Furman Cincinnati 10-9-12

8/13/2019 Furman Cincinnati 10-9-12

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2012 Virginia Mason Medical Center 2012 Virginia Mason Medical Center

Transforming Health CareVirginia 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


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Virginia Mason Medical Center

Integrated health care system501(c)3 not-for-profit336-bed hospital

Eight locations500 physicians5,500 employeesGraduate Medical Education

Research InstituteFoundationVirginia Mason Institute


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Our Strategic Plan

2012 Virginia Mason Medical Center


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The VMMC Quality Equation

Q: Quality

A: Appropriateness

O: Outcomes

S: Service

W: Waste

Q = A (O + S)

W


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Autonomy Protection

Entitlement

Improve

safety/quality

Implement EHR

Create service

experience

Be patient-focused

Improve access

Improve efficiency

Recruit/retain

quality staff

Traditional PromiseLegacy Expectations Imperatives

Clash Of Promise And Imperatives


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7/82 2012 Virginia Mason Medical Center 2012 Virginia Mason Medical Center

Seeing with our Eyes

Japan 2002



Hitachi Air Conditioning

Team Leader Kaplan

reviewing the flow ofthe 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


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Think Different

the human effort

the space

the equipment

the inventory

the investment

the engineering hours

the new product development time


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The Methods & Tools that Transform Work

Value Stream Development

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

Standard Work

Flow

Mistake Proofing RPIW (Rapid Process ImprovementWorkshop)


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Value Stream Map


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The Patients Perspective: Migraine

Value added Non-value added Variable value

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


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Organize the Workplace: 5S

Sort:Separate necessary fromunnecessary

Simplify:A place for everythingneeded and everythingneeded in its place andready to use.

Sweep:Inspection that

everything is where itbelongs.

Visual confirmationthat 5S agreements arebeing followed

Standardize:

Create commonagreements

Communicate tothe team

Self Discipline:Maintain standardsthrough training,empowerment,commitment and discipline


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5S Anesthesia - Before

Start with 5S


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5S Anesthesia Shadow Board After

5S Creates Safety


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Central Line Insertion Standard Work

Dry:

30 sec scrub30 sec dry

Wet:

2 min scrub1 min dry

Before

MaximumBarrier

Protection

Thyroid Angio Drapes

TransducerKit in TopDrawer of

Cart

Transducer Method Manometer Method

During

After

Approved to use Date/Initial

Complete Paperwork

Yellow top of cart White in chartprogress notes

OR

OR

Paws

AND


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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


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Flow Stations

CHARGESLIP

DOCUMENT

VISIT

Electronic

MESSAGE

URGENT

Flow Station

Inbox

(e.g. labs)Non-urgent

Flow Station

Inbox(e.g. mail)

CERNERTE

ST RESULT

REPORT,

RTE, Sign &

Review MD MA $


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22

Achieving Flow

Before:

Flow Station

and MD Office

far away

Provider

Office

Flow

Manager



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AfterIn Flow

Provider/FM side by

side

Standardize Flow

Stations

Eliminate Walking

Continuous Flow

Visual Control


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Shortening Waiting Times for

Appointments


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The Business Case for Quality

($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 practices, net margin before indirect cost


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Why Zero Defects is the

Only Acceptable StandardAt 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


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Mistakes vs. Defects

Mistakesare inevitablebut reversible

Defectsare mistakes that were not fixed soonenoughand are now relatively permanent

If you fix mistakes soon enough, your work willhave zero defects - what the customer wants!

Mistakes are leastharmful and easiestto fix thecloseryou get to the time and place they arise


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Mistakes are Fixed at the Source

Within

process

Just

After

Just

Before

Down-

stream

A B C

Poke-yoke SelfCheck

SuccessiveCheck


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Stopping the line


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Patient Safety Alert Process Created

August 2002

Leadership from the top

Drop and run commitment

24/7 policy, procedure, staffing

Legal and reporting safeguards


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Stopping the LineOrganization-wide Involvement

Staff identify and report

issues and concerns

using the Patient Safety

Alert System

Leadership involvementwith investigation and

resolution

Board Quality

Committee review andapprove closure of

high-severity issues

(Red PSAs)


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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 patientdischarge


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Business Case for Patient Safety:Total Number of Claims and PSAs Reported

Total number of claims excludes claims closed with no payment

8

2697

3500

3079

27262954

4322

5386

60

71

67

60

4446

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



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Hospital Professional Liability

Premiums

$-

$500,000.00

$1,000,000.00

$1,500,000.00

$2,000,000.00

$2,500,000.00

$3,000,000.00

$3,500,000.00

$4,000,000.00

$4,500,000.00

2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12

Premiums $4,068,476. $4,211,000. $3,900,000. $3,442,390. $3,275,723. $2,438,886. $2,151,457. $2,004,553. $1,779,427.

