LEAN HEALTHCARE, EXAMPLES FROM THE U.S.
FINAL VERSION
By: Gunn Iren Kleppe
Virginia Mason’s Journey – “Change or Die” Virginia Mason was the first medical center to integrate Toyota’s management philosophy throughout their entire system. Adopting the basic tenets of the Toyota Production System (TPS), they named it the Virginia Mason Production System (VMPS). Located in Seattle, Virginia Mason is a non-profit organization that offers a system of integrated health services. “There was a need to improve, otherwise we would be out of business,” says Faculty and Marketing Director at Virginia Mason Institute, Christopher J. Backous. While Virginia Mason was performing well in other areas, their economy wasn’t healthy. Thus, they were in danger of being acquired. Virginia Mason had pioneered too many things, which they didn’t want to lose. However, “If asked, ‘Who are we,’ we couldn’t say we were about the patient,” admits Backous. The American health system has typically centered around the physician, rather than the patient. “We used to judge a physician’s popularity by how long it takes to get in, but we need to gage it based on the health of the patient,” argues Backous. Thankfully, there has been a change in thinking since the late 90s. Long waits have gone from being a measure of popularity to a measure of poor performance. As patients wait, they get sicker. And the cost goes up. Needing to change in order to survive, Virginia Mason came up with a new strategic plan, which was all about putting the patient first. “We needed to find a method that changed our organization’s thinking at the DNA level. Culturally, we knew we needed to be different.” Purists Starting in 2001, four Lean ‘experiments’ were executed at Virginia Mason. “It was a model that engaged people all levels. It required focused leadership,” states Backous. The Virginia Mason Production System (VMPS) was formally launched at the beginning of 2002. “Why call it a production system? Ours is a process-based system. We produce health care encounters,” he explains. Though Lean has many offshoots, Virginia Mason chose to follow the fundamentals of Toyota’s Production System (TPS) from the start. From the start, a promise was also made to their staff that anyone who participated in Lean activities would not lose their job. “We are purists,” says Backous. Virginia Mason got their training directly from the Toyota Sensei, members of Toyota’s original group that invented TPS. Eight times a year the teachers come to assess Virginia Mason’s programs. “They challenge us deeper,” he explains. In addition, each summer Virginia Mason executives lead a group of employees to Japan for deep study. Commitment to zero defects Though many processes in a hospital or clinic don’t directly affect the patient, indirectly they all do. Lean provides a framework for scrutinizing these processes. More than ten years into their
Lean journey, they realize there is still much more to do. Expecting errors has generally been the norm in healthcare. “When the National Institute of Health reported that just under 100,000 people die every year of preventable errors, that was a wake-up call. Many other industries with that high a death rate would not be in existence,” Backous points out. “Our commitment to patients is to pursue zero defects.” One of the most useful concepts from TPS is that of the seven wastes. “They are all apparent in healthcare,” Backous points out. There is waste in all processes. People’s contributions are devalued because of it. One example is how staff and patients are made to walk long distances within hospitals. “What if what you need is wherever you need it at the time you need it?” he asks. “We have learned that by looking for waste, we see opportunity. Waste is a burden of work. If we can remove that burden, we can return time to do value added activities, focus on quality and enhance safety. To us, that is time with the patient.” “It depends – everything depends on something,” he continues. That could be things like, ‘If I had my information;’ ‘If I had the right tools;’ ‘If I had the time;’ etc. According to Lean, it is the variations and the lack of clear, standardized work that prevent people from achieving the highest standard of quality. Making work visible is another value of TPS. Take provider and patient conversations—they may seem like a productive use of time. However, if all the questions are already answered—but the information hidden—they become a waste of time. “You should have a mindset that you shouldn’t do anything that doesn’t add value or produces waste,” emphasizes Backous. Individuals empowered “The biggest gift is the whole concept of Stop the Line,” he continues. During a trip to Japan, Virginia Mason’s Medical Director for Quality was humbled by the power of the individual at Toyota. “People are running, not to belittle the person, but because they want to help. They have the power. If asked, would our own staff have that power, just about every person would say, ‘If I tried to stop the line, everybody would yell at me.’” True to Lean principles, Virginia Mason declared their own Stop the Line-system. Their Patient Safety Alert (PSA) is designed to detect and prevent defects. “Zero defects in healthcare is possible. People’s lives are at stake.” “Our patients receive care through processes. What we find of greatest value in TPS, is the commitment to quality, the pursuit of zero defects,” Backous emphasizes. “We have one customer, that is the patient. Whatever we do has to be better for the patient.” Both method and philosophy “That’s been our journey. It is 100 % what Toyota does,” says Backous. That means developing the ability to engage staff in pursuit of zero defects and meeting high patient expectations. “I think by now it has become hardwired into the organization.” That means thinking VMPS and getting things done right the first time.
“It is a method and a philosophy,” Backous states. “This can’t be initiated department by department; it has to be organization-wide. First of all, leaders’ mindsets need to change. It means a new attention to quality. We use the word quality, but do we know what it means?” he challenges. “We can go look, and we’ll see little glimmers of quality mixed in with the muck. Then, do we have the courage to say that 50 % of our process is waste? When we can see waste and identify it, it allows us to eliminate it.” Don’t delay Backous encourages Norwegian health care institutions to give it a try and learn from it. “Just do it. Nike had it right. Don’t wait,” he urges. And know it may not happen the way you expect it to. You have to identify waste, and then work with people to remove it. “They walk in it every day; it is like walking on loose gravel in sandals. If they could start removing the rocks in their staff’s shoes, I bet you they would see improvements for the patients.” Virginia Mason has formed the non-profit Virginia Mason Institute, now helping others transform health care through education and training in the Virginia Mason Production System. “We teach exactly what we learned, the purity of TPS,” explains Backous. They have, however, translated the Lean concept of flow from manufacturing and engineering to patient care. You can learn more about the Virginia Mason Production System and the Virginia Mason Institute at www.virginiamason.org. Some results from Virginia Mason
14,604 PSAs (Patient Safety Alerts) were reported from 2002 through 2009. Most reports are processed within 24 hours, compared to the 3-18 months such reports used to take previously. Nurses’ time spent in direct patient care was increased to 90 % (the average is 35 %). VMPS tools were used to create a new hyperbaric center in existing hospital space, saving $2 million in construction costs and increasing capacity from 2-3 patients at a time to 20. After applying VMPS to realign work, Virginia Mason’s 8 primary care clinics are consistently achieving positive net margins (compared to either losing money or—in a good year—breaking even). By analyzing flow and making key changes, providers can see more patients during a shorter work day while providing better quality care. Doctors can leave 2-3 hours earlier. Turnaround time for normal lab results was reduced from 25 days to 2 or fewer. The Finance Department applied VMPS to address outstanding revenue, resulting in a faster revenue cycle. All cancer services are now brought to the patient, substantially reducing the length of chemotherapy visits and the length patients have to walk within the hospital. The Emergency Department was able to decrease the number of hours the ED was closed and unable to receive new patients by over 90 %.