Furman Cincinnati 10-9-12

Transforming Health Care
Virginia Mason Medical Centers Pursuit of the Perfect Patient Experience

Greater Cincinnati Health Councils Solutions in Quality and Patient Safety October 9, 2012
Cathie Furman, Senior Vice President, Quality & Compliance Virginia Mason Medical Center Seattle, Washington
2012 Virginia Mason Medical Center
Virginia Mason Medical Center

Integrated health care system 501(c)3 not-for-profit 336-bed hospital Eight locations 500 physicians 5,500 employees Graduate Medical Education Research Institute Foundation Virginia Mason Institute
Our Strategic Plan
The VMMC Quality Equation
Q = A (O + S) W
Q: Quality A: Appropriateness O: Outcomes S: Service W: Waste
Clash Of Promise And Imperatives

Traditional Promise Legacy Expectations
Imperatives
Improve safety/quality
Autonomy Protection Entitlement
Implement EHR Create service experience Be patient-focused Improve access Improve efficiency Recruit/retain quality staff
Seeing with our Eyes Japan 2002
Hitachi Air Conditioning
Team Leader Kaplan reviewing the flow of the process with

Drs. Jacobs and Glenn
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
Start by Removing Waste

Waste of time Waste of making defective products or poor quality
Waste of overproduction
Waste of motion Waste of inventory Waste of over processing Waste of transportation
Think Different
the human effort the space the equipment the inventory the investment the engineering hours the new product development time
The Methods & Tools that Transform Work
Value Stream Development 5S (Sort, simplify, standardize, sweep, self-discipline) Standard Work Flow Mistake Proofing RPIW (Rapid Process Improvement Workshop)
Value Stream Map
The Patients Perspective: Migraine
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
Value added
Non-value added
Variable value
Organize the Workplace: 5S
Self Discipline:
Maintain standards through training, empowerment, commitment and discipline
Sort:
Separate necessary from unnecessary
Standardize:
Create common agreements Communicate to the team
Simplify:
A place for everything needed and everything needed in its place and ready to use.
Sweep:
Inspection that everything is where it belongs. Visual confirmation that 5S agreements are being followed
Start with 5S
5S Anesthesia - Before
5S Creates Safety
5S Anesthesia Shadow Board After

Central Line Insertion Standard Work

Before
Dry: 30 sec scrub 30 sec dry Wet:
Paws
2 min scrub 1 min dry
Maximum Barrier Protection
OR
AND
Thyroid
Angio Drapes
During
Transducer Kit in Top Drawer of Cart
OR
Transducer Method
Manometer Method
After
Approved to use Date/Initial Yellow
top of cart
White
in chart progress notes
Complete Paperwork
Make it Flow
Flow of Patients
Flow of Family and Relationships
Flow of Providers
Flow of Information
Flow of Medications
Flow of Supplies
Flow of Equipment
Flow of Process Engineering
After
Understanding Flow
Before
Flow Stations
URGENT Flow Station Inbox (e.g. labs) Non-urgent Flow Station Inbox (e.g. mail) Electronic MESSAGE
CERNERTE ST RESULT REPORT, RTE, Sign & Review
CHARGESLIP
MD
MA
DOCUMENT VISIT
Achieving Flow
Provider Office
Before: Flow Station and MD Office far away
Flow Manager
22
After In Flow
Provider/FM side by side Standardize Flow Stations Eliminate Walking
Continuous Flow
Visual Control
Maintaining Flow: Mistake Proofing Imaging

GO/NO GO MRI ORDER Order must fit evidence based indication for imaging
Shortening Waiting Times for Appointments
The Business Case for Quality

$1,200,000 $1,000,000 $800,000 $600,000 $400,000 $200,000 $0 ($200,000) ($400,000) ($600,000) ($800,000) ($1,000,000) $935,834 $1,010,072
($332,983) ($716,391) Year 1 Year 2 Year 3 Year 4
VM Primary Care practices, net margin before indirect cost

Build safety into the process Zero Defects
Pokayoke
Self-Check Successive Check
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 2 major airplane accidents per week 500 incorrect surgeries are completed every week 2,000,000 loss IRS documents per year 10,000 medication defects at VMH
Mistakes vs. Defects

