In this lesson, I want you to explore how health systems can implement lean? W Edward Deming spoke about the human side of change. The challenge of adaptive change. How will employees react? What motivates them? How will they behave? The approaches used by Virginia Mason and Denver Health to achieve lean transformation were very different. Let's explore their strategies and tactics. Dr. Gary Kaplan was appointed the CEO of Virginia Mason in 2000. Virginia Mason Medical Center, located in the heart of Seattle, Washington, was experiencing intense competition. The financial status of the medical center the two years preceding his appointment were worrisome. They had suffered budget deficits in both 1998 and 1999. He realized Virginia Mason needed a new approach. After multiple meetings with Boeing, the preeminent manufacturer of passenger jets and headquartered in Seattle, he was encouraged to embrace Toyota Production System. He and key leaders of Virginia Mason flew to Japan to learn directly from TPS masters. Armed with this new knowledge, he was ready to implement TPS system wide. But how did he achieve this profound adaptive change? He quickly realized that lean tools were not sufficient for transformation. It became clear that everyone in the medical center needed to adopt a single organization wide method. He and his team adapted TPS to healthcare and called their system Virginia Mason Production System. He realized that if everyone did not use these same methods, Virginia Mason could not improve. He also realized that the desire of physicians to maintain their autonomy would make adoption of Virginia Mason Production System impossible. To achieve adaptive change he created an urgency to improve using specific patient examples, as well as the fear of financial deficits. He promoted a shared vision of the future. He wanted everyone to contribute their ideas on what we will look like. He recruited physician leaders as change sponsors. And he encouraged commitment and alignment of leadership and management. Most important, with the help of his leadership team, he created a new physician compact of reciprocal expectations and accountability that everyone who worked at Virginia Mason was required to accept and sign. What was in the Virginia Mason Medical Centre Physician Compact? The details of the compact are copyrighted and therefore I will only provided an overview. For more details, please contact Virginia Mason Institute. The compact is broken down into two sets of agreements. Those agreed to by management, and those agreed to by physicians. First the management compact. The organization's responsibilities included agreements to foster excellence, to listen and communicate, to educate, to reward, and to lead. The physician's' responsibilities include an agreement to focus on patients, to collaborate on care delivery, to listen and communicate, to take ownership, and the one I like most, agree to change. This pact formalizes a willingness to continually change, as we have talked about throughout the earlier classes, continual changes required for quality improvement. Denver Health's pathway to the adoption of lean was quite different, but just like Virginia Mason Medical Center, it began with the CEO, Dr. Patty Gabow. Denver Health had recently gained independence from the city government, and this stimulated leadership to consider adopting a new approach to providing healthcare. In 2004, Dr. Gabow and her leadership team applied for a government funded grant through the Agency for Healthcare Research and Quality, AHRQ. This planning grant recruited experts outside of healthcare as will be described in video four. Leadership asked all employees, what do you see happening to patients that you don't think should be happening? And what keeps you from working efficiently? And they asked patients, how would you like to be engaged in your care? And how would you like access to information? Leadership also asked providers to create a series of process maps to illustrate the inefficiencies of their present systems. The conclusions of those who mapped many of the processes at Denver Health was, please tell me this is not what we do! Everyone realized they needed a comprehensive system with the right processes, the right services, the right environment, the right people, the right communication, and the right rewards. Based on the advice of the experts from AHRQ planning grant and input of patients and providers, Dr. Gabow concluded that Toyota Production System, Lean, had all the attributes they were looking for. This approach would allow the removal of waste and improvement of value streams to save money, save lives, and save jobs. Because of their year long, fact finding, and planning journey, Dr. Gabow had buy-in. She and her leadership team had pulled nearly everyone to embrace TPS. Her first step was to train lean experts within her institution. To accomplish this task, they hired a consulting firm with expertise in training TPS to a manufacturing firm. The consultants trained 50 lean black belts during the first year. Following completion of the training, Dr. Gabow charged 160 sites throughout the health system to perform 5S exercises under the supervision of the Denver Health's new lean black belts. The before and after pictures of the 5S exercise were impressive, and immediately demonstrated to everyone the potential of TPS. To guide implementation, Dr. Gabow assembled a steering committee of physician leaders and administrators to create an annual Transformation Plan of Care. The committee treated their health system as though it were a patient. Just as for patient care, they created an annual diagnostic and treatment plan to improve their system's health. To set priorities, they used a scoring template focusing on the priorities with the highest scores each year. As shown on this slide, Denver Health has been able to treat increasing numbers of patients without health insurance, despite nearly a level financial support from the City of Denver. And thanks to lean systems, they have maintained a positive financial balance. What are some of the lessons these two examples can teach us about implementing lean. Implementation requires alignment of everyone. Everyone must buy in. The CEO must be fully committed and be an enthusiastic champion. The organizing principles I described in our earlier class on Samuel Adams should be applied to create a leadership team and identify champions. Process mapping and 5S can be used as tactics to recruit new lean disciples. Active participation increases commitment and increases learning. To create sufficient institutional expertise, the institution will need to train a large number of lean black belts. Denver Health recommends approximately 250 trainees for a 500 bed hospital. Remember that the journey is long. A minimum of seven to ten years is required to build an effective system, but the journey is definitely worth it. As Koenigsaecker in his book, Leading the Lean Enterprise Transformation, see the reference list, maintains that full implementation of lean can be expected to increase productivity by fourfold and reduce errors by 99%. There is no doubt that lean can revolutionize modern healthcare. Thank you.
