Learning from Toyota and

W. Edwards Deming

Virginia Mason Medical Center’s

Quality Journey

The Quality Colloquium

August 2004

Gary S. Kaplan, MD
Chairman and CEO
Virginia Mason Medical Center
 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)
• 400 physicians
• 5000 employees
• Graduate Medical Education Program
• Research center
• Foundation
Virginia Mason Medical Center

• Tertiary Referral Center

• Education and Research
• Primary and Specialty Care
• “Academic Half-Way House”
• Innovation
• 16,000 Admissions
• 1.2 Million Visits
• Greater than $1.2 Billion Gross Charges
 Virginia Mason Medical Center

2000
● Leadership Change
● Issues
¾Survival
¾Retention of Best People
¾Need for Change
¾Build on a Strong Foundation
 Mandate for Change

● Economics
● Simultaneous Growth and Contraction
● Business Principles and Discipline
● Governance Change – Role of the Board
● Open Communication and Shared Vision
● Trust
Organizational Transformation
Physician Issues

• Clarity of Expectations
¾ Compact
¾ Job Descriptions
• Responsibility and Accountability
• Culture of Feedback
• Transparency
• Trust
 Virginia Mason Medical Center
Physician Compact
Organization’s Responsibilities Physician’s Responsibilities
Foster Excellence Focus on Patients
• Recruit and retain superior physicians and staff • Practice state of the art, quality medicine
• Support career development and professional • Encourage patient involvement in care and treatment
satisfaction decisions
• Acknowledge contributions to patient care and • Achieve and maintain optimal patient access
the organization • Insist on seamless service
• Create opportunities to participate in or Collaborate on Care Delivery
support research • Include staff, physicians, and management on team
Listen and Communicate • Treat all members with respect
• Share information regarding strategic intent, • Demonstrate the highest levels of ethical and
organizational priorities and business decisions professional conduct
• Offer opportunities for constructive dialogue • Behave in a manner consistent with group goals
• Provide regular, written evaluation and • Participate in or support teaching
feedback Listen and Communicate
Educate • Communicate clinical information in clear, timely
• Support and facilitate teaching, GME and CME manner
• Provide information and tools necessary to • Request information, resources needed to provide
improve practice care consistent with VM goals
Reward • Provide and accept feedback
• Provide clear compensation with internal and Take Ownership
market consistency, aligned with • Implement VM-accepted clinical standards of care
organizational goals • Participate in and support group decisions
• Create an environment that supports teams • Focus on the economic aspects of our practice
and individuals Change
Lead • Embrace innovation and continuous improvement
• Manage and lead organization with integrity • Participate in necessary organizational change
and accountability
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.
 Hospital Complications Exceed $9 Billion
(Study based on data from 994 hospitals in 2000.)
60
$60,000 12 days

50 Excess charges,
Left scale
10

40 Excess length
of stay, right
8
scale

30 6

20 4

10 2

0
Bedsores Accidental Infection Blood- Wound Foreign
Puncture Caused by stream Reopening Object Left
Medical Care Infections Inside Body
# Patients
41,440 11,810 11,449 2,592 843 536
affected annually

Mortality rate 7.23% 2.16% 4.31% 21.92% 9.63% 2.14%

Source: Journal of the American Medical Association
 Why Zero Defects is the
Only Acceptable Standard?

• At 99.9% quality levels, here is what

happens:
• 22,000 checks are deducted from the wrong bank
accounts every day
• 16,000 pieces of mail are lost by the Postal
Service every hour
• 2,000 unsafe airplane landings are made every
day
• 500 incorrect surgeries are completed every
week
Changing the Mind of Leadership

• At Virginia Mason our vision is to be the

Quality Leader in healthcare.
• We are committed to producing a
defect free product.
• We are pursuing that goal through the
adoption of the Virginia Mason
Production System.
The Virginia Mason Production
System is the Toyota
Production System based
management method by which
we will accomplish our vision
to be the quality leader.
 VMPS at Virginia Mason
We adopted the Toyota Production System
philosophies and practices and applied them to
healthcare because this industry and we were so
lacking in an effective management approach that
resulted in:

• Customer First,
• Highest Quality,
• Obsession with safety, and
• Highest staff satisfaction,
• A successful economic enterprise.
 Relentless War on Waste
7 Wastes
• Waste of overproduction
• Waste of transportation
• Waste of overprocessing
• Waste of inventory
• Waste of motion
• Waste of making defective products or poor
quality
 Principles

• Define Value
• Identify Value Stream
• Continuous Flow
• Pull
• Pursuit of Perfection
 7 Flows
Production Medicine
• People • Patients
• Raw Material • Providers
• Parts • Medication
• Production • Supplies
• Equipment • Information
• Information • Equipment
• Engineering • Process Engineering
 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
Seeing with our Eyes
Japan 2002
 Overview

• Introduction
• Toyota Museum of Industry and
Technology
• Hitachi Air Conditioning
• Toyota Motor Corporation
• Summary of Trip
• Our Plan
• Conclusion
 Hitachi Air Conditioning

• Team Leader
Kaplan reviewing
the flow of the
process with Drs.
Jacobs and Glenn
 Hitachi Air Conditioning

• Dave recording
the work flow
and timing cycle
time
 What We
Learned
‹ Air conditioners, cars, looms, airplanes and
forklifts…what do any of these products have to do
with health care?
• Health care, too, is full of production processes
• These Japanese products, like our services,
involve the concepts of quality, safety, customer
satisfaction, staff satisfaction and cost
effectiveness
• The completion of a product involves thousands
of processes—many of them very complex
• Many products, if they fail, can cause fatality
• They are in many ways, just like us
 What We
Learned

• Production processes have much in in common with

admitting a patient, having a clinic visit, going to
surgery or a procedure and sending out a bill
• To have smooth, high quality continuous flow of our
patients is delightful when it happens
• Our vision is that this would happen always for our
patients
• We are more convinced than ever that the principles
and tools of the Toyota Production System may well
become those of the Virginia Mason Production
System, the system of management behind the
achievement of becoming the Quality Leader
 The Plan
The plan for translating what we learned into reality at
Virginia Mason has seven areas of focus:

•“Patient First” will be the driver for all that we do

• Our brand of the Toyota Production System will be

the “Virginia Mason Production System”

•Create an environment in which our people feel sate

and free to engage in improvement – “No Layoff
Policy”
 The Plan
• The plan for translating what we learned into
reality at Virginia Mason has seven areas of focus:

• “Patient First” will be the driver for all that we

do

• Our brand of the Toyota Production System will

be the “Virginia Mason Production System”

• Create an environment in which our people feel

safe and free to engage in improvement – “No
Layoff Policy”
 The Plan
(Continued)

• Implement a company-wide defect alert

system called “The Patient Safety Alert
System”

• Encourage innovation

• Create a prosperous economic

organization. We will primarily reduce
costs by eliminating waste

• Require leadership accountability

 VMPS in Action

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

• RPIW (Rapid Process Improvement Workshop)
• 3-P (Production, Preparation, Process)
• Super Flow
• Daily work life
 What about Customers?
• Patient Satisfaction and Service
• Always puts the patient first
• Pre-surgery clinic
• Standard educational materials
• Standard work “scripts” at call center
• Clean, clutter free environment
• Less waiting
• More about the patient
• Better Flow
 What about Staff?
• Staff satisfaction
• Enthusiastic team participation from staff
• Ensuring work at Virginia Mason – No Layoff Policy
• Concern about jobs changing which tend to go away
upon completion
• Physicians are no different than staff
• Cross Training becoming widespread
• Certification of all Executives and Admin Directors
• >99% of staff attended Introduction to Lean
• Some leaders have a harder time ….
• Skepticism is dwindling….
 What about Quality?

