slide # 48

The customer with a defective

product is 100% dissatisfied

(The other 999 good products are invisible)

slide # 49

Leveled Production

JUST IN TIME

What is needed

In the amount needed

At the time needed

At the place needed

JIDOKA

One-by-one detection and response to every abnormality: “Stopping the line”

Materials

Machines

People

ConstantImprovement

ConstantImprovement

Virginia Mason Production System

Elimination of Waste

slide # 50

Theory of “Stopping the Line”

• Mistakes are inevitable…but reversible

• Defects are mistakes that were not fixed soon enough…and are now relatively permanent

• If you fix mistakes soon enough, your work will have zero defects

• Mistakes are least harmful and easiest to fix the closer you get to the time and place they arise (the reverse is also true)

slide # 51

The Basic Strategy for

Stopping the Line

• Inspect, stop, and fix at the source

• Every employee is an inspector

• Every employee can stop the line

• When you can’t fix on-the-spot: STOP

slide # 52

Level 1: Customer Inspects and Finds Defect

(OIG, DOH, Malpractice Suit)

Feedback

Suppliers 1 2 3 4 Customers5

Customer finds defect

MistakeOccurs

slide # 53

Level 2: Company Inspects at End of Process

(QA, Audit, Narcotic Count)

Feedback

Suppliers 1 2 3 4 Customers5

Inspector finds defect

MistakeOccurs

slide # 54

Level 3: Work Unit Inspects and Corrects

(Needle and sponge count)

Feedback

Suppliers 1 2 3 4 Customers5

Worker finds defect

MistakeOccurs

slide # 55

Level 4: Self-Inspection and Correction

(Patient ID, Surgery Site Check)

Suppliers 1 2 3 4 Customers5

Mistakedetected and

corrected

slide # 56

Level 5: Process redesign to eliminate mistakes

(CPOE)

Suppliers 1 2 3 4 Customers5

slide # 57

OR gas hoses are color codedand have unique connectors

Level 5 Inspection

slide # 58

Zero Defects – For Industry

• What the customer really wants

• Distinguishes mistakes from defects

• Essential elements:Check each product (one-by-one)Check at the sourceStop and fix at the source

• Applies to any product made by a defined process

slide # 59

Zero Defects - for Healthcare Safety

Healthcare is defined as a product having

safety in every step

Every safety mistake should be corrected

as soon as possible

as close as possible to its point of origin

You can stop the line for safety

The goal is zero safety defects in healthcare

slide # 60

Patient Safety Alert Results as of 12/31/04

• 347 Patient Safety Alerts• Diagnosis/Treatment 31

• Medication Errors 53

• Systems 196

• Equipment/Facilities 45

• Conduct 22

• Average # of PSAs/month is increasing

2002- 3/month

2003- 10+/month

2004- 17/month

• Average days to completion – 14

• Individuals taken off-line – 25

• Processes/Equipment taken off-line – 13

slide # 61

Case Studies

Case Study 1:

Numbers and Abbreviations

slide # 63

Case 1: Numbers and Abbreviations

slide # 64

Case 1: Numbers and Abbreviations

Day 1-2 (Issues Identified)

• The physician writes an order that retrospectively was unclear, the intended 2 looked like a 7

• The physician wrote an order using an unacceptable abbreviation (QD)

• The physician did not discuss the plan of care with the nurse prior to leaving the floor

• The HUC submitted the order with an unacceptable abbreviation

slide # 65

Case 1: Numbers and Abbreviations

• DAY 1-2 (Issues Identified)

• The pharmacist processed an order with an unacceptable abbreviation.

• Nursing did look at the order sheet and believed the 2 was a 7 but did not sign off the order on the Physician’s Order Sheet.

• Nursing gave the medication even though it had an unacceptable abbreviation.

• Nursing had not had a chance to review the care plan in the Progress Notes.

slide # 66

Case 1: Numbers and Abbreviations

Day 2-3 (Improvement)

Corrective Action Plan in development:Require number 7 be crossed on medication orders and audit.

Improved communication between caregivers with plan and safety concerns highlighted

Re-educate and audit staff on following standard work for unacceptable abbreviations and signing off orders.

slide # 67

Case 1: Numbers and Abbreviations

Day 3 (Improvement Continued)

Corrective Action Plan in development:

Multidisciplinary case review

Ultimately, mistake proofing will occur with the implementation of CPOE in 3/2005

slide # 68

VMPS Patient Safety Alert

Summary

• A key component of Lean (Jidoka)

• A process for producing safe healthcare

• Goal = zero defects

• Based upon Lean Production methods

• Source inspection

• One-by-one inspection

• Stop and fix at the source

slide # 69

Virginia Mason Results

• The Cost of Error

• Mistake Proofing and Improvement

• FTE Trends

• Learnings from Production Preparation

Process (3P)

