Pain huddle leads to less medication, lower readmissions

Engaged nurses improving the patient experience

Lean process competency enables nurses to practice at the top level of their education and make meaningful change for patients.

By Ellen Noel, MN, RN, CPHQ, Virginia Mason Institute Faculty

From the frontline to the boardroom, nurses are a valuable resource in solution-oriented health care. Their unique professional training and their role as advocates for patients and families along the wellness continuum make them essential to multidisciplinary teams that identify problems in health care and then work to develop sustainable solutions to improve care.

A 2010 Institute of Medicine report (“The Future of Nursing: Leading Change, Advancing Health,” October 2010) identified key messages to guide the nursing profession. Two of these recommendations are truer than ever today: Nurses should practice at the top level of their education, and they should partner with physicians and other health care colleagues to make meaningful change for patients.

Lean process competency enables nurses to do both. In organizations with cultures that encourage their employees to speak up with ideas and empower them to act, lean invites all levels to participate. Why is lean such a good fit for nurses leading change in health care systems?

  1. Lean is inclusive. When nurses meet with a multidisciplinary team that integrates multiple points of view, they can uncover the intricacies of a problem with a rapid, thorough root-cause analysis and devise a solution that can have a big impact on patients.
  2. Lean processes can enable nurses to scientifically and rapidly observe real-time health care delivery, analyze data, identify problems and focus the discussion. Because nurses work directly with patients in the exam room and at the bedside—and indirectly as they integrate evidence-based practice into organizational systems—they already understand the problems and processes at deep levels. While using lean processes, nurses are challenged to remove wasteful practices and make patient care better.
  3. Lean can enable nurses and their colleagues to create solutions to fix broken processes. They can use rapid-cycle learning to collaboratively develop plans of action and implement change. The patient is at the center of all they do, so they know that the end result can produce a new level of care with a value-added approach for their patients.

Case study

Like other health care organizations, Virginia Mason struggled with the complexities of caring for patients with persistent or chronic pain. The patients with persistent pain could be dependent on or addicted to strong pain medications, resulting in long hospitalizations and multiple readmissions. Even more, the many components of persistent pain syndrome led to delays in discharge and care progression and greatly impacted patients’ quality of life.

The old system

When checking on a patient experiencing persistent pain, a nurse might say, “How are you feeling now?” and the patient would often respond: “I’m in a lot of pain and need more pain medication.” A pain assessment typically produced a pain rating of 10 out of 10, so the nurse immediately contacted a physician to approve more pain medication. Unfortunately, the physician’s busy schedule meant this couldn’t happen right away, and there were delays. In addition, the physician might be wary about increasing a dose of a medication that didn’t work or giving a patient more than was needed. Physicians needed time to investigate other ways that might help relieve patients’ pain, and meanwhile, the patients were in pain, feeling frustrated and angry. To make matters worse, nurses’ dissatisfaction with their jobs increased because despite all their efforts as patient advocates and caregivers, they couldn’t help their patients who were in pain.

Improvement work

A team of anesthesiologists, nurses, nurse pain specialists, hospitalists and kaizen promotion office (KPO) specialists met to redesign the hospital system to support patients with persistent pain. First, through a process of discovery in their Rapid Process Improvement Workshop (RPIW), they analyzed the multifaceted elements of pain—emotional, cognitive, physical and psychological. Using evidence-based guidelines and inviting patients to be part of the process, they designed a “wellness wheel” that focused on functional comfort and gave nurses, physicians and patients a starting point in the conversation about pain. Instead of simply talking about the feeling of pain, clinicians and patients talked about the factors that contributed to the pain experience: appetite, activity, sleep, plans for the day, mood and medication. All the components were featured in the shape of a wheel on a poster, so that the clinician could point to one factor at a time to guide the conversation, step by step.

Then the RPIW group developed a new “pain huddle” to accompany the wheel and practiced simulations, tested the huddle with real patients at the bedside during the week, refined their scripting, built assessment tools, and compiled and analyzed feedback.

Leaders—nurses, anesthesiologists and hospitalists—were key to the project’s success. They kept it alive and really made it work for the patients and the staff because they believed it would benefit their patients physically, cognitively, psychologically and emotionally. It turns out they were right, and the wheel is used today to guide these important patient conversations.

The results

The 30-day and 60-day metrics showed that after training, the clinicians found the wellness wheel intuitive and embraced it. Even more significant, the hospital’s multiple requests for additional pain medication began to decrease. At last, clinicians were able to use a tool, founded on the tenets of evidence-based medicine, to guide their conversations with patients in a way that embraced a fuller picture of the patient experience. Within 60 days of the workshop, proof of process sustainability was found in the electronic medical record as the teams continually referenced the use of the wellness wheel in their patient care plans. The results were included in patients’ medical records, and reports showed that patients were more satisfied with their care, needed less pain medication and were discharged earlier.

Because nurses are so critical to the patient experience, it made sense to involve them in the process to help relieve the problems associated with their patients’ persistent pain. The nurses on the team were proud to roll out the new tool, train clinicians and see the positive effects on patient care. Their engagement in the process not only contributed to the team’s success but also paved the way for a sustainable solution and a future pathway of continuous improvement.

To learn more about how nurses, physicians and other clinicians can use lean processes to improve care at your organization, register today for Lean Training.

Ellen Noel, RN

Ellen Noel, RN

Ellen Noel, MN, RN, CPHQ, Virginia Mason Institute Faculty, has extensive experience in the translation and practical application of the Virginia Mason Production System. During her thirty-year tenure at Virginia Mason, she has held positions as an adult clinical nurse specialist and the director of quality and safety. Ellen’s in-depth knowledge of clinical processes, team development, health care outcomes and regulatory performance provides a solid foundation for an extraordinary learning experience. She is a Kaizen Fellow graduate and holds certification as a Qualified Professional in Healthcare Quality.

