Seeking Zero Defects: Applying the Toyota Production ... · Seeking Zero Defects: Applying the...

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1 Seeking Zero Defects: Applying the Toyota Production System to Medicine Estes Park Institute February 24, 2009 Gary S. Kaplan, MD, Chairman and CEO Virginia Mason Medical Center Seattle, Washington “If you are dreaming about it… you can do it.” Sensei Chihiro Nakao First, Some Background… Virginia Mason Medical Center An integrated healthcare system 501(c)3 Not for Profit 336 bed hospital 9 locations (main campus and regional centers) 470 physicians 5000 employees Graduate Medical Education Program Research center Foundation

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Page 1: Seeking Zero Defects: Applying the Toyota Production ... · Seeking Zero Defects: Applying the Toyota Production System to Medicine Estes Park Institute February 24, 2009 Gary S.

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Seeking Zero Defects: Applying the Toyota Production

System to Medicine

Estes Park InstituteFebruary 24, 2009

Gary S. Kaplan, MD, Chairman and CEOVirginia Mason Medical Center

Seattle, Washington

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

Sensei Chihiro Nakao

First, Some Background…Virginia Mason Medical Center

• An integrated healthcare system• 501(c)3 Not for Profit• 336 bed hospital• 9 locations (main campus and regional centers)• 470 physicians• 5000 employees• Graduate Medical Education Program• Research center• Foundation

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The Challenge of Healthcare• Poor Quality………………………3% defect rate

• Impact on individuals………………100% defect

• Cost of poor quality……………Billions of dollars

• Cost of healthcare tothose who pay……………………..Unaffordable

• Access…………………………………….Millions

• Morale of workers………….Unreliable systems

Virginia Mason Medical Center Strategic Plan

• Culture

• Lack of Shared Vision

• Misaligned Expectations

Why is Change So Hard?

g p

• No Urgency

• Ineffective Leadership

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1. Increase Urgency

2. Build the Guiding Team

3. Get the Vision Right

Kotter’s Eight Steps for Successful Large Scale Change

4. Communicate for Buy-in

5. Empower Action

6. Create Short-term wins

7. Don’t Let Up

8. Make Change Stick

An Embarrassingly Poor Product

The March 16, 2003 edition of The New York Times Magazine front cover reads, “Half of what doctors know is wrong.”

The lead story is titled “The Biggest Mistake of Their y ggLives” and chronicles four survivors of medical errors.

The article goes on to say that in 2003, as many as 98,000 people in the United States will die as a result of medical errors.

Investigators: Medical mistake kills Everett woman

Virginia Mason Medical CenterNovember 23, 2004

Hospital error caused death

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Traditional Compact

• Despite the fact things weren’t working, most physicians clung to the fundamental “gets” they felt due them

ProtectionProtection

Autonomy

Entitlement

• Physician-centered world view prevailed

Virginia Mason Medical Center Physician CompactOrganization’s ResponsibilitiesFoster 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

researchListen and Communicate• Share information regarding strategic intent,

organizational priorities and business decisions• Offer opportunities for constructive dialogue• P id l itt l ti d f db k

Physician’s ResponsibilitiesFocus 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 serviceCollaborate 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• Provide regular, written evaluation and feedback

Educate• Support and facilitate teaching, GME and CME• Provide information and tools necessary to improve

practiceReward• Provide clear compensation with internal and market

consistency, aligned with organizational goals• Create an environment that supports teams and

individualsLead• Manage and lead organization with integrity and

accountability

Participate in or support teachingListen and Communicate• Communicate clinical information in clear, timely manner• Request information, resources needed to provide care

consistent with VM goals• Provide and accept feedbackTake Ownership• Implement VM-accepted clinical standards of care• Participate in and support group decisions• Focus on the economic aspects of our practiceChange• Embrace innovation and continuous improvement• Participate in necessary organizational change

Hardwiring Compact

• OrientationReviewed at current orientationThis year orientation to be reconfiguredClinical Mentoring Process to be developedg p

• Job DescriptionsChiefSection HeadPhysicians

• Feedback

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Virginia Mason Medical Center Strategic Plan

The VMMC Quality Equation

Q = A × (O + S)

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

Q ( )W

New Management Method: The Virginia Mason Production System

We adopted the Toyota Production System philosophies and practices and applied them to health care because health care lacks an effective management approach that would produce:

Customer first• Customer first

• Highest quality

• Obsession with safety

• Highest staff satisfaction

• A successful economic enterprise

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“You should submit wisdom to the company.

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

t

GLOBAL PRODUCTION SYSTEM - Overview

sweat.