• Cost Avoidance and Savings

• RPIW Roll Up

slide # 70

The Cost of Error

Ventilator Acquired Pneumonia

• 2002 Cases 34 Est. Deaths 5

• 2002 Cost $ 500,000

Professional Liability Expense

• Claims Paid ² $ 4.6 Million

• Claims Paid ³ $ 4.5 Million

² 1999 - 2003 Average ³ Projected 2004

slide # 71

Mistake Proofing

Ventilator Acquired Pneumonia

• 2002 Cases 34 Est. Deaths 5

• 2002 Cost $ 500,000

• 2004 Cases * 4 Est. Deaths <1

• 2004 Cost * $ 60,000

* Projected 2004

slide # 72

Staffing Trends

Full Time Equivalents

1996: 2890

1997: 3264

1998: 3467

1999: 3528

2000: 3612

2001: 3647

2002: 3656

2003: 3581

2004: 3562

slide # 73

3P’s: Production, Preparation, Process

• Cancer

• Hospital

• Dermatology

• GI

• Hyperbarics

slide # 74

Cost Avoidance• 1M Capital Savings for Hyperbaric Chamber from 3P

• 1-3M Endoscopy Suites now staying in current location

• 6M Surgery Suites budgeted and planned - now not

building

• Hospital 3P

• Lead Time, Staffing, Space

• Cancer 3P

• Same amount of space 120 pts per day to 188 pts per

day

(57% increase)

• Patient Travel -1600 ft to 375 ft. (76% reduction)

slide # 75

Virginia Mason RPIW Activity

0

50

100

150

200

250

300

2000 2001 2002 2003 2004 2005 2006

To

tal

slide # 76

Total Kaizen ResultsTotal Results 2002-2004

175 RPIW’s thru 3/31/04

Inventory $1,350,000 Down 53%

Productivity 158 FTE’s 36% Redep.

Floor Space 22,324 SQ. Ft. Down 41%

Lead Time 23,082 Hours Down 65%

People Distance Traveled 267,793 Feet Down 44%

Product Distance Traveled 272,262 Feet Down 72%

Setup Time 7,744 Hours Down 82%

slide # 77

Validated Industry Averages

Direct Labor/Productivity Improved 45-75%

Cost Reduced 25-55%

Throughput/flow Increased 60-90%

Quality (Defects/Scrap) Reduced 50-90%

Inventory Reduced 60-90%

Space Reduced 35-50%

Lead Time Reduced 50-90%

Summarized results, subsequent to a 5-year evaluation, from numerous companies (over 15

aerospace-related). Companies ranged from 1 to >7 years in lean principles application/execution.

slide # 78

Performance of Virginia Mason

• Leapfrog

• Top 100 Hospitals - Solucient

• Healthgrades

• Economic

• 2001 - $ 22,239,000

• 2002 - $ 22,917,000

• 2003 - $ 22,000,000

• 2004 - $ ?

• BBB+ to A-

slide # 79

Leapfrog

Leapfrog 2003 Survey Results

Leapfrog

StandardCPOE ICU Volumes

CABG

CABGOutcomes

RankPCI

PCIOutcomes

RankAAA Esophagectomy

PancreaticResection

Virginia MasonAbove

national

average

Above

national

average

Evergreen n/a n/aDid not

participate n/a

NorthwestAbove

national

average

Did not

participate

OverlakeDid not

participate

Did not

participate

Swedish - 1st HillDid not

participate

Did not

participate

Swedish - ProvDid not

participate

Did not

participate n/a

UWAbove

national

average

Above

national

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.)

slide # 80

To Change Medicine…..

Change Your Mind

• Provider First

• Waiting is Good

• Errors are to be Expected

• At-risk Employment

• OTJ Training

• Diffuse Accountability

• Add Resources

• Reduce Cost

• Retrospective Quality Assurance

• Management Oversight

• We Have Time

• Patient First

• Waiting is Bad

• Defect-free Medicine

• Guaranteed Employment

• Explicit Training

• Rigorous Accountability

• No New Resources

• Reduce Waste

• Real-time Quality Assurance

• Management On Site

• We Have No Time

slide # 81

Commitment and Deployment

• Leadership and management

• Introduction to Lean

• Certification Track

• Lean Mastery

• Japan Gemba

• Kaizen Fellowship

slide # 82

Ongoing Challenges

• Culture Change

• Professional Autonomy

• “People are Not Cars”

• Belief in Zero Defects

• Rigor, Alignment, Execution

slide # 83

“This Day brings a lot of

Rearrangement”

Pastor Paul Stoot, Sr.

