Transforming Healthcare: An Overview of the Virginia Mason ... · •500 physicians •5,500...
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Transforming Healthcare: An Overview of the Virginia Mason Production System
© 2013 Virginia Mason Institute, all rights reserved
© 2013 Virginia Mason Medical Center
Virginia Mason Medical Center • Integrated health care system • 501(c)3 not-for-profit • 336-bed hospital • Nine locations • 500 physicians
• 5,500 employees • Graduate Medical Education • Research Institute • Foundation • Virginia Mason Institute
© 2013 Virginia Mason Medical Center
Sense of Urgency: Health Care Challenges
• Poor quality health care = 3% defect rate and
costs the U.S. billions of dollars
• Health care is unaffordable and unavailable to
millions of people
• Health care workers are negatively impacted by
unreliable systems
• VMMC financial loss for two successive years
Virginia Mason Medical Center
Strategic Plan
Shared Vision
© 2013 Virginia Mason Medical Center
Q: A: O: S: W:
Q = A × (O + S) W
The VMMC Quality Equation:
Quality Appropriateness Outcomes Service Waste
• Provider First
• Waiting is Good
• Errors are to be Expected
• Diffuse Accountability
• Add Resources
• Reduce Cost
• Retrospective Quality Assurance
• Management Oversight
• We Have Time
• Patient First
• Waiting is Bad
• Defect-free Medicine
• Rigorous Accountability
• No New Resources
• Reduce Waste
• Real-time Quality Assurance
• Management On Site
• We Have No Time
FROM TO
Transforming Healthcare…
Physician
Compact Aligned Expectations
Board
Compact
Leader
Compact
Visible & Committed Leadership
Dr. Kaplan reviewing the flow of the process with Drs. Jacobs and Glenn
Sense of Urgency
Visible & Committed Leadership
Aligned Expectations
Improvement Method
Technical & Human
Dimensions of Change
Requirements for Transformation
Shared Vision
The Virginia Mason Production System
1. The patient is always first
2. Focus on the highest quality and
safety
3. Engage all employees
4. Strive for the highest satisfaction
5. Maintain a successful economic
enterprise
We adopted the Toyota Production System key philosophies
and applied them to healthcare
1. The Patient is Always First
• The patient is at the top
of our strategic plan
• Value is defined by the
patient
• Patient’s voice is
embedded in our
improvement activities
2. Focus on Highest Quality & Safety
• Embedding mistake
proofing into
everything we do
• Patient Safety Alert
(PSA)
• 5S across VMMC
• Standard Work
“Stopping the line” Organization-wide Involvement
1. Staff report issues
using the Patient Safety
Alert System
2. Leadership investigates
and resolves issues
3. Board Quality
Committee review/
approve closure of
high-severity issues
40,000th PSA Reported
End of January 2014: 43,615
This is a good
question. He must
have read the
materials before the
meeting.
“Good Catch!” Safety Award
Patient Safety Alerts Newsletter
2011 Mary McClinton Safety Award Medication Reconciliation
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percent of Reconciled Medications on Discharge
% VM Target UCL LCL
November 2010:
PowerChart Phase II:
Effectiveness of Patient Safety Program: Total Number of Claims and PSAs Reported
Total number of claims excludes claims closed with no payment
8
2697
3500
3079
2726 2954
4322
5386
60
71
67
60
44 46
42
26
0
1000
2000
3000
4000
5000
6000
0
10
20
30
40
50
60
70
80
5/31/03-04 5/31/04-05 5/31/05-06 5/31/06-07 5/31/07-08 5/31/08-09 5/31/09-10 5/31/10-11
PSAs Reported
Reported Claims
8
Reduction of Hospital Professional Liability Premiums
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
Premiums $4,068 $4,211 $3,900 $3,442 $3,275 $2,438 $2,151 $2,004 $1,779
4% 7%
12% 5%
26% 12%
7% 13%
$0$500,000
$1,000,000$1,500,000$2,000,000$2,500,000$3,000,000$3,500,000$4,000,000$4,500,000
Hospital Professional Liability Premiums
% change from previous year
Report Published December 2010
Safety Culture Question Staff Speak Up Freely*
76%
74%
79% 79%
81%
70%
72%
74%
76%
78%
80%
82%
Year 1 Year 2 Year 3 Year 4 Year 5
*Question: Staff will speak up freely if they see something that may negatively affect patient safety
Respect for People refers to how we treat each other as we work together to create the
perfect patient experience.