Mistakes are inevitablebut reversible Defects are mistakes that were not fixed soon enoughand are now relatively permanent If you fix mistakes soon enough, your work will have zero defects - what the customer wants! Mistakes are least harmful and easiest to fix the closer you get to the time and place they arise
Mistakes are Fixed at the Source

Within process
A
Just After
B
Just Before
C
Downstream
Poke-yoke
Self Check
Successive Check
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
Stopping the Line Organization-wide Involvement

Staff identify and report issues and concerns using the Patient Safety Alert System Leadership involvement with investigation and resolution Board Quality Committee review and approve closure of high-severity issues (Red PSAs)
Safety Results
39% Reduction in SSI 1998 to 2008 45% Decrease in Patient Falls from 2008 to 2012 77% Decrease in Patient Falls with Injuries from 2008 to 2012 76% Reduction in Pressure Ulcers from 2008 to 2012 100% Medication Reconciliation at time of patient discharge
Business Case for Patient Safety:

Total Number of Claims and PSAs Reported
80 5386 70 71 67 60 5000 6000
60
60
4322 4000
50
3500 3079 44 2726 46 2954 42 PSAs Reported Reported Claims
40
2697
3000
30 26 20 2000
10
8
8
1000
0 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
Total number of claims excludes claims closed with no payment

Hospital Professional Liability Premiums

$4,500,000.00
4% 7%
$4,000,000.00
12%
$3,500,000.00 $3,000,000.00
5%
62% Reduction Since 2004

26%
$2,500,000.00 $2,000,000.00
12%
7% 13%
$1,500,000.00
$1,000,000.00 $500,000.00 $-
2003-04 Premiums $4,068,476.
2004-05 $4,211,000.
2005-06 $3,900,000.
2006-07 $3,442,390.
2007-08 $3,275,723.
2008-09 $2,438,886.
2009-10 $2,151,457.
2010-11 $2,004,553.
2011-12 $1,779,427.
CONFIDENTIAL: This information is being provided at the Direction of General Counsel in anticipation of litigation and is part of VMMC's CQIP and as such is protected under RCW 4.24.250, 43.70.510, and 70.41.200.
Let those who do the work improve the work

Kaizen:
Continuous Improvement of your current state Understand your current state
Kaikaku:
Reinvent your services and/or products
RPIW
Kaizen Events
3P
Everyday Lean Ideas
Deeper understanding of current state
RPIW
Kaizen Events
Everyday Lean Ideas
Nursing Cells The Idea
RN workflow
Group items w/Color Codes & Map Frequently used supplies at bedside
No waiting in line for OmniCell No missing items
Linen supplied daily by Housekeeper
Standard Bedside Report

WHY: Introduction of oncoming caregivers Involves the patient in discussion Builds in safety Adds time with patient
Bedside Handoff Checklist
1 Introduction
Name of oncoming RN and assistant

Explains handoff process Inquires how patient is feeling Age, MD, reason for admission Isolation Brief history Functioning prior to admission Key medications Tests for the day Patient identification High risk meds IV Physical assessment Precautions/Skin/Wound Patient input Plan of the Day Safety concerns Patient issues "Is there anything you need at this time?" Determine when will return
Background (Basics)

Current status

Assessment

Recommendations

Closing

First Draft of Bedside White Board to Enhance Communication Among All Team Members
Current white board
2012, Virginia Mason Medical Center
Nursing Cells Results > 90 days

RN time available for patient care = 90%!
Before 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
After 846 1256 126 0% 10% 16% 0% 11
Foundational Elements: Nursing

Geographic assignments
Documentation near the patient

In room handoffs
RN:PCT integration
Huddles every shift
Hourly rounds by caregivers

Daily Leader rounds People Link Boards updated and staff huddles done monthly
Experience-Based Design (EBD)