4%

7%

12%5%

26%

12%7%

13%

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.

62%

Reduction

Since 2004


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Deeper understanding

of current state

Let those who do the work improve thework

Kaizen:Continuous

Improvement of your

current state

Kaikaku:Reinvent your services

and/or products

Understand yourcurrent state

RPIWKaizen

Events3P

RPIWKaizen

Events

Everyday Lean Ideas

Everyday Lean Ideas


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Nursing Cells The Idea


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RN workflow

No waiting in line

for OmniCell

No missing items

Group items

w/Color Codes & Map

Linen supplied daily by

Housekeeper

Frequently used suppliesat bedside


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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

2 Background (Basics)

Age, MD, reason for admission

Isolation

3 Current status

Brief history

Functioning prior to admission

Key medications

Tests for the day

4 Assessment

Patient identification

High risk meds

IV

Physical assessment

Precautions/Skin/Wound

Patient input

5 Recommendations

Plan of the Day

Safety concerns

Patient issues

6 Closing

"Is there anything you need at this t ime?"

Determine when will return


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First Draft of Bedside White Board to Enhance Communication

Among All Team Members


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Current white board

2012, Virginia Mason Medical Center


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Nursing Cells Results > 90 days

Before After

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

846

1256126

0%

10%

16%

0%

11

RN time available for patient care = 90%!


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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


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Definition

EBD is a set of methodsfocused on understanding

peoples experiences so

we can design better

services

To learn more aboutexperiences in a

comprehensive way, what

matters to customers?

Customers include

patients, family membersor team members

Experience-Based Design (EBD)



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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 interruptflow and operations, create

rework

Experience-Based Design



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Key Principles Design for the human experience

Direct customer involvement

Understand what people naturallydo and feel

Three Methods Interviews

Surveys

Focus Groups




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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 eachtouch point in the process:

Mapping tools

Visuals and photos

Observations

Customers own words

Analyze and understand the

experiences to inform improvements



E i B d D i


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A visual depiction of key touch points in a process that

guides customers in sharing their experience

Experience-Based Design:Experience Questionnaires



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World-Class Management

Management

by Policy

Provides focus and direction

Daily

ManagementManages daily work

Cross-Functional

ManagementAligns across the organization

toward full customer satisfaction

World-Class

Management

System


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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


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We attractand

developthe best

team

People

We foster aculture oflearningandinnovation

Innovation

We create anextraordinary

patient experience

Service

We relentlesslypursue the

highest qualityoutcomes of care

Quality

Vision

To be the Quality

Leader

and transform health

careMissionTo improve the health and

well-being of the patients we serve

Values

Teamwork | Integrity | Excellence | Service

Strategies

Virginia Mason Team MedicineSMFoundational Elements

Patient

StrongEconomics

ResponsibleGovernance

Education Virginia MasonFoundation

IntegratedInformation

Systems

Research

Virginia Mason Production System

5 Year Plans

Annual Goals

Long Term Vision

Quality and Safety1. Ambulatory Prevention Bundles

2. Optimize Care Transitions

3. Zero Nosocomial Injuries

Fall PreventionHealth-care Acquired Infections

4. Patient Safety Curriculum

5. Innovative Clinical Value Streams

Align the Vision with Resource

KPO Priorities


World Class Management


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Adapted from elements of World Class Management, Management by Policy

ReflectionEnvironmental Scanning

Review 5 Year Plans

DeploymentProduction plan

Understanding/ awareness

Develop strategies forentire organization

departments

individuals

Check and

ReviewCompare performance toplan

Occurs at all company

levels

CatchballIdea exchange

Feedback, engagementIdentify resources / roles

Set measurement criteria

Elements of Management by Policy


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Management by Policy - Deployment



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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





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A management system for implementing breakthroughimprovements that is always focused on the elements of full

customer satisfaction

Cross-

Functional

Management


Cross-Functional Management


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DailyManagement

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

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


Daily Management


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Knowing Your BusinessAt a glance:

Staffing and Bed

Capacity is

understood.