November 27,2004

slide # 84

EXECUTIVE LEADERSHIP GOALS - 2004

QUALITY SERVICE STAFF EFFICIENCY

1. JCAHO

2. CPOE

3. PATIENT ID

4. PUBLICIZE QUALITY

OUTCOMES

5. APPOINTMENT

ACCESS

6. PHONE

ACCESS

7. SERVICE

RECOVERY

8. FACILITIES

PLANNING

9. COMMUNICATION

WITH STAFF

10. PACMED

TRANSITION

11. CANCER MODEL

LINE

12. 5S ADMIN.

PROCESSES

EFFICIENCY

BY 5%

13.

slide # 85

EXECUTIVE LEADERSHIP GOALS - 2005 Proposed

1.

QUALITY

OUTCOMES

5.

SERVICE

RECOVERY

3.

INPATIENT

ADMISSION

ACCESS

4.

OUTPATIENT

APPOINTMENT

ACCESS

2.

PATIENT

SAFETY

Executive Leadership Goal - 2005

Ensure the Safety of our Patients

“You Can’t Cross the Sea

Merely by Staring at the Water”

Rabindranath Tagore

1

Th

ed

aC

are

Syste

m fo

r Imp

rovem

en

t

Rem

ovin

g w

aste

, gettin

g le

an,

and p

reparin

g fo

r our fu

ture

IHI C

all to

Actio

n S

erie

s: D

rivin

g o

ut W

aste

B

eco

me

s th

e S

trate

gy fo

r He

alth

ca

re

Org

an

iza

tion

s

Fe

bru

ary

16

, 20

05

2

Sessio

n G

oals

It is n

otour g

oal to

day to

“teach le

an”

or

to “c

heer le

ad”

partic

ula

r pro

jects

.

Rath

er, it is

to d

efin

e, fo

r all m

anagers

, th

e T

hedaC

are

Syste

m o

f Impro

vem

ent

Most im

porta

ntly

, we n

eed to

cre

ate

dia

logue a

mong m

anagers

regard

ing

the

em

beddin

g o

f this

Syste

m in

to th

e

ThedaC

are

Cultu

re

3

Our S

yste

m G

oals

Th

e g

oals

rem

ain

the s

am

e. W

e m

ust

sim

ulta

neo

usly

…

Impro

ve th

e q

uality

of w

hat w

e d

o to

world

cla

ss le

vels

(95

thperc

entile

).

Becom

e th

e H

ealth

care

Em

plo

yer o

f C

hoic

e –

Fortu

ne 1

00 L

ist o

f Best

Em

plo

yers

.

Low

er o

ur c

osts

so w

e c

an lo

wer th

e p

rice

paid

for o

ur s

erv

ices

4

This

is a

bout h

ow

we a

re g

oin

g

to s

ecure

our fu

ture

…

By b

ein

g p

roactiv

e, n

ot re

activ

e, to

in

cre

asin

g d

em

and fo

r hig

h q

uality

/low

cost h

ealth

care

.We c

annot c

ontin

ue

incre

asin

g o

ur c

osts

to th

e d

etrim

ent o

f our c

usto

mers

.

By a

ctiv

ely

engagin

g c

usto

mers

, sta

ff, and p

rovid

ers

in th

e im

pro

vem

ent

effo

rts.

5

Ou

r Ove

rall M

etric

s h

ave

no

t ch

an

ge

d…

Qu

ality

Em

plo

ye

e

En

gag

em

en

tB

usin

ess

C

$10 M

illion/Y

ear

Pro

ductiv

ity/S

avin

gs

World

Cla

ss

Clin

ical a

nd S

erv

ice

Qu

ality

95

thP

erc

en

tile o

r G

rea

ter

Fortu

ne 1

00 L

ist o

fB

est E

mplo

yers

Consum

er’s

C

hoic

e

6

Th

ed

aC

are

’sM

issio

nth

e re

aso

n w

e a

re to

ge

the

r

“ThedaC

are

’s m

issio

n is

to im

pro

ve th

e

health

of o

ur c

om

munitie

s.”

7

Th

ed

aC

are

’sV

isio

na

pic

ture

of th

e id

ea

l sta

te to

be

ach

ieve

d

“To a

lways s

et a

nd d

eliv

er th

e h

ighest

sta

ndard

of h

ealth

care

perfo

rmance in

m

easura

ble

and v

isib

le w

ays s

o o

ur

custo

mers

are

confid

ent th

ey a

re m

akin

g

the rig

ht d

ecis

ion in

choosin

g u

s.”

8

Th

ed

aC

are

’sP

urp

ose

We e

xis

t to s

erv

e o

ur c

usto

mers

.

Our g

oal is

to p

rovid

e w

orld

cla

ss

clin

ical a

nd s

erv

ice q

uality

.

9

This

is n

ot a

“hors

e ra

ce”

but ra

ther a

contin

uous im

pro

vem

ent p

rocess.

10

Th

ed

aC

are

’sC

ultu

re

Cultu

re o

f consta

nt im

pro

vem

ent.