Definition
EBD is a set of methods focused on understanding peoples experiences so we can design better services To learn more about experiences in a comprehensive way, what matters to customers? Customers include patients, family members or team members
Experience-Based Design
Research
Soft stuff of emotions and experiences matters Anxious or frightened patients less able to absorb, retain information Customer loyalty impacted by not meeting emotional needs Poor experiences interrupt flow and operations, create rework
Key Principles
Design for the human experience Direct customer involvement Understand what people naturally do and feel
Three Methods
Interviews Surveys Focus Groups
The How of EBD
Identify touch points Where people come into contact with the service and experience is shaped Create story of what is happening at each touch point in the process: Mapping tools Visuals and photos Observations Customers own words Analyze and understand the experiences to inform improvements
Experience-Based Design:
Experience Questionnaires
A visual depiction of key touch points in a process that guides customers in sharing their experience
World-Class Management
Management by Policy
Provides focus and direction
Daily Management
Manages daily work
World-Class Management System
Cross-Functional Management
Aligns across the organization toward full customer satisfaction
The World-Class Management System is a leadership system that provides focus, direction, alignment, and a method of management for daily work
This
Or This
Align the Vision with Resource

Vision To be the Quality Leader and transform health Mission care To improve the health and well-being of the patients we serve Values
Patient
Long Term Vision
Teamwork | Integrity | Excellence | Service
Strategies
People Quality Service Innovation
Virginia Mason Team Medicine Foundational Elements

SM
We attract and develop the best team
We relentlessly We create an pursue the extraordinary highest quality patient experience outcomes of care Integrated Information Systems Education
We foster a culture of learning and innovation
5 Year Plans Annual Goals

Quality and Safety
1. Ambulatory Prevention Bundles 2. Optimize Care Transitions 3. Zero Nosocomial Injuries Fall Prevention Health-care Acquired Infections 4. Patient Safety Curriculum 5. Innovative Clinical Value Streams
Strong Responsible Economics Governance
Research Virginia Mason Foundation
Virginia Mason Production System
KPO Priorities
World Class Management

Elements of Management by Policy
Reflection
Environmental Scanning Review 5 Year Plans
Check and Review

Compare performance to plan Occurs at all company levels
Catchball
Idea exchange Feedback, engagement Identify resources / roles Set measurement criteria
Deployment
Production plan Understanding/ awareness Develop strategies for entire organization departments individuals
Adapted from elements of World Class Management, Management by Policy

Management by Policy - Deployment
Management by Policy - Check and Review
Regular checks and reviews are critical Determines current status of goal achievement Conducted regularly (e.g., daily, monthly, quarterly) Includes intensive, objective study of data Joint problem-solving, planning, and follow-up may be required
Cross-Functional Management
A management system for implementing breakthrough improvements that is always focused on the elements of full customer satisfaction
CrossFunctional Management
Daily Management
Repetitive daily activities and behaviors that leaders engage in to ensure customer demand is met and identify abnormal conditions: Know at a glance status of daily work Daily Management Completing planned work Understand status of upstream and downstream processes Standard work being followed Know when to take action and what action to take Engaging Staff
At a glance:
Staffing and Bed Capacity is understood.
Knowing Your Business
Daily Management
Demand is known.
There are four principal elements of Daily Management

Leader standard work
Discipline
Visual Controls
Daily Accountability Process
Leader Standard Work

Clinic Supervisor & Director Daily List
Leader standard work Discipline

Daily Accountability Process
Visual Controls
Standard work for leaders specifies the actions to be taken each day to focus on the processes in each leaders area of responsibility.
Visual Controls
Visual controls focus on the process and making it easy to compare expected versus actual performance
Leader standard work Discipline Daily Accountability Process Visual Controls
Hitachi
Visual Controls
Leader standard work Discipline Daily Accountability Process Visual Controls
Heres an example of how insurance payment closure understands their business daily
Visual signal for help
Staff member can see & re-assign to help
Visual Controls
At a glance:
Provider covering
Discipline Daily Accountability Process
Visual Controls
Capacity after lunch
WIP: Messages Forms Lab Results
Daily Accountability
Foundational Elements: Nursing
Geographic assignments Huddles every shift In-room handoffs RN:PCT integration Hourly rounds by caregivers Documentation near the patient Daily leader rounds PeopleLink Boards updated and staff huddles done monthly
Discipline Daily Accountability Process Leader standard work Visual Controls
Hospital Genba Rounds
Focus
Leadership rounding
is a key principle of effective leadership Standard Work for Leaders is a 2010 target across all KPOs Genba Rounds in the hospital were initiated in 2008 Variability across all units Lack of standards for participants conducting rounds No consistent use of visual control s to determine status of unit Kaizen Event to 5 S Genba rounds in March, 2010
Foundational Elements Progress Report
Unit:L9 JGoulding Streifel :Rowena Ponischil Month: March 2010
Created
Results
Foundational Elements Progress Report based on organizational goals, and nursing foundational elements Created Peer review process prior to Genba rounds Created standardized Genba Rounds Agenda template Created standard work for each Genba round participant Saved in shared folder on common G drive Team Agreements, Level 4 5 S achieved
Inpatient Gemba Rounds
AGENDA
Date: 23 march 2010 Time: 0930 Location: Unit L9 Ortho Meeting Length: 30 minutes
Item Legend A=Approval / Action Item D=Discussion / Input FYI=Information only No discussion at meeting R=Review ST=Standing U=Update
Materials Legend * Attached + Distributed at meeting
Statement of Purpose: Guide Inpatient Gemba Rounds on the unit.

