transforming healthcare: an overview of the virginia mason ... · •500 physicians •5,500...

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Transforming Healthcare: An Overview of the Virginia Mason Production System

© 2013 Virginia Mason Institute, all rights reserved

© 2013 Virginia Mason Medical Center

Virginia Mason Medical Center • Integrated health care system • 501(c)3 not-for-profit • 336-bed hospital • Nine locations • 500 physicians

• 5,500 employees • Graduate Medical Education • Research Institute • Foundation • Virginia Mason Institute


Sense of Urgency: Health Care Challenges

• Poor quality health care = 3% defect rate and

costs the U.S. billions of dollars

• Health care is unaffordable and unavailable to

millions of people

• Health care workers are negatively impacted by

unreliable systems

• VMMC financial loss for two successive years

Virginia Mason Medical Center

Strategic Plan

Shared Vision


Q: A: O: S: W:

Q = A × (O + S) W

The VMMC Quality Equation:

Quality Appropriateness Outcomes Service Waste

• 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

Transforming Healthcare…

Physician

Compact Aligned Expectations

Board

Compact

Leader

Compact

Visible & Committed Leadership

Dr. Kaplan reviewing the flow of the process with Drs. Jacobs and Glenn

Sense of Urgency

Visible & Committed Leadership

Aligned Expectations

Improvement Method

Technical & Human

Dimensions of Change

Requirements for Transformation

Shared Vision

The Virginia Mason Production System

1. The patient is always first

2. Focus on the highest quality and

safety

3. Engage all employees

4. Strive for the highest satisfaction

5. Maintain a successful economic

enterprise

We adopted the Toyota Production System key philosophies

and applied them to healthcare

1. The Patient is Always First

• The patient is at the top

of our strategic plan

• Value is defined by the

patient

• Patient’s voice is

embedded in our

improvement activities

2. Focus on Highest Quality & Safety

• Embedding mistake

proofing into

everything we do

• Patient Safety Alert

(PSA)

• 5S across VMMC

• Standard Work

“Stopping the line” Organization-wide Involvement

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

40,000th PSA Reported

End of January 2014: 43,615

This is a good

question. He must

have read the

materials before the

meeting.

“Good Catch!” Safety Award

Patient Safety Alerts Newsletter

2011 Mary McClinton Safety Award Medication Reconciliation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percent of Reconciled Medications on Discharge

% VM Target UCL LCL

November 2010:

PowerChart Phase II:

Effectiveness of Patient Safety Program: Total Number of Claims and PSAs Reported

Total number of claims excludes claims closed with no payment

8

2697

3500

3079

2726 2954

4322

5386

60

71

67

60

44 46

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 Liability Premiums

2003-04

2004-05

2005-06

2006-07

2007-08

2008-09

2009-10

2010-11

2011-12

Premiums $4,068 $4,211 $3,900 $3,442 $3,275 $2,438 $2,151 $2,004 $1,779

4% 7%

12% 5%

26% 12%

7% 13%

$0$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

Hospital Professional Liability Premiums

% change from previous year

Report Published December 2010

VMMC Quality Awards

http://www.npsf.org/

http://www.leapfroggroup.org/news/leapfrog_news/4784721

Safety Culture Question Staff Speak Up Freely*

76%

74%

79% 79%

81%

70%

72%

74%

76%

78%

80%

82%

Year 1 Year 2 Year 3 Year 4 Year 5

*Question: Staff will speak up freely if they see something that may negatively affect patient safety

Respect for People refers to how we treat each other as we work together to create the

perfect patient experience.

