Virginia Mason's Pursuit of the Perfect Patient Experience

Transforming Health Care:

Virginia Mason’s Pursuit of the

Perfect Patient Experience

Small & Rural Hospital Conference

Charlotte, North Carolina

November 12, 2013

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


• Integrated health care system

• 501(c)3 not-for-profit

• 336-bed hospital

• Nine locations

• 500 physicians

• 5,000 employees

• Graduate Medical Education

• Research Institute

• Foundation

• Virginia Mason Institute

Time for a Change

Year 2000

• Issues

Survival

Retention of the Best People

Loss of Vision

Build on a Strong Foundation

• Leadership Change

• A Defective Product

The Challenge of Healthcare

• Poor Quality………………………..3% defect rate

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

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

• Cost of healthcare to

those who pay……………………..Unaffordable

• Access………………………………….Millions

• Morale of workers………………..Unreliable systems

Our Strategic Plan

• Culture

• Lack of Shared Vision

• Misaligned Expectations

• No Urgency

• Ineffective Leadership

Why is Change So Hard?

1. Increase Urgency

2. Build the Guiding Team

3. Get the Vision Right

4. Communicate for Buy-in

5. Empower Action

6. Create Short-term wins

7. Don’t Let Up

8. Make Change Stick

Kotter’s Eight Steps for

Successful Large Scale Change

Urgency for Change at VMMC

— Gary Kaplan, VMMC Professional

Staff Meeting, October 2000

We change or we die.

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

Lives” 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

Hospital error caused death


November 23, 2004

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Ongoing Urgency

• In a time of constant

and tumultuous

change, avoid

complacency

Compact

• Expectations members of an organization

have that are:

Unstated yet understood

Reciprocal

• The give

• The get

Mutually beneficially

Set up & reinforced by society and the

organization

• Autonomy

• Protection

• Entitlement

• Improve

safety/quality

• Implement EHR

• Create service

experience

• Be patient-focused

• Improve access

• Improve efficiency

• Recruit/retain quality

staff

Traditional “Promise” Legacy Expectations

Imperatives

Clash Of “Promise” And Imperatives


Physician Compact Organization’s Responsibilities

Foster 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 research

Listen and Communicate

• Share information regarding strategic intent,

organizational priorities and business decisions

• Offer opportunities for constructive dialogue

• Provide regular, written evaluation and feedback

Educate

• Support and facilitate teaching, GME and CME

• Provide information and tools necessary to improve

practice

Reward

• Provide clear compensation with internal and market

consistency, aligned with organizational goals

• Create an environment that supports teams and

individuals

Lead

Manage and lead organization with integrity and

accountability

Physician’s Responsibilities

Focus 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 service

• Collaborate 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

• Listen and Communicate

• Communicate clinical information in clear, timely manner

• Request information, resources needed to provide care

consistent with VM goals

• Provide and accept feedback

• Take Ownership

• Implement VM-accepted clinical standards of care

• Participate in and support group decisions

• Focus on the economic aspects of our practice

• Change

• Embrace innovation and continuous improvement

• Participate in necessary organizational change

Hardwiring Compact

• Recruitment

• Orientation

• Job Descriptions

Chief

Section Heads

Physicians

• Feedback

Our Strategic Plan

The VMMC Quality Equation

Q: Quality

A: Appropriateness

O: Outcomes

S: Service

W: Waste

Q = A × (O + S)

W

Taiichi Ohno

“You should submit wisdom to the company.

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

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

Or resign.”

The Impact of Lean

• ½ the human effort

• ½ the space

• ½ the equipment

• ½ the inventory

• ½ the investment

• ½ the engineering hours

• ½ the new product development time

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

• Highest quality

• Obsession with safety

• Highest staff satisfaction

• A successful economic enterprise

Seeing with our Eyes

Japan 2002

Hitachi Air Conditioning

Team Leader Kaplan

reviewing the flow of

the process with

Drs. Jacobs and

Glenn

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 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

VMPS Tools in Action

• Value Stream Development

• RPIW (Rapid Process Improvement Workshop)

• 5S (Sort, simplify, standardize, sweep, self-discipline)

• 3-P (Production, Preparation, Process)

• Standard Work

• Daily Work Life

5S Anesthesia “Shadow Board” - Before

5S Anesthesia “Shadow Board” - After

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

Stopping the Line

Virginia Mason’s Patient

Safety Alert System

Stopping the line

Patient Safety Alert Process

Created August 2002

• Leadership from the top

• “Drop and run” commitment

• 24/7 policy, procedure, staffing

• Legal and reporting safeguards

40,000th PSA Reported

1000th

July

2005

10,000th

March

2008

20,000th

February

2011

# of PSAs

reported

monthly

As of 11/1/13: 41,108 ♦

30,000th

Sept.

2012

40,000th

Sept.