.
Units Criteria
Geographic Assignments Visual Controls

NA
RN/PCT Integration Audit Tool

NA
In Room Handoff Observation
Huddles Every Documentation Hourly Rounds Shift near the Patient by Caregiver Observation Observation Audit Tool
Daily Leader Rounds Observation
People Link Board (PLB) Updated Observation
Monthly Staff Huddles by PLB Observation

1
Item
Agenda Item Presenter C/T
COMMENTS/SUGGESTIONS/ACTION ITEMS
D/U
CCU-7 Level 7 Level 8 Level 9 Level 10 Level 11 Level 12 Level 14 Level 15 Level 16 Level 17 RHU ED
Foundational Element for Discussion: DAILY LEADER ROUNDS Inpatient Leader
D/U
Success to Highlight: Staff& Patient Feedback Inpatient Leader
D/U
NA NA
Recent Kaizen Work/PDSA RPIW Therapeutic Zones Inpatient Leader
Foundational Elements Progress Report
Dialogue 4 D Gemba participants

13
Genba Rounds Agenda
Summary Remarks
FYI *
FYI Attachments Foundational Elements Progress Reports
Not Implemented Implemented Plan with Progress Fully Implemented
2010 Virginia Mason
NOTE: The Hospital AD will make notes in the Comments/Suggestions/Action Items box during the course of the Gemba Rounds. The noted agenda is to be returned to the Inpatient Nurse Leader.
Discipline Daily Accountability Process
Visual Controls
People Link Boards updated, and managed with set agenda
Standard Work for Leaders

Establish a system for accountability with huddles/tiered reports
WHAT? Lead Supervisor Manager Director/Section Head AD VP/Chief Huddles Floor check Lead weekly people link Spot check standard work Review performance trends Verify leader standard work How Often? 2 x daily Daily Weekly Weekly Weekly Weekly % of work standard 80% 50% 25% 20% 15% 10%
I am just a biller
I look forward to every Thursday morning at 0730. I look
around the room and see people from such different

backgrounds, ethnicities, beliefs, cultures, job duties and titles but what I see is a common language, a common goal, common rules. The Strategic Plan is the glue that binds us, that teaches us the common language we speak.
Amy S.
VMPS Standard Work for Leaders

CEO Board
COO Board
VP Board
AD Board Director Board Supervisor Board Front Line Board
Support the Effort Kaizen Promotion Office (KPO)

1-5% of all non management staff as KPO KPO aligned with operational executive leadership Executive sponsorship with accountability for sustained results Education Standardization of tools, results reporting, and communication
The VMPS Structure

CEO
COO
Executives
KPO
Hospital Clinic Corporate Central
Kaizen Promotion Office (KPO) is aligned with the operational executive leadership Executive sponsors have accountability for sustained results
Educate the Staff and Leaders

All Staff Introduction to VMPS VMPS General Education (tools and methods) Everyday Lean Ideas Supervisors and Managers VMPS for Leaders Standard Work for Leaders Directors, Executives, and Physician Leaders VMPS Certification Standard Work for Leaders
Leaders Sustain the Rigor
Tuesday Stand up Friday Report Out Standard Work for Leaders
Go and See
Go and See
Big Ears, Big Eyes, Small Mouth