Surgical Attestation Video

3. Engage all Employees

• Employees trained in VMPS

• Involve employees in improving their own work with ELI

• RPIW/Kaizen

Defect by product grouping

Defect by Root Cause (Process Accountable)

Defect by Risk to the Patient (Red, Orange,

Yellow)

Employee Engagement: Sterile Processing

#4 Strive for Highest Satisfaction Levels

84

86

88

90

92

94

96

98

100

2007 2008 2009 2010 2011 2012

Clinic Patient Satisfaction and Likelihood to Recommend

Clinic Patient Satisfaction Likelihood to Recommend

22nd

Percentile

69th

Percentile

78

80

82

84

86

88

90

92

94

96

98

100

2007 2008 2009 2010 2011 2012

Hospital Patient Satisfaction and Likelihood to Recommend

Hospital Patient Satisfaction Likelihood to Recommend

30th

Percentile

90th

Percentile

23rd

Percentile

67th

Percentile

15th

Percentile

86th

Percentile

Virginia Mason Annual HCAHPS “Top Box” Performance Trend

VMMC Staff Partnership Results

68.5

72.4 74.1 73.3 74.2 74

50

55

60

65

70

75

80

85

90

95

2007 2008 2009 2010 2011 2012

Staff Partnership Score

59%

66%

73%

78%

83% 81%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

2007 2008 2009 2010 2011 2012

Staff Partnership Response Rates

5. Maintain a Successful Economic Enterprise

$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

Leadership Requirements

Needed to Sustain VMPS

1. Set priorities that align with the

vision

2. Use VMPS tools & methods

3. Lead change

4. Allocate resources to VMPS

5. Require accountability

6. Implement standard work for

leaders

Annual Goals

Long Term Vision

KPO Priorities

Clinic Priorities

Section Priorities

• Develop and implement a "know you" template in our electronic

medical record (EMR)

• Standard touch point behavior (Milkshake) TBD

• Contribute to my team's excellent phone service performance

• Work to resolve patients needs in one call

• Measure and improve message lead time

• Simplify scheduling "rules", share best scheduling practices, and

reduce appointment types

• Design and test innovative care delivery models

• Increase patient enrollment in MyVirginiaMason

• Pilot patient direct scheduling

• Identify new ways to engage patients to use the portal

• Know and explain how Virginia Mason is present for patients

within my community

• Schedule patients for follow-up appointments before they leave my

clinic

• Successfully implement our ambulatory computerized provider

order entry (ACPOE) system

• Give patients the specific information they need to navigate next

steps in their care

SHA

RE

PR

EPA

RE

• Implement new workflows using our electronic

medical record (EMR)

• Help us grow! Champion our locations, services

and quality to provide our patients what they need

How do I contribute to

these goals?

• Treat every call, every message as our patient

Clinic Focus Areas: Our Work in 2014

BE TH

ERE

• Be present with our patients; demonstrate that

we know them and care

• Engage patients in using MyVirginiaMason to

improve their health and well-being

• Just say yes! Offer patients care when, where and

how it is desired

Aligning Vision with Resources

VMPS Education

Intro to VMPS

VMPS

General

Education

VMPS

Leadership

Training

VMPS

Certification

VMPS

Fellowship

The VMPS Structure

• Kaizen Promotion Office (KPO) is aligned with the operational executive leadership

• Executive sponsors have accountability for sustained results

• 27 KPO staff

CEO

COO

KPO Hospital

Clinic

Corporate

Central

Executives

C O R P O R A T E

H O S P I T A L

C L I N I C

C O R P O R A T E

H O S P I T A L

C L I N I C

Kaizen Promotion

Office

Creating a Versatile Leadership Team

Accountability: Tier Reporting

PeopleLink Tier 3 Reporting: Managers report to department staff and Administrative Directors

“Stand Up” Tier 2 Reporting: Vice Presidents, KPO and Administrative Directors report updates on key

metrics to the Chief Executive Officer

Tier 1 Reporting: Senior Executive Leadership reports updates on key metrics to the Board

of Directors

PeopleLink Board Example

Accountability: Genba Walks

Go to the place, look

at the process, talk

with the people

VMMC Leaders Have Two Jobs

1. RUN their business

2. IMPROVE their business

Daily Team Huddle Board

Courtesy of Christin Gordanier, Hospital Level 9 (Tele)

Standing Topics for

each huddle appear

FIRST

New items added to

reflect current issues

Wipe board pulls off

of wall to use during

huddle, then goes

back up

Standard Work for Leaders

Key activities are

segregated by time

(daily, weekly,

monthly)

Used by all leaders

on Level 9

(Director, ANM’s,

etc.)