Demand is

known.

World-Class ManagementDaily

Management


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There are four principal elements of

Daily Management

Leaderstandard work

Visual Controls

DailyAccountability

Process

Discipline

Leaderstandard

work


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Clinic Supervisor & Director Daily List

Leader Standard Workwork

VisualControls

DailyAccount-

abilityProcess

Discipline

Standard work for leaders specifies the actions to

be taken each day to focus on the processes in

each leaders area of responsibility.

Leaderstandard

work


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Hitachi

Visual Controlswork

VisualControls

DailyAccount-

abilityProcess

Discipline

Visual controls focus on the process and making it easy to

compare expected versus actual performance

Vi l C t lLeader

standard


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Visual Controls

Visual signal for

help

Staff member cansee & re-assign

to help

Heres an example of how insurance

payment closure understands their business daily

work

VisualControls

DailyAccount-

abilityProcess

Discipline

Leaderstandard

work


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Visual Controls

At a glance:

Provider covering

Capacity after

lunch

WIP:

Messages

Forms

Lab Results

VisualControls

DailyAccount-

abilityProcess

Discipline


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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

Daily AccountabilityFoundational Elements: Nursing

Leaderstandard

work

VisualControls

DailyAccount-

abilityProcess

Discipline


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Leaderstandard

work


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People Link Boards updated, and managed

with set agenda

Daily Accountability VisualControlsDaily

Account-ability

Process

Discipline


St d d W k f L d


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Standard Work for Leaders

Establish a system for accountability withhuddles/tiered reports

WHAT? How Often?

% of work

standard

Lead Huddles 2 x daily 80%

Supervisor Floor check Daily 50%

Manager Lead weekly people link Weekly 25%

Director/Section Head Spot check standard work Weekly 20%

AD Review performance trends Weekly 15%

VP/Chief Verify leader standard work Weekly 10%

I j bill


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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


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VMPS Standard Work for Leaders

Front Line

Board

Supervisor

Board

Director

Board

AD

Board

VP

Board

COO

Board

CEOBoard

Support the Effort


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Support the Effort

Kaizen Promotion Office (KPO)

1-5% of all non management staffas KPO

KPO aligned with operational

executive leadership Executive sponsorship with

accountability for sustained results

Education

Standardization of tools, resultsreporting, and communication


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The VMPS Structure

Kaizen PromotionOffice (KPO) is

aligned with the

operational executiveleadership

Executive sponsorshave accountability for

sustained results

CEO

COO

KPOHospital

Clinic

Corporate

Central

Executives


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Leaders Sustain the Rigor

Tuesday Stand up

Friday Report Out

Standard Work for

Leaders


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Go and See

Big Ears, Big Eyes, Small Mouth

Go and See

Capture Wisdom


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Capture Wisdom

Everyday Lean Idea Form


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Critical massfeels urgency for

change

Visible and committedleadership

New compactaligns expectations

with vision

Improvement MethodApplied to ALL Processes

Executives addresstechnical AND

human dimensionsof change

Requirements for Transformation

Broad and deepcommitment toshared vision

Change the Paradigm


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Change the Paradigm

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


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Strive for the


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Highest Satisfaction Levels

88.6 89.489.9 90 90.8

50

55

60

65

70

75

80

85

90

95

Clinic Patient Satisfaction

2007 2008 2009 2010 2011

83.7 84.386.4 86.7

87.7

50

55

60

65

70

75

80

85

90

95

Hospital Patient Satisfaction

2007 2008 2009 2010 2011

68.5

72.474.1 73.3 74.2

50

55

60

65

70

75

80

85

90

95

Staff Satisfaction

2007 2008 2009 2010 2011

Maintain a Successful Economic


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Enterprise

$0.70

$3.20

$12.00

$18.40

$29.40

$49.40

$40.90

$31.70

$0

$10

$20

$30

$40

$50

2000 2005 2006 2007 2008 2009 2010 2011

$(Millions) Shared Success

Program


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VMMC Quality Awards
http://www.leapfroggroup.org/news/leapfrog_news/4784721http://www.npsf.org/


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In times of change,

learners inheri t th e

earth , whi le the learned

f ind themselves

beaut i fu l ly equ ipped todeal wi th a wo rld that

no longer exists.

Eric Hoffer

Documents

Furman Cincinnati 10-9-12