Most im

porta

nt a

ttribute

is th

e th

inkin

g

capability

of o

ur p

eople

.

Consta

ntly

impro

vin

g p

rocesses to

deliv

er a

perfe

ct e

xperie

nce fo

r custo

mers

will b

e a

never-e

ndin

g

journ

ey.

11

Pro

ductiv

ity :

It’s a

Matte

r of L

ife a

nd D

eath

“C

om

pan

ies that are m

ore efficien

t than

their co

mpetito

rs in p

rovid

ing cu

stom

ers

with

hig

h q

uality

goods an

d serv

ices will

thriv

e.C

om

pa

nies th

at a

re less efficient

than th

eir com

petito

rs will p

erish.”

Source: T

he T

oyota P

roductio

n S

ystem

, Toyota

Mo

tor C

orp

.

12

Th

e T

he

da

Ca

re

Impro

vem

ent S

yste

m

The 3

tenets

for c

hange:

Respect fo

r people

.

Teachin

g th

rough e

xperie

nce.

Focus o

n w

orld

cla

ss p

erfo

rmance.

13

Re

sp

ect fo

r Pe

op

le

Wh

at it is

:

Erro

r-free p

ractic

e

Tim

ely

serv

ice

No

wa

ste

No la

y-o

ff philo

sophy

Pro

fessio

na

ls w

ho

wo

rk

togeth

er to

impro

ve

perfo

rmance

Wh

at it is

no

t:

Lo

ng

wa

it time

s

Cre

atin

g/d

oin

g n

on-

va

lue

-ad

de

d w

ork

Waste

d tim

e

Waste

d m

ate

rials

People

focused o

n

tasks ra

ther th

an p

atie

nt

outc

om

es

14

Te

ach

ing

Th

rou

gh

Exp

erie

nce

We

will le

arn

by d

oin

g!

“Dirty

Hands”

appro

ach to

learn

ing

Rapid

, real tim

e d

ecis

ions

Focus o

n le

arn

ing fro

m s

ignific

ant

changes in

pro

cesses

Bia

s fo

r takin

g a

ctio

n n

ow

Not ju

st fo

r a fe

w “c

hosen”

em

plo

yees –

all w

ill be e

ngaged o

ver tim

e.

15

Fo

cu

s o

n W

orld

Cla

ss

Pe

rform

an

ce

Pa

st a

cco

mp

lish

me

nts

do

no

t pre

dic

t the

fu

ture

Ne

ce

ssa

ry to

sta

y c

om

pe

titive

ove

r time

Evid

en

ce

-ba

se

d a

nd

da

ta-d

rive

n, a

nd

cu

sto

me

r focu

se

d

Co

mm

itme

nt to

pu

blic

rep

ortin

g o

f resu

lts

Cre

atin

g s

tan

da

rd w

ork

in b

oth

ad

min

istra

tive

an

d c

linic

al p

roce

sse

s

16

Improvem

ent

FirefightingInnovation

FirefightingIm

provement

The O

ldT

he N

ew

Th

e 3

–L

eg

ged

Sto

ol o

f the

Th

ed

aC

are

Imp

rov

em

en

t S

yste

m

Impro

ved

Sta

ffM

ora

le

Impro

ved

Pro

du

ctiv

ity

Impro

ved Q

uality

(re

du

ctio

n o

f de

fects

)

18

Lean

too

ls a

nd

prin

cip

les c

an

an

d d

o

wo

rk e

very

wh

ere

…in

clu

din

g

health

care

. We w

ill be u

sin

g th

ese

too

ls a

s o

ne v

ery

imp

orta

nt a

pp

roach

in

ou

r cu

ltura

l ch

an

ge p

rocess.

19

Th

e N

ew

Cu

lture

will b

e

Counte

r –In

tuitiv

e fo

r aw

hile

….

Reducin

g w

aste

and n

on-v

alu

e a

dded

work

will c

om

e b

efo

re a

ddin

g

technolo

gy, b

uild

ing a

nd m

anpow

er.

Redeplo

y th

e b

estem

plo

yees, n

ot th

e

poor o

r marg

inal p

erfo

rmers

.

20

Th

is w

ill req

uire

ne

w b

eh

avio

rs…

Sm

alle

r, “right-s

ized”

gro

ups o

f work

ers

or te

chnolo

gie

s in

“cells

”ra

ther th

an

larg

e, c

um

bers

om

e p

rocesses.

Stro

ng, s

om

etim

es d

irectiv

e le

aders

hip

, augm

entin

g m

ore

traditio

nal te

am

appro

aches.

Less b

atc

hin

g o

f work

, in fa

vor o

f “right

now

”, real tim

e a

ctio

n.

21

All D

ivis

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upply

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quatin

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rience s

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ph

on

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ge

time

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cu

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e fro

m 1

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