Very little is

“permanent” on the

board

Courtesy of Christin Gordanier, Hospital Level 9 (Tele)

FIVE Principle Elements of Daily Management

(Standard Work for Leaders) 1. Visual Controls

Create linked visual systems

that drive action

2. Daily Accountability

Process

Establish rounding process

at all levels

3. Leader Standard Work

Leaders routinely complete key

activities necessary to run and improve

their business

4. Root Cause Analysis

Asking “why” and using data and analysis to

attack problems

5. Discipline Leaders

consistently verify the health of processes and

systems

VMPS Methods and Tools

Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)

Leveled Production (Heijunka)

Just in time

Operate with the

minimum resource

required to reliably

deliver

•Just what is needed.

•In just the required

amount.

•Just where it is needed.

•Just when it is needed.

Jidoka

One-by-one confirmation to detect abnormalities.

Stop and respond to every abnormality.

Separate machine work from human work.

Enable machines to detect abnormalities and stop autonomously.

Pull System Production

One Piece Flow Production

Supermarket System

Takt Time

Production

Andon

Operational

Availability

Standard Work in Process

Kanban

Standard

Work

Materials

Machines

People

The Virginia Mason

Production System To Make things the Right Way

Deeper understanding of current state

VMPS Improvement Pathways

Kaizen: Continuous

Improvement of your current state

Kaikaku: Reinvent your services

and/or products

Understand your current state

RPIW Kaizen Events

3P

RPIW Kaizen Events

Everyday Lean Ideas

Everyday Lean Ideas

Waste: Any task or item

that does not add

value from the

perspective of the

customer.

Processing

Inventory

Time

Defects

Motion

Transportation

Over- production

Just in Time (JIT)

Definition:

Producing…

• Just what is needed

• Just the amount needed

• Just when it is needed

Using the…

• Minimum number of people

• Minimum materials

• Minimum equipment

• Minimum space

3P: Build-To-Order (BTO)

Focus Results Support Respect for People by reducing the burden of work: • SPD staff • Distribution team • OR Turnover team • Scrub Techs

Achievable vision and timeline has been established

Support OR turnover by reducing set-up time for each case

Creation of a BTO guiding team to move this work forward

Guiding principle of Just-in-Time: to give the surgical team only what the specific provider needs for their specific case

Build To Order Results

EVENT OLD NEW

Craniotomy

SPD Set Up = 34:00 min SPD Set Up = 18:27 min

OR Set Up = 24:09 min OR Set Up = 2:34 min

Laminectomy

SPD Set Up = 34:00 min SPD Set Up = 20:15 min

OR Set Up = 24:09 min OR Set Up = 2:29 min

Minor Set OR Set Up = 19:21 min

OR Set Up = 0:20 sec

Setup

is the time spent

preparing to provide

the next product or

service.

Setup reduction is a

method to reduce or

eliminate setup time to

increase capacity and

flexibility.

Typical setup activities:

• gathering

• transporting

• opening

• removing from packaging

• assembling

• installing

• adjusting

• presenting

• disassembling

• cleaning

Heijunka: Leveling the Workload

Min

ute

s

Takt Time

MA

Setup

Setup

MD

Setup

Setup

MA MD

Setup

After Setup Before Setup

• Eliminates walking

• Continuous flow

(no batching)

• Visual control

• Line of sight

• MD and FM

side-by-side

Flow Management at Flow Stations

CHARGE

SLIP

DOCUMENT

VISIT

CERNER

MESSAGE

URGENT

Flow

Station

Inbox

(e.g. labs) Non-urgent

Flow Station

Inbox

(e.g. mail)

CERNER

TEST

RESULT

REPORT,

RTE,

Sign &

Review

MD MA $

After – In Flow

• Provider/FM side by

side

• Standardize Flow

Stations

• Eliminate Walking

• Continuous Flow

• Visual Control

Redesign for Strong Economics Net Margin Before Indirect Cost

($716,391)

($332,983)

$935,834 $1,010,072

($1,000,000)

($800,000)

($600,000)

($400,000)

($200,000)

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

Year 1 Year 2 Year 3 Year 4

VM Primary Care Kirkland and Main Campus Practices

Value Stream Map

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

Jidoka Definition

Jidoka is a method to

increase productivity

by implementing

intelligent automation

and defect elimination

strategies.

