Published in the February 2004 issue of Today’s Hospitalist
In an effort to improve patient care, physicians and executives at Virginia Mason Medical Center in Seattle turned to an unlikely source: the assembly lines of two well-known Japanese manufacturers.
Their reasoning was simple, if unorthodox: The production systems of these companies “Toyota and Hitachi “use a management approach based on the concept of making processes “lean.” A system that has worked so well for a company like Toyota, they said, must have some application in the waste-filled business of American health care.
If Toyota could build better cars and give consumers more of what they want “and do it more efficiently and consistently “by following “lean manufacturing principles,” they asked, why couldn’t Virginia Mason employ the same principles to improve the safety, quality and cost of their product, not to mention staff and patient satisfaction?
(To understand the lingo, think food. “Lean” refers to unnecessary fat that slows, endangers and adds costs to the end product.)
So 30 top executives and physicians embarked on a trip to Japan. They visited Toyota and Hitachi. They visited factories that built cars and air conditioners.
They witnessed how concepts like “just-in-time supply” and “mistake-proofing” work in these production facilities. They learned how to run “rapid process improvement workshops” to make significant changes “from ensuring that they never run out of gloves in exam rooms to reducing the time it takes for test results to be reported “in days, not months.
The result, known as the “Virginia Mason production system,” was born in 2000. As described by Robert S. Mecklenburg, MD, chief of Virginia Mason’s department of medicine, it is based on the principle of “evaluating what’s important to the patient, what adds value to patient care, what doesn’t add value (waste) and then eliminating the waste.”
In 2003, he says, the medical center held 130 “rapid process improvement workshops,” and 240 are scheduled for 2004. Many of the sessions have markedly improved how hospitalists on the wards now do their jobs.
Delays in consults
One workshop, Dr. Mecklenburg explains, was designed to address a problem that most hospitalists take for granted: the lag between when a hospitalist orders a subspecialty consult for a patient for something important but not emergent or urgent, and the time when the consult is actually done. The workshop went one step further and examined when treatment based on the consultant’s recommendations is started.
(Virginia Mason has a team of more than 10 hospitalists who manage all medical patients.)
Consider a common scenario: A patient is admitted to the hospital at 6 p.m. for pneumonia, and he is quickly found to have high blood sugar. The hospitalist calls for a diabetes consult.
The workshop examined Virginia Mason’s old system by using stop watches and flow charts. Hospital officials found that hospitalists would walk to the ward secretary and say that Mrs. Jones needed a diabetes consult. The secretary would then call the diabetes section to relay the message to another secretary.
That second secretary would then put a yellow sticky note on the desk of the doctor who was thought to be on call that day. The diabetologist would see the note when she came back from seeing patients “or possibly the next morning “and see the patient when she could. That could occur as late as lunch the next day or in the evening, when she was done with her regularly scheduled patients.
“From the doctor’s point of view, a lag of 12 or even 24 hours for a nonurgent consult is just one of those things we accept. It’s not even particularly frustrating to anyone. We have lived with it for years,” explains Dr. Mecklenburg. He acknowledges that as an endocrinologist, he has been just as guilty as anyone in tolerating the status quo.
“But think of what’s important to the patient,” he continues. “The patient and the family are fretting ever since they learned there is a problem that needs a specialist. They want to talk to somebody about it.”
A new system
Moreover, Dr. Mecklenburg notes, the time wasted between when the consult was ordered and when it actually occurred represents time when patients are not receiving care for the condition that brought them to the hospital in the first place.
“It’s time when they might have been discharged,” he explains. “It’s time when mistakes in care could occur. It’s time when the person might get a high blood sugar and get sick. It’s time when there is confused communication and lack of good integration of care.” And because it is time in a hospital, he adds, it is expensive time.
In September 2003, Dr. Mecklenburg led a workshop team that included a hospitalist, a resident, a surgeon, two nurses, an administrator and two specialty consultants. They were charged with reducing delays in how inpatient consultations are done.
The groups started on Monday, and by noon on Friday “after being pulled from their regular duties for the week “they had cut out the involvement of secretaries in the process. They also created call calendars that were posted online and regularly updated.
The groups also instituted a system where the doctor requesting the consult sends a text message to the consultant’s pager directly, which the consultant must answer within 10 minutes “for the condition at least to set up a plan. The results were dramatic: The time between when consultations are first ordered and the charge is submitted by the consultant dropped by 62%.
“People aren’t cars”
Not surprisingly, the idea of turning to the manufacturing process to improve patient care struck some physicians as a bad idea.
“When we first went to Japan,” Dr. Mecklenburg recalls, some colleagues at the medical center disparaged the effort. They argued that “people are not cars; we need the variation because everybody is different.”
But that critique, Dr. Mecklenburg says, is “hogwash. The unique human interaction between provider and patient is not the target of any of this. Surrounding that very special and highly variable interaction are all sorts of production processes.”
For instance, he explains, “The time I spend talking with the patient and their family about diabetes is value-added. But if part of the interaction with the patient is spent looking for the records, that is a production issue. That is something that can be the subject of lean thinking.”
In addition to the type of delays addressed by the inpatient consultation workshop, “lean” thinking also tries to cut out “re-work.” This concept refers to redoing tests, rescheduling and multiple bed moves. Virginia Mason used it to target areas like overproduction, including defensive medicine and excessive paperwork; “movement,” which includes unnecessary transport of people or information; and “defects,” which can lead to medical errors.
In other “lean” projects, Virginia Mason has standardized the equipment it uses for some procedures, and it instituted a way to have teams round on inpatients together. “The idea is to look at what we do through the eyes of the patient, rather than the health care providers,” Dr. Mecklenburg says.