• Quality
• Reduction in variation with standard work

• Reduction in handoffs by creating flow and

eliminating non-value added work

• Reduction in defects and errors

Standard Work = Evidence-Based + Best Practice

EXISTING EVIDENCE-BASED EMERGING EVIDENCE,

GUIDELINES GOOD GUESSES,
(National, Regional, Local) LOCAL TALENT

LEAN / RPI
Value
Flow
Waste
Kaizen

STANDARD WORK
(Best Practices)
 What about Safety?
• Safety
• Reduction in clutter (environment)
• Standard work ensures the best practices
are consistently used (patient and staff
safety)
• Reduction in error – Mistake Proofing
• “It Takes Two” patient safety initiative
• Patient Safety Alert (PSA) in active use
 Stopping the Line 

Virginia Mason’s Patient

Safety Alert System
 Virginia Mason Production System (VMPS)

Constant
Improvement
JUST IN TIME People JIDOKA
What is needed One-by-one detection
In the amount needed Materials and response to every
At the time needed abnormality: “Stopping
At the place needed the line”
Machines
Leveled Production
Elimination of Waste
 Patient Safety Alert 
Process Overview

• Report if likely to cause significant harm

• 24/7 hotline, procedure, and staffing
• “Drop and run” commitment (code)
• Evaluate and fix immediately
• Or the stop process, do a root cause
and restart when fixed (<29 days)
 Patient Safety Alert Results
as of 5/31/04

• 201 Patient Safety Alerts

• Diagnosis/Treatment 16
• Medication Errors 32
• Systems 119
• Equipment 21
• Conduct 10
• Average # of PSAs/month appears to be leveling off
2002- 3/month
2003- 10+/month
2004- 11+/month
• Average days to completion – 6.4
• Individuals taken off line – 15
• Processes take off line – 7
Patient Safety Alert (PSA Recap* (as of 5/31/04
*PSA Policy/Procedure Initiated 8/1/02
Year 2002 YTD 2003 YTD 2004 YTD
(5 month) (12 month) (5 month)
Category:

Clinical Dx/Tx 6 6 4

Medication 4 17 11

Systems 4 74 41

Facilities/Equipment 1 22 1

Conduct/Scope of Practice 3 6 1

Total PSAs 18 125 58

PSAs/Month 3.6 10.4 11.6

Average Days to Completion 18.4 13 6.4

Processes Taken Off-Line 1 4 2

Employees Taken Off-Line 6 5 4

Employees Terminated 2 3 2
 RPIW Example Areas
• GI Ambulatory • Rehab Medicine Patient Flow
• HR Business Partner • Inpatient Medication Integration
• PACU • Histology Slide Turn-out
• Radiology • Inpatient Incomplete Chart
• Hospital 3P Processing
• Periop Induction Room • Lindeman Pavilion Pharmacy
• Adult Ambulatory Visit Flow • Human Resources Service and
• Dermatology 3P Processing
• Ambulatory Specialty Scheduling • Orthopedics/Sports Medicine
• Federal Way Specialty Clinic and • Clinical Research
ASC • PM & R
• Disease State Management • Ambulatory Neurology
• Supply Chain • Ambulatory Transplant
• Skilled Nursing Placements • Cardiology
• Specimen Collection Mistake • Emergency Department
Proofing
Electrophysiology Workshop

An example of a Rapid Process

Improvement Workshop
Improving the flow of patients through the cardiac procedures labs to the PCU was the focus of the
latest Rapid Process Improvement Workshop. The EP Cath Lab to PCU workshop team
completed their work on September 12, 2003
Here’s the Team!

Team members from left to right: Gordon Kritzer, MD, Gary Kaplan, MD, Robert Mecklenburg, MD, Julie
Legaros, RN, Chris Fellows, MD, Steven Piccolo, RN, Jackie Kubu, Janette Trube, Kellie Bradfield, Julie
King, Melanie W inters, RN (Team members are holding a sign that reads, “W e are Reinventing
Healthcare”)

W orkshop Leader was: Gary Kaplan, MD

OPI W orkshop Leader: Chris Backous
Team Leader was: Julie King
Sub-Team Leader was: Robert Mecklenburg, MD