Surgical Attestation Video
3. Engage all Employees
• Employees trained in VMPS
• Involve employees in improving their own work with ELI
• RPIW/Kaizen
Defect by product grouping
Defect by Root Cause (Process Accountable)
Defect by Risk to the Patient (Red, Orange,
Yellow)
Employee Engagement: Sterile Processing
#4 Strive for Highest Satisfaction Levels
84
86
88
90
92
94
96
98
100
2007 2008 2009 2010 2011 2012
Clinic Patient Satisfaction and Likelihood to Recommend
Clinic Patient Satisfaction Likelihood to Recommend
22nd
Percentile
69th
Percentile
78
80
82
84
86
88
90
92
94
96
98
100
2007 2008 2009 2010 2011 2012
Hospital Patient Satisfaction and Likelihood to Recommend
Hospital Patient Satisfaction Likelihood to Recommend
30th
Percentile
90th
Percentile
23rd
Percentile
67th
Percentile
15th
Percentile
86th
Percentile
Virginia Mason Annual HCAHPS “Top Box” Performance Trend
VMMC Staff Partnership Results
68.5
72.4 74.1 73.3 74.2 74
50
55
60
65
70
75
80
85
90
95
2007 2008 2009 2010 2011 2012
Staff Partnership Score
59%
66%
73%
78%
83% 81%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
2007 2008 2009 2010 2011 2012
Staff Partnership Response Rates
5. Maintain a Successful Economic Enterprise
$0.70
$3.20
$12.00
$18.40
$29.40
$49.40
$40.90
$35.40
$25.63
$22.68
$0
$10
$20
$30
$40
$50
2000 2005 2006 2007 2008 2009 2010 2011 2012 2013
Virginia Mason Net Margin (in Millions)
Shared Success Program
Leadership Requirements
Needed to Sustain VMPS
1. Set priorities that align with the
vision
2. Use VMPS tools & methods
3. Lead change
4. Allocate resources to VMPS
5. Require accountability
6. Implement standard work for
leaders
Annual Goals
Long Term Vision
KPO Priorities
Clinic Priorities
Section Priorities
• Develop and implement a "know you" template in our electronic
medical record (EMR)
• Standard touch point behavior (Milkshake) TBD
• Contribute to my team's excellent phone service performance
• Work to resolve patients needs in one call
• Measure and improve message lead time
• Simplify scheduling "rules", share best scheduling practices, and
reduce appointment types
• Design and test innovative care delivery models
• Increase patient enrollment in MyVirginiaMason
• Pilot patient direct scheduling
• Identify new ways to engage patients to use the portal
• Know and explain how Virginia Mason is present for patients
within my community
• Schedule patients for follow-up appointments before they leave my
clinic
• Successfully implement our ambulatory computerized provider
order entry (ACPOE) system
• Give patients the specific information they need to navigate next
steps in their care
SHA
RE
PR
EPA
RE
• Implement new workflows using our electronic
medical record (EMR)
• Help us grow! Champion our locations, services
and quality to provide our patients what they need
How do I contribute to
these goals?
• Treat every call, every message as our patient
Clinic Focus Areas: Our Work in 2014
BE TH
ERE
• Be present with our patients; demonstrate that
we know them and care
• Engage patients in using MyVirginiaMason to
improve their health and well-being
• Just say yes! Offer patients care when, where and
how it is desired
Aligning Vision with Resources
VMPS Education
Intro to VMPS
VMPS
General
Education
VMPS
Leadership
Training
VMPS
Certification
VMPS
Fellowship
The VMPS Structure
• Kaizen Promotion Office (KPO) is aligned with the operational executive leadership
• Executive sponsors have accountability for sustained results
• 27 KPO staff
CEO
COO
KPO Hospital
Clinic
Corporate
Central
Executives
C O R P O R A T E
H O S P I T A L
C L I N I C
C O R P O R A T E
H O S P I T A L
C L I N I C
Kaizen Promotion
Office
Creating a Versatile Leadership Team
Accountability: Tier Reporting
PeopleLink Tier 3 Reporting: Managers report to department staff and Administrative Directors
“Stand Up” Tier 2 Reporting: Vice Presidents, KPO and Administrative Directors report updates on key
metrics to the Chief Executive Officer
Tier 1 Reporting: Senior Executive Leadership reports updates on key metrics to the Board
of Directors
PeopleLink Board Example
Accountability: Genba Walks
Go to the place, look
at the process, talk
with the people
VMMC Leaders Have Two Jobs
1. RUN their business
2. IMPROVE their business
Daily Team Huddle Board
Courtesy of Christin Gordanier, Hospital Level 9 (Tele)
Standing Topics for
each huddle appear
FIRST
New items added to
reflect current issues
Wipe board pulls off
of wall to use during
huddle, then goes
back up
Standard Work for Leaders
Key activities are
segregated by time
(daily, weekly,
monthly)
Used by all leaders
on Level 9
(Director, ANM’s,
etc.)
