Oh No: We Have to Make Another OE System
Obviously, at this point, you can tell that Virgina Mason and Thedacare have started to evolve and change their minds about “what you need to do…”. In your opinion what changed? What did these two leaders learn? If you had to build a new OE system, what would you do?
Notes to use while writing paper:
What changed?:
-Focus shifted from the OE tool kit to a total, complete system (holistic change)
-New emphasis on daily problem solving and quality of leadership
What did they learn?:
-It is about changing culture and not just focusing on monetary improvements
-What they were doing was not enough
-The importance of creating readiness for change (urgency, openness, not everyone can come along)
New pieces of the system?:
-Holistic change-not just the tools
-Daily management system-changing the daily experience, everyone problem solving every day
-Leadership behavior-go to the gemba, shadow example, quality leadership
-Transformation-readiness to transform into a target condition
-Continuous improvement-goal setting and problem solving
-Ideal situation-reward value, not volume
Why Lean doesn’t work for everyone
Gary S Kaplan,1 Sarah H Patterson,2 Joan M Ching,2 C Craig Blackmore3
1Virginia Mason Health System,
Seattle, Washington, USA
2Virginia Mason Medical Center,
Seattle, Washington, USA
3Center for Health Services
Research, Virginia Mason
Medical Center, Seattle,
Washington, USA
Correspondence to
Dr C Craig Blackmore, Center for
Health Services Research,
Virginia Mason Medical Center,
Mailstop: R3–324, 1202 Terry
Avenue, Room 324, Seattle, WA
98101, USA;
craig.blackmore@vmmc.org
Received 28 May 2014
Revised 3 July 2014
Accepted 7 July 2014
Published Online First
23 July 2014
To cite: Kaplan GS,
Patterson SH, Ching JM, et al.
BMJ Qual Saf 2014;23:
970–973.
ABSTRACT
Popularisation of Lean in healthcare has led to
emphasis on Lean quality improvement tools in
isolation, with inconsistent results. We argue that
delivery of safer, more efficient, and higher
quality-patient focused care requires
organisational transformation of which the Lean
toolkit is only one component. To successfully
facilitate system transformation toward higher
quality care at lower cost, Lean tools must be
part of a comprehensive management system,
within a supportive institutional culture, and with
committed leadership.
INTRODUCTION
Lean, and other industrial improvement
methodologies, are increasingly touted as
solutions to the quality and cost challenges
in healthcare. However, despite
infiltration of Lean terminology into the
vernacular of healthcare delivery, and the
encroachment of exotic ‘Kaizen’ quality
improvement events into hospital conference
rooms, results have often been
disappointing.1
In the year 2000, Virginia Mason
Medical Center in Seattle, Washington,
USA, for the first time faced severe financial
challenges threatening the continued
long-term viability of the institution.
Following the quality concerns highlighted
by the Institute of Medicine
reports on patient safety,2 3 the organisation
was shocked in 2004 by the occurrence
of an avoidable medical error
leading directly to the death of a
patient.4 This stark awareness of quality
and cost concerns drove us to explore
and subsequently adopt the Lean methodology
of the Toyota Production System
as our management method.5 Though
our Lean journey is still early when compared
to the 60 years of experience at
Toyota, one clear lesson has been that the
delivery of safer, more efficient, and
higher quality patient-centred care
requires not simply the use of Lean tools
and events, but rather organisational
transformation based on Lean principles.
In this report, we summarise what is
needed for this arduous journey and
explore why Lean doesn’t work for
everyone.
Transformation at our organisation
relies on what we term the ‘Virginia
Mason Production System’ (VMPS), our
adoption of the Toyota Production
System to healthcare. The use of ‘Virginia
Mason’ emphasises that we have ownership
for implementing and improving a
methodology that has grown organically
at our institution. Implementation at
other institutions will cause new eponymous
production systems to grow to meet
each specific institutional circumstance.
We use the term ‘Production System’
because it is comprehensive, underlying
all our work in creating the perfect
patient experience. Lean is deployed not
simply for quality improvement, but
rather as an overall management strategy,
coupled with an evolving institutional
culture and focused invested leadership.
ELEMENTS OF VMPS
VMPS is based on the application of
Lean tools as part of a comprehensive
management system together with institutional
culture change and leadership
focused on implementing change.
Lean toolkit
The Lean toolkit has been discussed
extensively in the medical literature, but
can be summarised as a focus on the
identification and elimination of waste
from healthcare delivery processes. Waste
is defined as any product or activity that
does not add value for the patient.6 7
Processes are standardised, and variability
is reduced through dedicated ‘Kaizen’
quality improvement activities and
Plan-Do-Study-Act cycles. Lean tools supporting
these efforts include Value
Stream Maps, Andon indicators for
process control, Kanban cards for inventory
control, and Jidoka or human supervised
automation.5 8 These Lean tools
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and events can lead to significant improvements in
processes throughout the healthcare enterprise.9–11
However, the Lean toolkit alone is insufficient for
transformational change leading to sustainable success
in improving quality and lowering costs.
