Health Care, Virginia Mason, and LeanSteve Schaefer
April 16, 2015
© 2014 Virginia Mason Medical Center
© 2014 Virginia Mason Medical Center
The Virginia Mason Production System
An adoption of philosophies and practices we took from
manufacturing and applied them to health care because
our industry was so lacking in an effective management
approach that would produce:
Customer first
Highest quality
Obsession with safety
Highest staff engagement
A successful economic enterprise
© 2014 Virginia Mason Medical Center
Traditional Health Care Management “System”
© DC Comics
© 2014 Virginia Mason Medical Center
Healthcare 2015
© 2014 Virginia Mason Medical Center
© 2014 Virginia Mason Medical Center
Today, these
Americans are
between 48–66
years old.
10,000 Boomers are
reaching the age of
65 per day, in 2012.
7
© 2014 Virginia Mason Medical Center
© 2014 Virginia Mason Medical Center
The Time is Now!
We are at the
beginning of what
many expect will be
the single fastest
transformation of any
industry in US
history.
© 2014 Virginia Mason Medical Center
"Baseball is 90% mental; the other half is physical.”
-Yogi Berra
So where do you start? The mind!
© 2014 Virginia Mason Medical Center
And who do you start with? The Leader!
• 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
© 2014 Virginia Mason Medical Center
Why the leader?
“Leaders have a disproportionately large
effect on the cultures of organizations. By
their behaviors, leaders create the conditions
that either hinder or aid innovation.”
-NHS Institute
And So, From The Beginning,
This Has Been Led Top Down
Anything else would have been
a complete exercise in futility!
But the Staying Power of
Kaizen is its Bottom Up
Impetus for Change and Waste
Removal
Anything else will not transform
your culture!
“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
Line ImprovementsLine
Line
Link processes to create a cell. Flow production begins here. Flow paves the way for line improvements
• Change production method from “Push” to “Pull”
• Plan for Leveling
• Develop Standard Operations
• Quickly Solve Flow Problems
• Add Production Tracking Boards – practice visual control
• Standard Work for Leaders – Daily Production Visibility
Plane Improvements
Plane
Link cells to produce a product. The model line is used as a reference and replicated across the plane.
The Kaizen Path
15-20Years
5-10Years
Point
Point
Point
Eliminate waste at source - starting at the point closest to the customer
Root out basic problems, make improvements, build a foundation
Point Improvements
Height3rd Dimensional
Link all elements from concept to customer.
Raise improvement to the other planes: Finance, HR, Suppliers, etc.
Spatial Improvements
10-15Years
• Non Value Added vs. Value Add tasks identified
•Work In Process (WIP) Reduction
•VMPS Leader Training
•Daily Waste Elimination of Taiichi Ohno’s 7 Wastes
•Kaizen Plan and People Link in place
•Implement Mistake Proofing
•Balance the Line
•Heijunka – level the work
•1 x 1 Production Flow
•Feeder lines e.g., Ancillary, RX, Supply Chain, Sterile Processing are integrated
•Up & downstream value streams e.g., IT, HR, Payroll, Finance embedded
Tools at point of use
So Be Prepared………….
© 2014 Virginia Mason Medical Center
…It will be like turning the Queen Mary
Where was Toyota in the 1950s?
Or “Made in Japan” in the 1960’s?
© 2014 Virginia Mason Medical Center
The Paradox
• Daily Sense of Urgency in our Attack
on Waste + Daily Genba 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
© 2014 Virginia Mason Medical Center
How did it all start at Virginia Mason?
Our story began on
November 9th, 2000
© 2014 Virginia Mason Medical Center
• 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.
© 2014 Virginia Mason Medical Center
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.
Copyright © 2008 Virginia Mason Medical Center. All Rights Reserved. Any further use or distribution of these materials is prohibited.
© 2014 Virginia Mason Medical Center
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!”
© 2014 Virginia Mason Medical Center
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…
© 2014 Virginia Mason Medical Center
My First Value Stream Map
1996, John Black and Associates
Taiichi Ohno's Seven Wastes
TransportationConveying, transferring,
picking up.setting down,
piling up and otherwise
moving unnecessary
items.