Very little is
“permanent” on the
board
Courtesy of Christin Gordanier, Hospital Level 9 (Tele)
FIVE Principle Elements of Daily Management
(Standard Work for Leaders) 1. Visual Controls
Create linked visual systems
that drive action
2. Daily Accountability
Process
Establish rounding process
at all levels
3. Leader Standard Work
Leaders routinely complete key
activities necessary to run and improve
their business
4. Root Cause Analysis
Asking “why” and using data and analysis to
attack problems
5. Discipline Leaders
consistently verify the health of processes and
systems
VMPS Methods and Tools
Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)
Leveled Production (Heijunka)
Just in time
Operate with the
minimum resource
required to reliably
deliver
•Just what is needed.
•In just the required
amount.
•Just where it is needed.
•Just when it is needed.
Jidoka
One-by-one confirmation to detect abnormalities.
Stop and respond to every abnormality.
Separate machine work from human work.
Enable machines to detect abnormalities and stop autonomously.
Pull System Production
One Piece Flow Production
Supermarket System
Takt Time
Production
Andon
Operational
Availability
Standard Work in Process
Kanban
Standard
Work
Materials
Machines
People
The Virginia Mason
Production System To Make things the Right Way
Deeper understanding of current state
VMPS Improvement Pathways
Kaizen: Continuous
Improvement of your current state
Kaikaku: Reinvent your services
and/or products
Understand your current state
RPIW Kaizen Events
3P
RPIW Kaizen Events
Everyday Lean Ideas
Everyday Lean Ideas
Waste: Any task or item
that does not add
value from the
perspective of the
customer.
Processing
Inventory
Time
Defects
Motion
Transportation
Over- production
Just in Time (JIT)
Definition:
Producing…
• Just what is needed
• Just the amount needed
• Just when it is needed
Using the…
• Minimum number of people
• Minimum materials
• Minimum equipment
• Minimum space
3P: Build-To-Order (BTO)
Focus Results Support Respect for People by reducing the burden of work: • SPD staff • Distribution team • OR Turnover team • Scrub Techs
Achievable vision and timeline has been established
Support OR turnover by reducing set-up time for each case
Creation of a BTO guiding team to move this work forward
Guiding principle of Just-in-Time: to give the surgical team only what the specific provider needs for their specific case
Build To Order Results
EVENT OLD NEW
Craniotomy
SPD Set Up = 34:00 min SPD Set Up = 18:27 min
OR Set Up = 24:09 min OR Set Up = 2:34 min
Laminectomy
SPD Set Up = 34:00 min SPD Set Up = 20:15 min
OR Set Up = 24:09 min OR Set Up = 2:29 min
Minor Set OR Set Up = 19:21 min
OR Set Up = 0:20 sec
Setup
is the time spent
preparing to provide
the next product or
service.
Setup reduction is a
method to reduce or
eliminate setup time to
increase capacity and
flexibility.
Typical setup activities:
• gathering
• transporting
• opening
• removing from packaging
• assembling
• installing
• adjusting
• presenting
• disassembling
• cleaning
Heijunka: Leveling the Workload
Min
ute
s
Takt Time
MA
Setup
Setup
MD
Setup
Setup
MA MD
Setup
After Setup Before Setup
• Eliminates walking
• Continuous flow
(no batching)
• Visual control
• Line of sight
• MD and FM
side-by-side
Flow Management at Flow Stations
CHARGE
SLIP
DOCUMENT
VISIT
CERNER
MESSAGE
URGENT
Flow
Station
Inbox
(e.g. labs) Non-urgent
Flow Station
Inbox
(e.g. mail)
CERNER
TEST
RESULT
REPORT,
RTE,
Sign &
Review
MD MA $
After – In Flow
• Provider/FM side by
side
• Standardize Flow
Stations
• Eliminate Walking
• Continuous Flow
• Visual Control
Redesign for Strong Economics Net Margin Before Indirect Cost
($716,391)
($332,983)
$935,834 $1,010,072
($1,000,000)
($800,000)
($600,000)
($400,000)
($200,000)
$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
Year 1 Year 2 Year 3 Year 4
VM Primary Care Kirkland and Main Campus Practices
Value Stream Map
PCP PCP
MRI PCP
TIME
Waits and delays
Non value-added
Evidence-based value
Waiting has indirect cost to
employer of over $18/hr
Neurosurg PT visits 1-15
Physiatry
Value Stream Mapping Right Process: Patient Perspective for Back Pain
Wait for appt
Spine Clinic
TIME
Waits and delays
Non value-added
Waiting has indirect cost to employer of over $18/hr
PT: 2.8 visits
Evidence-based value
Value Stream Mapping Right Process: Care of Back Pain Redesigned
Jidoka Definition
Jidoka is a method to
increase productivity
by implementing
intelligent automation
and defect elimination
strategies.