Capture Wisdom
Everyday Lean Idea Form

Requirements for Transformation

Improvement Method Applied to ALL Processes
Critical mass feels urgency for change
Executives address technical AND human dimensions of change
New compact aligns expectations with vision
Visible and committed leadership
Broad and deep commitment to shared vision
Change the Paradigm

FROM
Provider First Waiting is Good Errors are to be Expected Diffuse Accountability Add Resources Reduce Cost Retrospective Quality Assurance
TO
Patient First Waiting is Bad Defect-free Medicine Rigorous Accountability No New Resources Reduce Waste Real-time Quality Assurance
Management Oversight
We Have Time
Management On Site
We Have No Time
Dont Let Up
Strive for the Highest Satisfaction Levels

2007 95 90 85 80 75 70 65 60 55 50 2008 2009 2010 2011 95 90 85 80 2007 2008 2009 2010 2011 95 2007 2008 2009 2010 2011
86.4 86.7 83.7 84.3
87.7
90 85 80 75 70 65 60 55 50
89.9 88.6 89.4
90
90.8
72.4 68.5
74.1 73.3 74.2
75
70 65 60 55 50
Staff Satisfaction
Hospital Patient Satisfaction
Clinic Patient Satisfaction
Maintain a Successful Economic Enterprise

$50 $49.40 $40.90 $40
$ (Millions)
$30
Shared Success Program
$31.70 $29.40
$20
$18.40
$12.00
$10
$3.20 $0.70 $0 2000 2005 2006 2007 2008 2009 2010 2011
VMMC Quality Awards
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

Furman Cincinnati 10-9-12

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Transforming Health Care

Virginia Mason Medical Centers Pursuit of the Perfect Patient Experience

Virginia Mason Medical Center

Our Strategic Plan

2012 Virginia Mason Medical Center

The VMMC Quality Equation

Clash Of Promise And Imperatives

Autonomy Protection Entitlement

2012 Virginia Mason Medical Center

Seeing with our Eyes Japan 2002

2012 Virginia Mason Medical Center

Hitachi Air Conditioning

Team Leader Kaplan reviewing the flow of the process with

2012 Virginia Mason Medical Center

New Management Method: The Virginia Mason Production System

Start by Removing Waste

2012 Virginia Mason Medical Center

The Methods & Tools that Transform Work

Value Stream Map

2012 Virginia Mason Medical Center

The Patients Perspective: Migraine

2012 Virginia Mason Medical Center

Organize the Workplace: 5S

2012 Virginia Mason Medical Center

5S Anesthesia Shadow Board After

Central Line Insertion Standard Work

Dry: 30 sec scrub 30 sec dry Wet:

2 min scrub 1 min dry

Maximum Barrier Protection

Transducer Kit in Top Drawer of Cart

in chart progress notes

2012 Virginia Mason Medical Center

2012 Virginia Mason Medical Center

CERNERTE ST RESULT REPORT, RTE, Sign & Review

2012 Virginia Mason Medical Center

Before: Flow Station and MD Office far away

2012 Virginia Mason Medical Center

Maintaining Flow: Mistake Proofing Imaging

2012 Virginia Mason Medical Center

Shortening Waiting Times for Appointments

2012 Virginia Mason Medical Center

The Business Case for Quality

($332,983) ($716,391) Year 1 Year 2 Year 3 Year 4

VM Primary Care practices, net margin before indirect cost

Build safety into the process Zero Defects

2012 Virginia Mason Medical Center

Why Zero Defects is the Only Acceptable Standard

Mistakes vs. Defects

2012 Virginia Mason Medical Center

Mistakes are Fixed at the Source

2012 Virginia Mason Medical Center

Stopping the line

2012 Virginia Mason Medical Center

Patient Safety Alert Process Created August 2002

Drop and run commitment

Legal and reporting safeguards

2012 Virginia Mason Medical Center

Stopping the Line Organization-wide Involvement

2012 Virginia Mason Medical Center

Business Case for Patient Safety:

3500 3079 44 2726 46 2954 42 PSAs Reported Reported Claims

0 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

Total number of claims excludes claims closed with no payment

Hospital Professional Liability Premiums