CEO SUMMARY: Laboratory and pathology services at Virginia Mason Medical Center are an integral part of its hospital-wide Lean quality management initiative. Because of the importance of lab test data to so many clinical services, the laboratory often finds itself making key contributions in the process improvement efforts mounted by such clinical services as the emergency department and outpatient clinics.
IN SEATTLE, WASHINGTON, Virginia Mason Medical Center (VMMC) is one of the nation’s first hospitals to fully embrace both the philosophy and techniques of Lean quality management methods.
But there is another unusual twist in the VMMC story. To help administrators, managers, physicians, and nurses better learn how to effectively use Lean methods, VMMC has regularly sent teams to Japan. During these trips, VMMC’s staff get to see, first-hand, how Lean techniques are used in some of the world’s best-run manufacturing plants and businesses.
During the past year, THE DARK REPORT provided early intelligence about how the laboratories in three major hospitals/health systems became first in the nation to use Lean to re-engineer the work processes in their high-volume core chemistry and hematology laboratories. (See TDR, September 8, 2003.) The three labs each posted gains of 50% or more in key measures as a result of their Lean “make overs,” which generally took only 14 weeks to accomplish.
Within the hospital industry, Virginia Mason Medical Center (336 beds) is an early-adopter. Its decision to make Lean the primary management philosophy throughout the organization sets it apart even from the handful of hospitals known to have chosen Six Sigma management systems to underpin their evolution into the next generation of quality management.
Both the clinical lab and the anatomic pathology department at VMMC are engaged in learning and applying Lean management methods. What is distinctive about their experience with Lean to date is that the laboratory and the pathology departments participate in the multi-disciplinary Lean teams. For this reason, VMMC provides an early look at ways in which a hospital-wide quality management transformation will change many long-standing aspects of laboratory and pathology support services.
“Lean is transforming our hospital organization and the way all of us view our work processes,” stated Lee Darrow, Administrative Director of Laboratories at VMMC. “Lean techniques consistently allow us to streamline and refine work processes that cross several departments within the hospital. As multiple departments get involved in these projects, long-standing divisions melt away, replaced by effective collaboration. Lean can be both energizing and empowering.”
In an exclusive interview with THE DARK REPORT, Darrow explained how VMMC has deployed Lean techniques within the hospital. “We use what are called ‘Rapid Process Improvement (RPI) Workshops.’ These focus our quality efforts by concentrating all the necessary resources into a one-week session,” she explained.
“The organization of an RPIW is simple and consistent,” explained Darrow. “There are four to five weeks of data gathering and preparation prior to the actual week-long session. Day one is devoted to teaching Lean techniques and giving the work team data and targets. During days two, three, and four, the team studies their data and moves to the gemba (shop floor) to apply solutions that enable them to achieve their targets. Implementation of solutions involves all departments and service areas of the hospital necessary to effect the change.
“On Friday morning, day five, the RPIW team reports its findings and actions in a meeting that is open to everyone, from the top administrators, and clinicians to line staff,” she noted. “Any implementation work remaining is continued and reported in a system-wide newspaper. The full implementation is expected to be completed within 30 days following the end of that RPIW. Follow-up data is collected at 30, 60, and 90 days to insure that all gains made as a result of the RPIW are sustained.”
VMMC’s Lean journey began in June 2002, when the first group of senior administrators and board members traveled to Japan. Upon their return, the commitment was made to implement Lean management methods throughout the hospital, its affiliated clinic sites, and other facilities.
“During the second half of 2002, there were six Rapid Process Improvement Workshops,” stated Darrow. “Lean training commenced throughout the organization. In 2003, the number of RPIWs increased steadily. Today, 100% of our 5,000 employees are familiar with Lean. There are an average of three to four RPIWs each week. This level of activity is generating a steady stream of improvements and changes to work processes in every aspect of our health system’s operations.”
Trip To Japan in 2003
Darrow was on the team which visited Japan in June 2003. “It was a two-week trip that was eye-opening. We visited only industrial facilities and did not go into any healthcare organizations,” she recalled. “I was most impressed with the Japanese emphasis on quality and safety. We were taught to ‘look with our eyes’, but to ‘see with our hands.’ It is an important part of the Lean process to interact directly with the work processes themselves. In other words, to ‘get dirty’ and be part of the actual work process under review.
“During part of my visit, we worked eight-and ten-hour days on the factory floor of an air conditioning factory that has practiced Lean for years. We also visited Toyota and saw the unprecedented results of 50 years of Lean methods,” she said. “It was an intense learning process and made us realize how much we could improve our work processes at VMMC.”
How Lean Came to Virginia Mason
IT WAS A CHANCE ENCOUNTER on an airplane in 2001 that introduced the President of Virginia Mason Medical Center (VMMC) to how Lean quality management methods could improve the quality of services in his hospital and affiliated clinics.