The Business Case for Quality
Efficient Spine Clinic
1. Lower cost
FTE
Area, ft2
29%
78%
2. Greater revenue
RVU/MD/day
New patients /yr
76%
64%
3. Greater margin/year
Estimated from VM BSR & direct costs 56%
Overall Costs Decreased 20% Greatest Benefit: Avoiding Hospitalizations
62
Dental
Office Visits
-100% -80% -60% -40% -20% 0% 20%
ER Visits
Lab
Admits
Radiology
Costs (standardized)
Out-patient (other)
Outpatient Visits
Hospital
Days
Prescriptions
Home Health Visits
Prescriptions (day supply)
Jidoka Definition
Jidoka is a method to
increase productivity
by implementing
intelligent automation
and defect elimination
strategies.
VMPS Tools
Lead Time, Cycle Time and Takt Time
Lead time the entire time required to provide a product or service, from request to completion
Cycle time the time required for one operator or machine to complete one cycle of work
Takt time the pace of customer demand
Ch
eck
in
Wai
t
Ro
om
an
d
Vit
als
Wai
t
Exam
Wai
t
Pla
n o
f C
are
Wai
t
Test
ing
Periop Flow
Clinic Experience
Inpatient Care
Follow Up Care
Orthopedic Model Line
© 2013 Virginia Mason Medical Center
VMPS Flows of Medicine® Flow of
Family and Relationships
Flow of Providers
Flow of Patients
Flow of Medications
Flow of Supplies
Flow of Information
Flow of Equipment
Flow of Process
Engineering
5S
is a strategy that
helps to keep our
workplace safe and
organized
5S is cyclical
© 2013 Virginia Mason Medical Center
Self Discipline: • Maintain standards
through training, empowerment, commitment and discipline
Sort: • Separate necessary
from unnecessary
Simplify: • A place for everything
needed, in its place and ready to use
Sweep: • Inspection that every-
thing is where it belongs
• Visual confirmation that 5S agreements are being followed
Standardize: • Create common
agreements
• Communicate to the team
5S Anesthesia - Before
5S Creates Safety
5S Anesthesia “Shadow Board” –After
5S Creates Safety
Mistake
Proofing
Defects are mistakes that go
uncorrected
The purpose of VMPS is to ensure
zero defects
So what’s good enough?
Imagine 99.9% quality at VM…
•15 defective surgeries/year
•17 defective transfusions/year
•1,000 defective medication
administrations/year
•182 wrong meals served/year
•17,000 defective bills sent/year
•125 defective paychecks/year
The basic elements of
mistake-proofing are: • inspection
• standard work
• visual control
• devices
Inspection Methods
Within process
Just After
Just Before
Down-stream
A B C
Poke-yoke Self Check
Successive
Check
– Taiichi Ohno Founder of the Toyota Production System
Standard Work
“ ” Without standards, there can be no improvement.
© 2013 Virginia Mason Medical Center
Variation STANDARDIZATION Improvement
“Without Standards There can be no
Improvement”
Adopt Standard Work
Central Line Insertion Standard Work
Dry:
30 sec scrub 30 sec dry
Wet:
2 min scrub 1 min dry
Before
Maximum Barrier
Protection
Thyroid Angio Drapes
Transducer Kit in Top Drawer of
Cart
Transducer Method Manometer Method
During
After
“ Approved to use ” Date/Initial
Complete Paperwork
Yellow – top of cart White – in chart progress notes
OR
OR
Paws
AND
Visual Controls
Skillet Example: www.mistake-proofing.com
Methods, devices, or
mechanisms used to
visually manage
operations
Devices
PDSA Teaching
How do we do our work?
• vigorously pursue waste
• use the PDSA method
Plan-Do-Study-Act
• continuously test/refine ideas
• focus on results
Example: defects down 66%
Observe and develop a new vision
Study the results
Awareness: a change
in thinking
Rapid implementation
– give it a try
PDSA Cycle
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
“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
Questions?