ProcessingUnnecessary processes
and operations
traditionally accepted as
necessary
OverproductionProducing 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.
•RepairsWaste
© 2014 Virginia Mason Medical Center
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.
© 2014 Virginia Mason Medical Center
Two RPIW Examples
Copyright © 2008 Virginia Mason Medical Center. All Rights Reserved. Any further use or distribution of these materials is prohibited.
© 2014 Virginia Mason Medical Center
Hospital Late Charge RPIW December 2002
Copyright © 2008 Virginia Mason Medical Center. All Rights Reserved. Any further use or distribution of these materials is prohibited.
© 2014 Virginia Mason Medical Center
Do You Want This?
© 2014 Virginia Mason Medical Center
Or This?
© 2014 Virginia Mason Medical Center
This is a value stream (aka Billing) at Virginia Mason
Copyright © 2008 Virginia Mason Medical Center. All Rights Reserved. Any further use or distribution of these materials is prohibited.
© 2014 Virginia Mason Medical Center
This is NOT the
revenue stream
(“Billing”) at
Virginia Mason
Copyright © 2008 Virginia Mason Medical Center. All Rights Reserved. Any further use or distribution of these materials is prohibited.
© 2014 Virginia Mason Medical Center
As in any river, defects flow downstream
And the revenue stream (“Billing”) is no different
© 2014 Virginia Mason Medical Center
If the
water is
impure
(polluted)
…
… life
dwindles.
Getting the wrong insurance information delays
payment (“cash”), effecting our economic health.
© 2014 Virginia Mason Medical Center
48.7
52.3
42.4
39.3 38.636.7
30.929.4 30.2 30.4
28.729.7
20
25
30
35
40
45
50
55
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Day
sClinic Accounts ReceivableDays Revenue Outstanding
© 2014 Virginia Mason Medical Center
$471
$505
$548 $560
$614
$673
$735 $746
$786
$827$844
$300
$400
$500
$600
$700
$800
$900
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Cas
h (
mill
ion
s)Cash Collections
© 2014 Virginia Mason Medical Center
11.58
12.51
8.5
6.145.37
4.954.21
3.54
2.27 2.161.76
1.041.44 1.53 1.28
0
2
4
6
8
10
12
14
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Clinic Credit Balances(Average Daily Revenue)
© 2014 Virginia Mason Medical Center
Suzanne Tyler M.A. 2004 RPIW
Do we really put the patient first?
“If we really do, why
wouldn’t we all get flu shots?”
Staff resistance
Staying the course
Organizational Pride
© 2014 Virginia Mason Medical Center
VMMC Influenza Vaccination Rates
38.0%
54.0%
29.5%
97.6%
98.5%
98.7%
98.9%
99.8%
99.6%
99.7%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
2002 2003 2004 2005 2006 2007 2008 2010 2011 2012
© 2014 Virginia Mason Medical Center
2002: Stopping the Line
© 2014 Virginia Mason Medical Center
Patient Safety Alert SystemKey Concepts
Every employee is an inspector
Inspect, stop, and fix at the source
Every employee can stop the line
When you can’t fix on-the-spot: STOP
© 2014 Virginia Mason Medical Center
Have you really
mistake proofed this
issue?
Board Quality Oversight Committee
© 2014 Virginia Mason Medical Center
And then Mary McClinton came to Virginia Mason to
have a routine procedure on November 4th, 2004
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
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)
© 2014 Virginia Mason Medical Center
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”
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
So what happened on November 4th, 2004?
• Two unlabeled containers were
presented in the sterile field
• One contained marker dye, and the
other contained Chlorhexidine
© 2014 Virginia Mason Medical Center
• 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
© 2014 Virginia Mason Medical Center
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
© 2014 Virginia Mason Medical Center
Virginia Mason Medical CenterNovember 23, 2004
Investigators: Medical mistake kills Everett woman
Hospital error caused death
© 2014 Virginia Mason Medical Center
At her memorial service, Pastor Paul A.
Stoot Sr. spoke on:
What’s in the Dash?