Team Goals:
Reduce non-value added time in the value stream for patient and improve efficiency of performance for the
Section of Cardiology, Cath and EP Labs, and PCU by:
• Level loading cardiac procedures across the days of the week and hours of the day, and
• Coordinating care between the Section of Cardiology, the cath lab and PCU.
 Target Progress Report
Team Name: EP/Cath Lab to PCU Flow Date: Sept8-12, 2003
Department: Heart TAKT Time*: Cath: 60 minutes; EP: 134 minutes

Product/Process Summary: Team Leader: Julie King/Bob Mecklenburg

Outpatient scheduling of a cardiac catheterization (cath) or Workshop Leader: Gary Kaplan
electrophysiology (EP) procedure through patient discharge
from the Procedure Care Unit (PCU)
Goals: Level Loading, Improved Coordination

Metric Baseline Target Day 5 % Change Key Changes

Space (square feet) 1, 334 sq feet 0 0 100% Enhanced level loading of PCU
PCU weekly turnaway (alternate hospital patient flow eliminating need to
beds occupied when PCU has been use hospital beds for overflow
filled).Baseline represents an average of 7
patients turned away each week.
Inventory (dollars) $1,901.70 $950 50% Work with supplier to increase
Cath procedure packs; current state $950 frequency reducing need for
PAR level noted in baseline is 30 stock on hand by 50%
packs @$63.39 each
Staff Walking Distance: 140 feet 70 feet 12 feet 91% AM supermarket to avoid
Trips to/from Omnicell by PCU RNs unnecessary walking-kanbans in
place to restock as needed
during their day shift. Baseline is 12
preventing pile-up of inventory in
trips per day supermarket
Parts Travel Distance (feet) NA NA NA NA
Lead Time (minutes): time from EP: 30, 078 EP: EP: 75% EP/Cath:Schedule balancing
Cardiology Clinic CSR medical minutes 15,039 EP: 7,506 allowing for consistent flow of
information collection/scheduling until Cath: 3,116 Cath: 10% procedures through lab resulting
patient discharge from the PCU minutes Cath: Cath: 2,798 in more predictable PCU flow
1,558
Work In Process (WIP): Number of EP EP: 58 EP: 29 EP: 25 in 3 EP: 56% Increaed flow reduces Que and
and Cath patients waiting for their Cath: 24 Cath: 12 weeks) Cath: 0% WIP
procedure. WIP is determined by patients Cath: 24
scheduled for procedures past current day
Quality (defects)(%): a. EP:17%; a. EP: 0; Cath: TBD Delay: 0% Exrternalilzing set-up for
a. Daily Procedure Delays (based on Cath: 35% 0 (TBD) procedures and ensuring data
3 days of data collection in the 0 collection done in cllinic at time
labs) b. 12% b. 0 Med Info: of scheduling as well as
100% developing standard work and
b. Patients without a medical clear MD expectations reduces
information packet at time of defects ie patients should not
check-in to PCU. Baseline arrive in PCU with incomplete
number represents one month of information
data collection
Productivity Gain (FTE): EP: 65 hours EP: 0 TBD 0% Scheduling level loading
1. Average monthly overtime hours for (.37 FTE) Cath: 0 (TBD) increases number of procedures
Cath and EP staff (excluces call-back Cath: 63 within scheduled hours allows
Overtime). Baseline based on 6 months hours (.36 elimination of OT and increased
of data. FTE) capacity
Environmental, Health & Safety 3 4 4 100% New EP lab
(5S):
New EP Lab
Set-up Reduction (minutes): Cath: 255 Cath and EP: 18 Cath: 97% See above
Cardiology CSR information preparation minutes Cath: 9 minutes minutes EP: 99%
(from medical information collection by EP: 1,467 EP: 9 minutes
CSR through authentication by physician minutes
and sending to PCU )

