Upload
others
View
7
Download
0
Embed Size (px)
Citation preview
1
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
2
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
3
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
4
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
5
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
6
“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
7
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
8
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
9
5S Anesthesia “Shadow Board” - Before
5S Anesthesia “Shadow Board” - After
Stopping the Line™
Virginia Mason’s Patient Safety Alert System™
10
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
11
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
12
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
13
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
14
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
15
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