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

Or resign.”Taiichi Ohno

Taiichi Ohno’s Seven Wastes

Time on Hand(Waiting)

DefectiveProducts

Overproduction

MUDA Transportation

Processing

Movement

Stock on Hand(Inventory)

Relentless “War on Waste”:Key to Quality

• Waste of overproduction • Waste of transportation Patient transfers

Lab tests

7 Wastes:

• Waste of over processing • Waste of inventory• Waste of motion• Waste of making defective

products or poor quality• Waste of engineering

Charge tickets

Drugs, supplies

Searching for charts

Professional liability

Large centralized machines

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The Impact of Lean

• ½ the human effort

• ½ the space

• ½ the equipment½ the equipment

• ½ the inventory

• ½ the investment

• ½ the engineering hours

• ½ the new product development time

Seeing with our EyesJapan 2002

Hitachi Air Conditioning

Team Leader Kaplan reviewing the flow of gthe process with Drs. Jacobs and Glenn

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Summary

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

• Every manufacturing element is a production processes

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

A team of people who do the work, fully

Definition of an RPIWThe Rapid Process Improvement Workshop

engaged in a rigorous and disciplined five-day process, using the tools of Lean to achieve immediate results in the elimination of waste.

© 1996 John Black & Associates

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

• Rehab Medicine Patient Flow• Inpatient Medication Integration • Histology Slide Turn-out • Inpatient Incomplete Chart

Processing • Lindeman Pavilion Pharmacy • Human Resources Service and Adult Ambulatory Visit Flow

• Dermatology 3P • Ambulatory Specialty Scheduling • Federal Way Specialty Clinic and ASC• Disease State Management• Supply Chain• Skilled Nursing Placements• Specimen Collection Mistake Proofing

Processing• Orthopedics/Sports Medicine • Clinical Research• PM & R• Ambulatory Neurology• Ambulatory Transplant• Cardiology• Emergency Department

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5S Anesthesia “Shadow Board” - Before

5S Anesthesia “Shadow Board” - After

Stopping the Line™

Virginia Mason’s Patient Safety Alert System™

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Stopping the line

Patient Safety Alert Resultsas of December 31, 2008

11,677 Patient Safety AlertsDiagnosis/Treatment 26%Medication Errors 21%Systems 37%Equipment/Facilities 3%Safety/Security/Conduct 13%y y

Average # of PSAs/month2002- 3/month2003- 10+/month2004- 17/month2005- 251/month2006- 276/month2007 -238/month2008 - 226/month

GI Services 2001-2007• 11 RPIW’s• Focus

StandardizationTravelTurnoverSet UpScheduling

$620,000

$755,783$904,305

$996,435

$1,163,149

600,000

800,000

1,000,000

1,200,000

SchedulingResult ReportingInventorySuppliesPQ & Analyze

• Net Margin Per Room +88% • Net Margin Increase $ 3.8 Million• No Additional Procedure Rooms

(est. savings $2,000,000)• GI Clinic Access Improved 50%

0

200,000

400,000

Net Margin Per Room2001 2003 2005 2006 2007

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Primary Care – Flow Stations

Lean Concepts of a Flow Station

• Waste of motion (walking)

• Continuous flow

• Visual control (Kanbans)

• External setup

CERNER MESSAGE

URGENT

PAPER MAIL

• Water strider

• U-Shaped Cell

Creating MD Flow Reduces Patient Wait Times

CHARGESLIP

$

DOCUMENT VISIT

$RESULT REPORT

“Nursing Cells” – Results > 90 daysBefore After•RN # of steps = 5,818•PCT # of steps = 2,664•Time to the complete am cycle of work = 240’• Patients dissatisfaction = 21%

846 1256126’0%

Example – Nursing Cells

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’

0% 10%16%0%11’

RN time available for patient care = 90%!

Hospital Acute LOSLead Time Reduction

4.40

4.60

4.80LOS Linear (LOS)

RN CellEstablished

Focus on ELOS

ELOS RPIW #2

ELOSRPIW #1

HighRisk ID

MobilityRPIW

2 BinSystem

RN/PCT Skill Task

CCU ELOSRPIW

RN Bedside Handoff

Hospital Monthly Acute LOS

3.40

3.60

3.80

4.00

4.20

Jun-05

Jul-05 Aug-05

Sep-05

Oct-05

Nov-05

Dec-05

Jan-06

Feb-06

Mar-06

Apr-06

May-06

Jun-06

Jul-06 Aug-06

Sept.06

Oct.06

Nov.06

Dec.06

Jan.07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07 Aug-07

Palliative CareProgram Started

RPIW #2SNF and

Greater than

Lead Time ReductionDeclared as Divsional Goal

CNL RoleImplemented

ELOS #3Care Team

NutritionRPIW

CCU ELOSKAIZEN

Alignment

On Line SNFRequest

Target ELOS floorsKaizen Plan and CNL

CNL/MSW Handoff

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VMPS Educational Strategies• Everyday Lean Idea Campaign – All Staff