1935 – 2004
“This day brings a lot of rearrangement”
November 27,2004
© 2014 Virginia Mason Medical Center
© 2014 Virginia Mason Medical Center
“Stopping the line”
Organization-wide Involvement
0
100
200
300
400
500
600
700
800
900
Number of PSAs Reported per Month
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
© 2014 Virginia Mason Medical Center
Effectiveness of Patient Safety Program
Total Number of Claims and PSAs Reported
59
8
2697
3500
3079
27262954
4322
5386
60
71
67
60
4446
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
© 2014 Virginia Mason Medical Center
Reduction of Hospital Professional/General Liability
Premiums
$-
$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
'04-'05 '05-'06 '06-'07 '07-'08 '08-'09 '09-'10 '10-'11 '11-12 '12-'13 13-'14
74% overall
reduction in premium
since 2004-0512%
5%
26%
12%
12%
11%
12%
30%
7%
16
© 2014 Virginia Mason Medical Center
Kaizen Concepts that Foster Cultural
Transformation
• Respect for People
• PeopleLink
• Daily: Standard Work for Leaders,
Production Control Boards, and
Huddles
© 2014 Virginia Mason Medical Center
The Core of Kaizen: Respect for People
© DC Comics
© 2014 Virginia Mason Medical Center
Respect for PeopleJames P. Womack
• Ask employees for the problems with the way the work is
being done
• Have a dialogue with employees to determine the real
problem
• Ask employees what is causing the problem and have a
dialogue about root cause
• Ask what should be done about the problem – get
multiple solutions
• Ask how everyone (manager and employees) will know
when the problem has been solved – how do we
measure
• Have employees set out to implement the solution
PeopleLink
© 2014 Virginia Mason Medical Center
From Ideas to ActionPeopleLink
PeopleLink Reporting is part of the Tier Reporting System
Tier I Reporting
Senior Leadership reports updates on key metrics to the Board
of Directors
Tier II Reporting
Vice Presidents report updates on key metrics to the Chief
Executive Officer
Tier III Reporting
Managers report to department staff and Directors
© 2012 Virginia Mason Medical Center
© 2014 Virginia Mason Medical Center
Kaizen Promotion Office Standup (Tier 2)Every Tuesday 7:00-7:30am
© 2014 Virginia Mason Medical Center
Patient Financial Services PeopleLink (Tier 3)Every Thursday 7:30-8:00am
© 2014 Virginia Mason Medical Center
PeopleLink Boards updated and managed
with set agenda
Weekly Accountability
© 2014 Virginia Mason Medical Center
From Ideas to ActionPeopleLink
Examples of People
Link Boards
PeopleLink Board
information may be
displayed in different
formats, but the
information categories
are standard across
every department
© 2014 Virginia Mason Medical Center
Standard Work For Leaders: Exec Rounding
Hitachi
Production Control Boards
Genie
Boeing
© 2014 Virginia Mason Medical Center
Example: Inpatient Orthopedics
Example: Health Information Services
Have daily huddles with your team
Daily Accountability
© 2014 Virginia Mason Medical Center
Daily Huddle
© 2014 Virginia Mason Medical Center
Where is Virginia Mason 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
© 2014 Virginia Mason Medical Center
ED Results: Achieving the “mutually exclusive”
52745305
5651
86.6 %87.9 %
90.8 %
5000
5100
5200
5300
5400
5500
5600
5700
5800
5900
6000
186
188
190
192
194
196
198
200
202
204
206
208
QTR 1 QTR 2 QTR 3
2013 ED Length of Stay, Census and Patient Satisfaction Score
ED ALOS mINUTES Census PG Patient Satisfaction Score
© 2014 Virginia Mason Medical Center
Maintaining Successful Economic Enterprise
81
$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
© 2014 Virginia Mason Medical Center
Patient Satisfaction Trend
37th
Percentile
89th
Percentile
15th
Percentile
77th
Percentile
© 2014 Virginia Mason Medical Center
Lessons Learned
• 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 Organization is WASTE … Not Finance…. or IT….or HR…
• The problems of healthcare will be resolved onthe genba with your staff….…not in the halls of Congress
The biggest room
in the world is the room
for improvement
Japanese proverb
© 2014 Virginia Mason Medical Center
“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
A lean journey is a learning journey.
Let us help you.
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