Hospitals Nationwide for Digestive Disorders

Virginia Mason Medical Center2004, 2005. 2006 Distinguished Hospital Award for Clinical

ExcellenceHealthGrades* rated VM among the top five percent of acute-care

hospitals in the U.S. for overall clinical performance.

Virginia Mason is the only recipient in Washington State .

VM Providers Recognized on Seattle magazine's 2005 Best Doctors List

The listing features 125 Virginia Mason doctors - nearly 40 percent of all of the physicians on the list. The cover of the magazine features William DePaso, MD of The Sleep Disorders Center at Virginia Mason.

Financial UpdateApril 2006 YTD Results

($’s in Millions) 2006 2005Operating Income Actual $6.771 $3.975

VMMC Organizational Goal – 2006

Ensure the Safety of our Patients:Eliminate Avoidable Death and Injury

1. Zero avoidable deaths

2. Zero failures to follow specified critical safety policies:

Patient ID; Procedural Pause; Solutions/Medication Labeling; MD Response to calls; Patient Summary List; Critical Results Reporting; Clinical Hand-off Communication

3. 100% performance with Clinical Care “bundles”:

Acute Myocardial Infarction (heart attack) “AMI”; Congestive Heart Failure “CHF”; Stroke; Central Line “CL”; Ventilator Associated Pneumonia “VAP”; Surgical Site Infection “SSI”;

4. Zero Adverse Drug Events

Medication Reconciliation

Ongoing Challenges - Culture

Patient First

Belief in Zero Defects

Professional Autonomy

“Buy In”

“People are Not Cars”

Pace of Change

Victimization

Leadership Constancy

Rigor, Alignment, Execution

Drive for Results

“It is not by accident that you were chosen to be a leader. It is your

destiny.”

Sensei Chihiro Nakao

Discussion