Remarks:
*TAKT Time is based on the following information:
Cath: An average of 45 patients have procedures Monday-Friday of each week, 9 patients per day if procedures were level loaded. Available time for the lab is 9 hours
per day (540 minutes). 540/9=60 minutes
EP: An average of 25 patients have procedures Monday-Friday of each week, 5 patients per day if procedures were level loaded. Available time for the lab is 56 hours
per week (3, 360 minutes). 3360/25=134 minutes
 3Ps Production, Preparation,
Process
• Cancer
• Hospital
• Dermatology
• GI
• Hyperbarics
 Commitment and Deployment
• Leadership and management
• Introduction to Lean
• Certification Track
• Lean Mastery
• Japan Gemba
• Kaizen Fellowship
 The Returns: Cost Avoidance

• $1M Capital Savings for Hyperbaric Chamber

for 3P
• $1-3M Endoscopy Suites now staying in
current location
• $1.8M Breast Cancer mammography Suites
9200 sq to 5400 sq post 3P
• $6M Surgery Suites budgeted and planned –
now not building
• New outpatient building
 Target Progress Report
Team Name: Lean Leadership Team Date: 4/30/04
Client: VMMC Takt Time:
Product/Process Summary: 2003 34d-4th Q RPIW Target Sheet Rollup Team Leaders: G. Kaplan/M.Rona
Metric (units of measurement) Baseline Target 90-Day Percent
Change
Space (square feet) 11,541 sqft 5,770.5 sqft 6,323 sq ft 45.2%
Inventory $1,957,186 $195,718.60 $971,661.50 50.4%
Staff Walking Distance (feet) 148,577 ft 74,288.5 ft 84,310 ft 43.3 %
Parts Travel Distance (feet) 17,876 ft 8,938 ft 2,517 ft 85.9%
Lead Time (minutes) 272,557’ 136,278’ 59,216’ 78.3%
Work in Process (WIP) (units) 624,573 312,286 241,584 61.3%
Quality (defects) (%) (a) 20%
Productivity Gain (b) 83.4 57.2 31.4%
Environmental, Health & 5 units at 2 All units at 4 3 units at 3
Safety (5S) (levels 1 thru 5) 2 units at 3 15 units at 4
5 units at 3
6 units at 4
Set-up Reduction (minutes) 3,656’ 1,828’ 252’ 93.1%
Remarks: Additional revenue gains:
$21,215 annually eliminated in nursing overtime costs / Chemo Delivery RPIW
$9,160 saved by reduced need for vendor services/Coding RPIW
 Leapfrog
Leapfrog 2003 Survey Results

Leapfrog
CPOE ICU Volumes
Standard
CABG PCI
Pancreatic
CABG Outcomes PCI Outcomes AAA Esophagectomy
Resection
Rank Rank
Above Above
Virginia Mason national national
average average
Did not
Evergreen n/a n/a participate n/a
Above
Did not
Northwest national
participate
average
Did not Did not
Overlake participate participate

Did not Did not

Swedish - 1st Hill participate participate

Did not Did not

Swedish - Prov participate participate n/a
Above Above
UW national national
average average

Valley Medical n/a n/a n/a n/a

~ Fully implemented Leapfrog's recommended safety practice

~ Good progress in implementing Leapfrog's recommended safety practice
~ Good early stage effort in implementing Leapfrog's recommended safety practice
~ Willing to report publicly; did not yet meet Leapfrog's criteria for a good early stage effort
N/A ~ Not applicable (e.g., IPS standard does not apply because hospital does not have an ICU.)
 Performance of Virginia Mason
• Leapfrog
• Top 100 Hospitals - Solucient
• Healthgrades
• Economic
• 2001 - $ 22,239,000
• 2002 - $ 22,917,000
• 2003 - $ 22,000,000
• BBB+ to A-
 To Change Medicine…..
Change Your Mind
• Provider First • Patient First
• Waiting is Good • Waiting is Bad
• Errors are to be Expected • Defect-free Medicine
• At-risk Employment • Guaranteed Employment
• OTJ Training • Explicit Training
• Diffuse Accountability • Rigorous Accountability
• Add Resources • No New Resources
• Reduce Cost • Reduce Waste
• Retrospective Quality Assurance • Real-time Quality Assurance
• Management Oversight • Management On Site
• We Have Time • We Have No Time
If you are dreaming about it…
You can do it.”

Chihiro Nakao