Management system
Success in improving quality in a healthcare organisation
requires the understanding that quality improvement
should not exist as an isolated silo or add-on,
but must be the foundation for all management activities,
including day-to-day operations. By identifying
VMPS as a management system early on, we took
‘project based’, ‘opt-in/opt-out’, off the table. All
activities from supply chain to operative procedures to
primary care visits are based on VMPS value streams,
and changes are effected through Lean process
improvement workshops and activities. In effect, all
management activities are focused on quality improvement;
doing the work becomes inseparable from
improving the work. This required development of an
educational infrastructure to train providers and staff
at all levels complemented by a quality improvement
division of specialists with deep expertise and fulltime
work focusing on improvement. It should be
emphasised, however, that the quality improvement
specialists do not work in isolation but rather in collaboration
with operational leaders who have also
been through VMPS training.
As an example, to enable important early fluid
resuscitation in patients with sepsis, we held a VMPS
2-day improvement event physically on an intermediate
care unit, with front-line nurses, physicians and
quality improvement specialists together contributing
to immediate changes. By the conclusion of the event,
the changes had become part of day-to-day operations,
with the improvement team now being the
management team using the Lean toolkit for implementation.
In this way, having VMPS as a management
system provides the continuity to help address
the challenge of sustaining improvements.
Not every improvement proceeds from a formal
workshop. Fundamental to VMPS is empowerment of
and respect for the front line workers, who are
uniquely positioned to inspect for quality and contribute
improvement ideas. Leaders are expected to
convene daily team huddles on the work floor allowing
for constructive bidirectional feedback. Further, all
employees undergo basic Lean training, starting on
the first day of work. It is not unusual to overhear
conversations between staff, such as two transporters
in the elevator talking about mistake-proofing their
work.
Institutional culture
Institutional culture is critically important12 and probably
the most elusive aspect of VMPS. Foundational
to institutional culture is the shared vision that value
to the patient is the focus of all activities. This does
not mean simply that care is respectful and responsive
to individuals, but rather, that all measures of quality
(including efficiency, effectiveness, equity, safety, timeliness
and outcomes)3 are viewed from the perspective
of the patient. In reality, most healthcare delivery is
built around the needs of the doctors, nurses and
managers, rather than around the needs of the
patients. The simplest example of this is patient
waiting rooms. Worldwide, we spend hundreds of millions
of dollars building waiting rooms, so that
patients can hurry up, be on time and wait for us in
what are, in essence, large holding tanks. This
extreme waste from the Lean perspective is the antithesis
of efficient and timely care from the patient’s perspective
and representative of the scale of
transformation required to truly become ‘patient
driven’ in healthcare. Through VMPS, we have
achieved incremental and breakthrough tangible gains
in redesigning care around our patients, including
opening a clinic with no waiting rooms, and reconstructing
our care delivery for conditions like low
back pain, headache and breast concerns around same
day access and patient needs. Celebrating these
patient-focused gains within the organisation reinforces
the VMPS institutional culture.
Physician culture at VM also had to adapt to the
VMPS. Traditional models of healthcare delivery that
feature physician hierarchies separate from that of
nurses, support staff and administrative personnel, do
not support efficient patient-focused care. Customary
physician expectations of autonomy, protection and
entitlement can conflict with care quality, safety and
patient-centeredness. To address physician culture, we
engaged in a year process led by front-line physicians
to formulate a new physician compact, a reciprocal
agreement between providers and the organisation.13
Provider’s responsibilities include implementing
evidence-based practice, respecting all team members,
and willingly embracing innovation and organisational
change. Organisational responsibilities include providing
tools and information necessary to improve practice,
supporting career development and professional
satisfaction, and being transparent about organisational
priorities and business decisions. The compact
defines the relationship between organisation and
physicians and is incorporated into provider orientation,
performance management and annual review.
Cultural change is not rapid, and requires constant
commitment from leadership. Not everyone at VM
was initially accepting of VMPS, and evolution in the
institutional culture required time. There was resistance,
particularly early on, to change in general, and
to the concept of using a manufacturing approach in
healthcare, as ‘patients are not cars.’ Acceptance
increased gradually, prompted by trips to Japan and
other industry visits for many leaders, and by gradually
increasing visibility of VMPS successes. A small
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number of providers left as a consequence of VMPS,
but at the same time, others came to VM specifically
because of the institutional focus on quality and
safety.
Leadership for implementation
Leadership is required for a quality healthcare system.
At its core, quality improvement is about change, and
the large-scale and transformational changes required
in healthcare can only be achieved with active,
unwavering leadership. At Virginia Mason, the entire
executive team, including the board of directors is
required to undergo deep training in VMPS, and to
participate in training trips to Japan for in-depth
study of Toyota and other Lean companies. All leaders
undergo formal training in VMPS, and are expected
to use the tools to lead events and to support teams,
through daily management. This ensures consistency
in leadership throughout the institution, that is not
dependent on any one individual.
