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Health Care, Virginia Mason, and LeanSteve Schaefer

April 16, 2015


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


Traditional Health Care Management “System”

© DC Comics


Healthcare 2015


Today, these

Americans are

between 48–66

years old.

10,000 Boomers are

reaching the age of

65 per day, in 2012.

7


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.


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

-Yogi Berra

So where do you start? The mind!


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


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………….


…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 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


How did it all start at Virginia Mason?

Our story began 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.


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.


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!”


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

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


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.


Two RPIW Examples



Hospital Late Charge RPIW December 2002


Do You Want This?

Or This?


This is a value stream (aka Billing) at Virginia Mason



This is NOT the

revenue stream

(“Billing”) at

Virginia Mason


C:/Documents and Settings/Vhpsms/



As in any river, defects flow downstream

And the revenue stream (“Billing”) is no different


If the

water is

impure

(polluted)

…

… life

dwindles.

Getting the wrong insurance information delays

payment (“cash”), effecting our economic health.


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


$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


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)


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


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


2002: Stopping the Line


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


Have you really

mistake proofed this

issue?

Board Quality Oversight Committee


And then Mary McClinton came to Virginia Mason to

have a routine procedure on November 4th, 2004


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



• 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)



• 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”



• 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


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


• 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 CenterNovember 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?

1935 – 2004

“This day brings a lot of rearrangement”

November 27,2004


“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


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


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


Kaizen Concepts that Foster Cultural

Transformation

• Respect for People

• PeopleLink

• Daily: Standard Work for Leaders,

Production Control Boards, and

Huddles


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


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



Kaizen Promotion Office Standup (Tier 2)Every Tuesday 7:00-7:30am


Patient Financial Services PeopleLink (Tier 3)Every Thursday 7:30-8:00am


PeopleLink Boards updated and managed

with set agenda

Weekly Accountability


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


Standard Work For Leaders: Exec Rounding

Hitachi

Production Control Boards

Boeing


Example: Inpatient Orthopedics

Example: Health Information Services

Have daily huddles with your team

Daily Accountability


Daily Huddle


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


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


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


Patient Satisfaction Trend

37th

Percentile

89th

Percentile

15th

Percentile

77th

Percentile


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


“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.