• Intro to VMPS (course) & Mistake Proofing – All Staff requirement

• Management Courses in VSM, Std. Ops, Mistake-Proofing &5S

• VMPS for Leaders – 100+ Leaders per year

• VMPS Certification – Senior management requirementVMPS Certification – Senior management requirement

• Kaizen Fellowship – Select senior management

• Japan Gemba Kaizen – Management & staff

• Japan Flow Tour – Fellows and advanced senior leaders

• 3P Certification – select certified leaders

VMMC:Joint Accountability at

Department Level

• Financial performance• O i ht d it i f ti

Vice President Chief

• Oversight and monitoring of operations including patient care, business processes and quality

• Strategic planning and decision making• Performance review of section heads,

administrative directors and managers

Why a Team Leadership Model?

• Provides diversity of skills and perspectives• Able to respond to changing demands more

quickly• Reduces over dependence on individuals• Reduces over-dependence on individuals• Improves communication• Encourages personal growth and development• Enhances willingness to take risks

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Developing “The Learning Team”• Formal leadership training programs• 360° assessment of leadership skills—share results?• Informal feedback/coaching for each other—debrief

sessions• Sh i ti l b k l d hi• Sharing articles, books on leadership• Practice art of giving and receiving feedback• Spend time together – build trust• Use conflict as a learning tool• Share self-assessment of strengths/weaknesses,

personality differences as tool for building respect and trust

Virginia Mason Medical CenterLeadership Compact

Foster ExcellenceRecruit and retain the best peopleAcknowledge and reward contributions to patient care and the organizationProvide opportunities for growth of leadersContinuously strive to be the quality leader in health careCreate an environment of innovation and learning

Focus on PatientsPromote a culture where the patient comes first in everything we doContinuously improve quality, safety and compliance

Lead and AlignCreate alignment with clear and focused goals and strategiesContinuously measure and improve our patient care, service and efficiencyManage and lead organization with integrity and accountabilityResolve conflict with openness and empathyEnsure safe and healthy environment and systems for patients and staff

Promote Team Medicine Develop exceptional working-together relationships that achieve resultsDemonstrate the highest levels of ethical and professional conduct.Promote trust and accountability within the team

Listen and CommunicateShare information regarding strategic intent, organizational priorities, business

Listen and CommunicateCommunicate VM values g g g , g p ,

decisions and business outcomesClarify expectations to each individualOffer opportunities for constructive open dialogueEnsure regular feedback and written evaluations are providedEncourage balance between work life and life outside of work

Courageously give and receive feedbackActively request information and resources to support strategic intent, organizational priorities, business decisions and business outcomes

EducateSupport and facilitate leadership training Provide information and tools necessary to improve individual and staff performance

Take ownershipImplement and monitor VM approved standard work Foster understanding of individual/team impact on VM economics Continuously develop one’s ability to lead and implement the VM Production SystemParticipate in and actively support organization/group decisionsMaintain an organizational perspective when making decisionsContinually develop oneself as a VM leader

Recognize and Reward Provide clear and equitable compensation aligned with organizational goals and performanceCreate an environment that recognizes teams and individuals

Foster Change and Develop OthersPromote innovation and continuous improvement Coach individuals and teams to effectively manage transitionsDemonstrate flexibility in accepting assignments and opportunitiesEvaluate, develop and reward performance dailyAccept mistakes as part of learningBe enthusiastic and energize others

Stand Up Report

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The Boards’ Role in Qualityand Patient Safety Oversightand Patient Safety Oversight

At Virginia Mason

Leaders’ Role in Signal Generation

“Leaders are signal generators who reduce uncertainty and ambiguity about what is important and how to act”.

OROR

— Charles O’Reilly III

Ongoing Challenges - Culture

• Patient First

• Belief in Zero Defects

P f i l A

• Pace of Change

• Victimization

L d hi C• Professional Autonomy

• “Buy In”

• “People are Not Cars”

• Leadership Constancy

• Rigor, Alignment,

Execution

• Drive for Results

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First Challenge is Changing the Mind of Medicine

• Provider First

• Waiting is Good

• Errors are to be Expected

• Diffuse Accountability

• Patient First

• Waiting is Bad

• Defect-free Medicine

• Rigorous Accountability

FROM TO

• Add Resources

• Reduce Cost

• Retrospective Quality Assurance

• Management Oversight

• We Have Time

• No New Resources

• Reduce Waste

• Real-time Quality Assurance

• Management On Site

• We Have No Time

LEADERSHIP MUST CHANGE ITS MENTALITY.

SCARCITY:You are not paying us enough.

ABUNDANCE:We have more than enough.

“Leaders are Dealers in Hope.”

Napoleon Bonaparte