VMMC President Michael Rona found himself seated next to John Black, who is President of John Black and Associates, LLC/Shingijutsu America, LLC. This company is the American arm of Shingijutsu, a leading Japanese Lean consulting company. Upon his return to Seattle, Rona shared this new knowledge with VMMC Chairman and CEO Gary S. Kaplan, M.D. Both men were quick to act. The decision was made to engage Black/Shingijutsu to help VMMC implement a Lean program.
“We knew the status quo methods were not working,” stated Kaplan in a published interview. “Even with a strong culture of teamwork, it would be difficult to make rapid changes to improve the patient experience without the new [Lean] methods and new tools discovered through what is now called the Virginia Mason Production System.”
Kaplan was hoping to accelerate the time required to realize quality improvements—and do it in such a way that improvements would be strongly embedded and not subject to unraveling or backsliding in subsequent months. He also wanted to move past incremental improvements that took months and create a system that achieved breakthrough results in hours.
“One of the things we’re doing is beginning to think of our work in terms of service lines,” Kaplan noted. “We’re looking at aligning our metrics and our measuring tools around service-line performance.”
First Lab/Pathology RPIW
Back in 2002, VMMC’s first series of rapid process improvement workshops targeted improvements in surgery. It was a multi-disciplinary effort. “Before my trip to Japan in June 2003, we made a value stream map of surgical pathology,” stated Darrow. “Also on the trip was Christina Isaacson, M.D., Deputy Chief of Pathology. After our return, in August 2003, we conducted an RPIW focused on surgical pathology.
“This RPIW had several goals,” she continued. “We wanted to reduce defects [errors] in surgical pathology, reduce transcription time, and speed up the flow of specimens in histology. The outcomes from this RPIW were impressive.
“First, we reduced specimen labeling errors by 52% and cassette labeling errors by 73%. The removal of non-urgent outpatient cases from the busy—and often chaotic—inpatient surgical pathology lab allowed us to slash lead times for gross dictation of outpatient surgical specimens by 67%! A similar work flow redesign cut our dictation lead time for inpatient surgical specimens by 49%,” observed Darrow.
Surgical Pathology Project
“I should also add that this surgical path RPIW was done in conjunction with efforts to improve work processes in our surgery suites,” she added. “VMMC’s Lean process takes a wide view across all disciplines which affect the primary subject of an RPIW.”
An example of the “wide view” perspective is an early RPIW which targeted how to improve the patients’ experience when they visited outpatient clinics affiliated with VMMC. In looking to improve clinical outcomes and patient safety while also increasing patient satisfaction, the project team identified turnaround time for lab test reporting as a key influence.
Patients Are Part of RPIWs
This RPIW included patients, which happens frequently at VMMC. One outcome of this project is that the actual time it took to report test results back to patients was reduced by 85%. This project also identified the importance of having certain test results available to the physician at the time of the patient’s appointment, such as a diabetic patient’s hemoglobin A1C test results at the time of the physician visit.
“The laboratory has done a number of RPIWs,” said Darrow. “One focused on phlebotomy services. By utilizing single piece work flow in our system, we cut average wait times for outpatient phlebotomy during peak times from 45 minutes to an average of under 10 minutes. This also cut the number of patients waiting in the phlebotomy reception area by 55%.
“RPIWs have also been done for the clinical laboratory,” she continued. “A project in hematology addressed work flow and safety issues. We removed fixed counters and reconfigured the work cell into a U-shape. This freed up 486 square feet of lab space and allowed us to move the cell marker laboratory into hematology. Staff walking distance in hematology was reduced by 62%. We now also can float staff between hematology and cell markers in response to fluctuations in workflow.”
Darrow’s lab is regularly involved in RPIWs focused on other hospital services. “Not surprisingly, we are often asked to use our LIS to create additional processes that will speed up delivery of test results to physicians. We also reduced turnaround times to support pre-operative testing and emergency department lab testing needs.”
The Laboratory’s Role
Such demands upon the laboratory are consistent with its role as the “information factory” for the hospital and its affiliated clinics. THE DARK REPORT believes this is a logical outcome for a hospital-wide Lean quality management program, since laboratory test data is critical to the hospital’s clinical mission.
Virginia Mason Medical Center’s experience in deploying Lean techniques reinforces the importance of lab medicine to the institution’s mission of high quality outcomes, improved patient safety, and increased patient satisfaction—not to mention lower costs per healthcare encounter because of better quality inside and outside the lab.
Lean Methods Allow Focus On Four Key Strategies
UNDER the Virginia Mason Production System, Lean methods allowed the institution to replace 15 strategies that described how it would achieve its goals with just four strategies, listed below:
1• Recruiting and retaining the best people.
2• Relentlessly pursuing the highest quality outcomes of care.
3• Unequivocally insisting
on extraordinary patient service.
4• Promoting a culture of innovation.