VMPS also requires leaders to move from the ‘hero
mentality’ of problem solvers to being coaches who
build learning teams that use VMPS for long-term
improvement. This implies a change from the usual
physician or administrative leadership model with its
silos and advocacy for one’s own chain of control to
transparency and systems-thinking. At Virginia
Mason, we developed a uniform ‘standard work for
leaders,’ a series of tools and processes designed to
improve communication between leaders and staff
(daily huddles and leadership rounds), to increase the
visibility of the daily work and goals (production
boards and visual controls), to enable early identification
of problems in daily work (dashboards and root
cause analysis), and to improve accountability of
leaders and staff (leadership checklists and Genba
observations). All leaders learn standard work for
leaders as part of their VMPS training, and the
uniform application of these tools promotes transparency
and accountability. As a consequence, teams
learn to identify and solve problems on their own,
and leaders become managers of the system rather
than problem solvers. The visibility of leaders deploying
VMPS also contributes to the institutional culture.
Our journey was not without challenges. Early on, we
focused too much on the Lean toolkit, and teams
equated success with use of the tools alone. This misinterpretation
led to overzealous regimentation by a few
managers. We also overestimated the scale of change
from a quality improvement event, expecting instant
transformation rather than iterative improvement.
Finally, we underestimated the challenges in leading
people through change. Simply developing solutions in
Lean quality improvement events did not equate with
long-term improvements. Instead, to implement and
sustain improvements, we rely on the key strategies discussed
above throughout the institution (table 1).
CONCLUSION
In the first decade of the Lean journey at Virginia
Mason, we have succeeded in improving quality and
lowering costs.14 Even more importantly, however, we
have demonstrated that Lean principles can provide a
structure for the transformational change needed in
healthcare.Why then does Lean not work for everyone?
Because simple changes from the use of the Lean toolkit
in isolated quality improvement silos are not enough.
Instead, transformation requires using Lean as part of a
comprehensive management system in concert with
institutional culture change and new leadership
approaches to all aspects of healthcare delivery.
Table 1 Key strategies for VMPS
Unrelenting focus on the patient All activities are evaluated by whether or not they add value from the patient’s perspective, a
unifying shared vision
Uniform improvement method A common language and approach used by all, for us, Lean
A strategic plan that serves as the organisation’s
compass
Strategic plan is highly visible, presented at the start of all improvement and management meetings,
with the relevance of that meeting to the strategic plan defined
Integration of daily management and quality
improvement
The same teams and the same tools for daily management and quality improvement. In effect, all
management is quality improvement, which is critical to sustain gains
Leadership present on the shop floor,
understanding and supporting teams
Leaders can best know what is going on in the organisation, and can best coach and support teams
when physically present where the work is occurring
Daily leader routines that are transparent and
predictable
Leading by example requires standard work by leaders, and transparency promotes bidirectional
accountability for managers and staff
Respect for people All staff are empowered to contribute to improvement, and all are valued for their contribution to
the institution
Physician, leadership and board compacts Reciprocal agreements between the institution and physicians, leaders and board members defining
the responsibilities and expectations for all parties.
A visual environment so one easily sees operational
conditions
Work is made open and visible so that any problems become apparent and can be addressed in real
time. Production dashboards are publicly displayed
Long-term thinking Constancy of purpose among leadership, ensuring continuity independent of specific individuals
Alignment Alignment from the board of directors through frontline staff. All must understand the unwavering
commitment to the patient focus and the VMPS method
VMPS, Virginia Mason Production System.
Viewpoint
972 Kaplan GS, et al. BMJ Qual Saf 2014;23:970–973. doi:10.1136/bmjqs-2014-003248
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Contributors GSK: Responsible for article conception and
design, article drafting and revision, final approval, and
agreement to be accountable for all aspects of report accuracy
and integrity. SHP: Responsible for article conception and
design, article critical revision, final approval, and agreement to
be accountable for all aspects of report accuracy and integrity.
JMC: Responsible for article conception and design, article
critical revision, final approval, and agreement to be
accountable for all aspects of report accuracy and integrity.
CCB: Responsible for article conception and design, article
drafting and revision, final approval, and agreement to be
accountable for all aspects of report accuracy and integrity.
Competing interests CCB reports book royalties from Springer
Publishing for Evidence Based Imaging textbooks. The other
authors report no financial disclosures or conflicts of interest.
Provenance and peer review Not commissioned; internally peer
reviewed.
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Viewpoint
Kaplan GS, et al. BMJ Qual Saf 2014;23:970–973. doi:10.1136/bmjqs-2014-003248 973
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Why Lean doesn’t work for everyone
Gary S Kaplan, Sarah H Patterson, Joan M Ching and C Craig Blackmore
doi: 10.1136/bmjqs-2014-003248
BMJ Qual Saf 2014 23: 970-973 originally published online July 23, 2014
http://qualitysafety.bmj.com/content/23/12/970
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