The Business Case for Quality

Efficient Spine Clinic

1. Lower cost

FTE

Area, ft2

29%

78%

2. Greater revenue

RVU/MD/day

New patients /yr

76%

64%

3. Greater margin/year

Estimated from VM BSR & direct costs 56%

Overall Costs Decreased 20% Greatest Benefit: Avoiding Hospitalizations

62

Dental

Office Visits

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

ER Visits

Lab

Admits

Radiology

Costs (standardized)

Out-patient (other)

Outpatient Visits

Hospital

Days

Prescriptions

Home Health Visits

Prescriptions (day supply)

Jidoka Definition

Jidoka is a method to

increase productivity

by implementing

intelligent automation

and defect elimination

strategies.

VMPS Tools

Lead Time, Cycle Time and Takt Time

Lead time the entire time required to provide a product or service, from request to completion

Cycle time the time required for one operator or machine to complete one cycle of work

Takt time the pace of customer demand

Ch

eck

in

Wai

t

Ro

om

an

d

Vit

als

Wai

t

Exam

Wai

t

Pla

n o

f C

are

Wai

t

Test

ing

Periop Flow

Clinic Experience

Inpatient Care

Follow Up Care

Orthopedic Model Line


VMPS Flows of Medicine® Flow of

Family and Relationships

Flow of Providers

Flow of Patients

Flow of Medications

Flow of Supplies

Flow of Information

Flow of Equipment

Flow of Process

Engineering

5S

is a strategy that

helps to keep our

workplace safe and

organized

5S is cyclical


Self Discipline: • Maintain standards

through training, empowerment, commitment and discipline

Sort: • Separate necessary

from unnecessary

Simplify: • A place for everything

needed, in its place and ready to use

Sweep: • Inspection that every-

thing is where it belongs

• Visual confirmation that 5S agreements are being followed

Standardize: • Create common

agreements

• Communicate to the team

5S Anesthesia - Before

5S Creates Safety

5S Anesthesia “Shadow Board” –After

5S Creates Safety

Mistake

Proofing

Defects are mistakes that go

uncorrected

The purpose of VMPS is to ensure

zero defects

So what’s good enough?

Imagine 99.9% quality at VM…

•15 defective surgeries/year

•17 defective transfusions/year

•1,000 defective medication

administrations/year

•182 wrong meals served/year

•17,000 defective bills sent/year

•125 defective paychecks/year

The basic elements of

mistake-proofing are: • inspection

• standard work

• visual control

• devices

Inspection Methods

Within process

Just After

Just Before

Down-stream

A B C

Poke-yoke Self Check

Successive

Check

– Taiichi Ohno Founder of the Toyota Production System

Standard Work

“ ” Without standards, there can be no improvement.


Variation STANDARDIZATION Improvement

“Without Standards There can be no

Improvement”

Adopt Standard Work

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

Visual Controls

Skillet Example: www.mistake-proofing.com

Methods, devices, or

mechanisms used to

visually manage

operations

Devices

PDSA Teaching

How do we do our work?

• vigorously pursue waste

• use the PDSA method

Plan-Do-Study-Act

• continuously test/refine ideas

• focus on results

Example: defects down 66%

Observe and develop a new vision

Study the results

Awareness: a change

in thinking

Rapid implementation

– give it a try

PDSA Cycle

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

“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

Questions?

transforming healthcare: an overview of the virginia mason ... · •500 physicians •5,500...

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