2013

21% 16%

58%

21%

47%

81% 82% 84% 90%

88%

0%

25%

50%

75%

100%

Overall staff response rate


2013 AHRQ Mean = 51%

Reduction of Hospital

Professional/General Liability Premiums

'04-'05 '05-'06 '06-'07 '07-'08 '08-'09 '09-'10 '10-'11 '11-12 '12-'13 13-'14

% change from previous year, with 74% overall reduction in premium since 2004-05

7%

12%

5%

26%

12% 12%

11%

12%

30%

Primary Care – Flow Stations

VMPS Concepts of a Flow Station

• Waste of motion (walking)

• Continuous flow

• Visual control (Kanbans)

• External setup

• Water strider

• U-Shaped Cell

Creating MD Flow Reduces Patient Wait Times

CHARGESLIP

$

DOCUMENT VISIT

$

CERNER MESSAGE

URGENT

PAPER MAIL

RESULT REPORT

During 2007 – 2009 VM and Boeing

collaborated to implement an

“ambulatory ICU” program

Aim: reduce Boeing’s healthcare cost for employees with the most expensive health conditions by 15% while improving their health status

The Boeing Company: Connect and protect people

globally

VM’s cost/utilization metrics were outstanding

Prescriptions (day supply)

Prescriptions

Home Health Visits

Dental

Office Visits

-100% -80% -60% -40% -20% 0% 20%

ER Visits

Outpatient Visits

Lab

Admits (acute)

Hospital Days (acute)

Radiology

Costs (standardized)

Out-patient (other)

The Marketplace Collaborative Purchasing Power Drives the Quality Agenda

Employer Defines Products Most Costly Conditions

1. Screening and prevention

2. Back pain

3. Shoulder, knee and hip pain

4. Headache

5. Respiratory symptoms

6. Breast symptoms

7. Depression

8. Diabetes

9. Abdominal pain

10. Chest pain

High volume, low per-capita

cost conditions

Quality Standard Set by Purchasers Aligning Providers with Customers

1. Evidence-based care

2. 100% patient satisfaction

3. Same-day access

4. Rapid return to function

5. Affordable price for buyer and seller

Better Quality & Value for Headache With Medical Evidence and Systems

Value added Non-value added Variable value

Redesign creates:

1. Evidence-based care

2. High patient satisfaction

3. Same-day access

4. Rapid return to function

5. Lower cost for buyers and sellers

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

Evidence-based Imaging No Costly Vendor-based Inspection Steps

Headache: -23%

Low back pain: -23%

Sinusitis: -27%

Mistake-proofing

Implemented

Reduction in imaging

J Am Coll Radiol 2011;8: 19-25.

Orthopedic Value Stream

For an uncomplicated

Single Total Knee Replacement or

Single Total Hip Replacement

Our patients experience a very complex journey

when they come for joint replacement

Periop Flow

Clinic Experience

Inpatient Care

Follow Up Care

Clinic Visits – Patient Request until Surgery Scheduled

Day of Surgery

Hospital Floor – Day 1



“Nursing Cells” – Results > 90 days

Before After

• RN # of steps = 5,818

• PCT # of steps = 2,664

• Time to the complete am cycle of work = 240’

• 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’

846

1256

126’

0%

10%

16%

0%

11’

RN time available for patient care = 90%!

6%

7%

5%

2%

3%

1%

2%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

Q1 08 Q2 08 Q3 08 Q4 08 Q1 09 Q2 09 Q3 09

Prevalence of Hospital-Acquired Pressure Ulcers

Lindeman Surgery Center

Throughput Analysis

Before Today % Change

• Time Available 600 min 600 min 0% (10 hr day)

• Total Case Time 107 min 65.5 min 39%

(cut to close plus set-up)

• Case Turnover 30 min 15 min 50%

Time (pt out to pt in) (ability to be <10 min)

• Cases/day 5 cases/OR 8 cases/OR 60%

• Cases/4 ORs 20 cases 32 cases 60%

VMMC Leadership Compact Organization’s Responsibilities

Foster Excellence

• Recruit and retain the best people

• Acknowledge and reward contributions to patient care and the organization

• Provide opportunities for growth of leaders

• Continuously strive to be the quality leader in health care

• Create an environment of innovation and learning

Lead and Align

• Create alignment with clear and focused goals and strategies

• Continuously measure and improve our patient care, service and efficiency

• Manage and lead organization with integrity and accountability

• Resolve conflict with openness and empathy

• Ensure safe and healthy environment and systems for patients and staff


• Share information regarding strategic intent, organizational priorities, business decisions and business outcomes

• Clarify expectations to each individual

• Offer opportunities for constructive open dialogue

• Ensure regular feedback and written evaluations are provided

• Encourage balance between work life and life outside of work

Educate

• Support and facilitate leadership training

• Provide information and tools necessary to improve individual and staff performance

Recognize and Reward

• Provide clear and equitable compensation aligned with organizational goals and performance

• Create an environment that recognizes teams and individuals

Leader’s Responsibilities

Focus on Patients

• Promote a culture where the patient comes first in everything we do

• Continuously improve quality, safety and compliance

Promote Team Medicine

• Develop exceptional working-together relationships that achieve results

• Demonstrate the highest levels of ethical and professional conduct.

• Promote trust and accountability within the team


• Communicate VM values

• Courageously give and receive feedback

• Actively request information and resources to support strategic intent, organizational priorities, business decisions and business outcomes

Take ownership

• Implement 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 System

• Participate in and actively support organization/group decisions

• Maintain an organizational perspective when making decisions

• Continually develop oneself as a VM leader

Foster Change and Develop Others

• Promote innovation and continuous improvement

• Coach individuals and teams to effectively manage transitions

• Demonstrate flexibility in accepting assignments and opportunities

• Evaluate, develop and reward performance daily

• Accept mistakes as part of learning

• Be enthusiastic and energize others

Tuesday “Stand Up”

Leaders’ Role in Signal Generation

“Leaders are signal generators who reduce

uncertainty and ambiguity about what is

important and how to act”.

OR

— Charles O’Reilly III

Productive range of

distress

Threshold of

learning

Limit of tolerance

Time

Disequilibrium

“Distress” and Adaptive Work

Adaptive challenge

Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108

Effective Sponsorship

• Vision of success

• Set stretch goal

• Provide resources

• Remove barriers

• “Fail forward fast”

• Celebrate achievements

Genchi Genbutsu

• “It’s all lies”

• Go where the action is

• Know your people and let them know you

• Vulnerability is ok

• Connect the dots

Holding the Gains

• It takes hearts and minds

• Great people and great systems

• The gift of time is a treasure

• Accountability and audit

Managerial Courage

• It will be worth it

• Patients and staff depend on it

• Leading change is hard work

• Skeptics can become champions

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Our Quality & Safety Journey Toyota Production

System

Introduced to VMMC

2nd IOM1

Report

ADEPT2

Preprinted

Order Sets

Virginia Mason

Production System

established

Patient

Safety

Alert

(PSA) for

clinical

events

Strategic

Quality

Plan

1st

Safety

Culture

Survey

Executive

Walk

Rounds

PSA for

non-clinical

events

2nd

Safety

Culture

Survey

Mary L.

McClinton

Fatal medical

error CPOE

Go Live

Move to

yearly

AHRQ4

Safety

Culture

Survey

Declare One

Organizational

Goal: Patient

Safety

MD

Disclosure

Training

IHI3 100,00

Lives

IHI3 5

Million

Lives

Leapfrog

Governance

Award

Staff &

Patient

Leader

Rounds

Patient/

Family

Engagement

AHRQ4

Safety

Culture

Survey: 81%

Participation

AHRQ4

Safety

Culture

Survey:

82%

Participation (all staff, all

electronic)

2010

HealthGrades

Patient Safety

Award

Time

Out ST-

PRA5

Just

Culture

Falls

ST-

PRA5

1st IOM1

Report

VM Board:

Business

Case for

Quality

1st

Culture

of Safety

Work

Plan

PSA

Case

Studies

1. Institute of Medicine

2. Adverse Drug Events Prevention Team

3. Institute for Healthcare Improvement

Standard

Quality Goal

Reporting

Process

CEO

Mandates

PSA System

MDM

RPIW6

4. Agency for Healthcare Research and Quality

5. Sociotechnical Probabilistic Risk Assessment

6. Must Do Measure Rapid Process Improvement Workshop

Cross

Pillar

Culture

of Safety

Work

Plan

Leapfrog

Top

Hospital

of the

Decade

Q4Q Site

Visit

AHRQ4

Safety

Culture

Survey: 84%

Participation

PSA

3P

Patient

Safety Risk

Registry

Respect for

People

Training

Quest for

Quality

Citation of

Merit

Flu Vaccination “Fitness for Duty”

• Do we put patient first?

• Compelling science

• Staff resistance

• Staying the course

• Organizational Pride

38.0%

54.0%

29.5%

97.6% 98.5% 98.7% 98.9% 98.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2002 2003 2004 2005 2006 2007 2008 2009

Em

plo

ye

es

Im

mu

niz

ed

(%

)

Year

Figure: Influenza Immunization Rates

Critical mass feels urgency for

change

Visible and committed leadership

New compact aligns expectations

with vision

Improvement Method Applied to ALL Processes

Executives address technical AND

human dimensions of change

Requirements for Transformation

Broad and deep commitment to shared vision

We are Twelve Years into the Journey 2002 - 2004 2005 - 2006

2007 -

present

December 2010

Chosen By Businesses:

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

First Challenge is Changing the Mind of Medicine

• 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

SCARCITY: You are not paying us enough.

ABUNDANCE: We have more than enough.

LEADERSHIP MUST CHANGE ITS MENTALITY.

“Leaders are Dealers

in Hope.” Napoleon Bonaparte

“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

Copyright © 2009 Virginia Mason Medical Center. All Rights Reserved.