Analyzing the “Big Idea”: Extending the Success of the Marketplace Collaborative

An Interview with Robert Mecklenburg, MD, Center for Health Care Solutions, Virginia Mason Institute

In Harvard Business Review’s article “The Employer-Led Health Care Revolution,” coauthor Robert Mecklenburg, MD, describes his work with Intel to create a successful health care collaborative in metropolitan Portland, Oregon. In 2007, Dr. Mecklenburg encouraged Intel to lead market-based health care reform and provided Virginia Mason Institute’s clinical content and processes, known as Clinical Value Streams, to ensure that Intel’s efforts produced higher-quality, patient-centered care at a significantly lower cost. The outcomes were laudable: medical costs dramatically declined, patient satisfaction was high and patients returned to work faster. The results were so striking that Intel is now extending its work to benefit its employees outside Portland. Dr. Mecklenburg sees the Intel model as a road map and inspiration for numerous employers who want to rein in their costs and produce healthier employee populations.

Light BulbWhy is the HBR article important?

RM: First, it shows that the Healthcare Marketplace Collaborative model that Virginia Mason developed in 2005 can be scaled and transported to a different market, different provider groups, a different health plan and multiple employers, which is very exciting. It also shows that employers can drive market-based health care reform to purchase care of the highest quality for their employees, with high patient satisfaction at a much more affordable price. By effectively using their purchasing power, they can bring out the best in providers and health plans. For providers, this model can help lower their cost of production substantially while capturing market share.

The article further shows that Virginia Mason Institute’s clinical content and processes, our Clinical Value Streams, can be readily adopted outside of Virginia Mason by provider groups with different cultures and different organizational structures.

In the article, you discussed your role in the landmark health care transformation at Intel. What were the key components that made it work so well?

RM: The purchaser, Intel, agreed to use its purchasing power to manage its health care supply chain. To make it effective, I presented to Intel the five market-relevant quality indicators we had developed with Seattle employers that could be used as purchasing requirements. I also assisted Intel leaders in understanding the methods, process and structure of the Marketplace Collaborative model to ensure that providers would produce quality, employers would purchase quality, and health plans would pay for quality in health care.

Another key component was Intel’s use of Virginia Mason Institute’s standardized, evidence-based care pathways. This enabled diverse groups of providers to deliver very high-quality, affordable care, while ensuring high patient satisfaction.

Change management was crucial, too, in implementing a different approach to delivering and purchasing health care. It had to include clinicians in all three provider groups as well as Intel and Cigna leaders. It was essential to interact with a full range of personnel—from executives to frontline workers in the provider clinics—to explain how successful implementation of Clinical Value Streams requires application of the methods of change management, lean thinking, cost accounting and evidence-based medicine.

What lesson did you learn that would make this journey worthwhile for another top employer like Intel?

RM: I’d advise employers to manage their health care supply chain with the care they would for any goods or services they purchased. We’ve been showing employers how to work directly and productively with providers for more than 10 years.

What types of organization is this model suited for?

RM: This model is well suited for providers who wish to reduce their cost of producing health care while capturing market share with a high-quality product. It’s for employers who want higher quality and high employee satisfaction while reducing health care costs.

As a physician, what advice do you have to make this model appealing to physicians? Is this just another form of cookbook medicine?

RM: This approach has been appealing to physicians for a decade. The big pull for physicians is that they have the opportunity to apply their expertise and experience to create a more satisfying method of delivering health care. They have the opportunity to engage directly with their employer/customers and they learn effective tools to improve their financial performance. They also get home in time for dinner.

Do employer-led health care models produce healthier populations? If so, shouldn’t governments tap into these models?

RM: State governments are currently adopting elements of these models to create purchasing standards. As these states achieve sustainable health care costs and high employee satisfaction, more public sector purchasers may follow their lead. Producing best outcomes for patients nationally—even internationally—is why Virginia Mason Institute exists. It’s not theoretical anymore; the health care collaboratives are doing what they set out to do and stakeholders are seeing the results.

What’s your advice for a company that’s struggling with employee health care expenses right now?

RM: Do your research, come together as a team and follow the 7 Steps to Affordable Health Care: Using Purchasing Power to Drive Market-Based Reform.

To learn how to create better, faster, more affordable health care, see Virginia Mason Institute’s work on health care collaboratives and Clinical Value Streams.

Robert Mecklenburg, MD

Robert Mecklenburg, MD

Robert Mecklenburg, Medical Director, Center of Health Care Solutions at Virginia Mason Institute, has authored over 50 scientific articles and has been lead author on two studies published in the New England Journal of Medicine. He has studied the Toyota Production System in Japan and is a certified instructor in these methods. His work with employers on the production, payment and purchasing of quality in health care has been featured in The Wall Street Journal, Health Affairs, the Harvard Business Review and Institute of Medicine’s publication, The Healthcare Imperative: Lowering Costs and Improving Outcomes.

How can you spread standard work successfully?

By Ingrid Gerbino, MD, Virginia Mason Institute Faculty


It’s official. Your small team in primary care has developed new standard work and your team’s clinicians and staff members have been trained. When you’ve measured the work at 30, 60 and 90 days, the results are exceeding expectations. But spreading it throughout your clinic and the organization’s other clinics is daunting. You want to improve patient care and safety in larger numbers, but how can you make sure it will work at the other clinics?

The 5 secrets of spreading standard work

Successfully spreading standard work throughout a department, in multiple different clinics, is challenging. Here are five elements we have found to be helpful:

  1. Be sure your standard work is in keeping with organizational goals so that leaders and teams share the same sense of urgency. Low-hanging fruit is tempting to work on — and at times it should be considered — but it may not be a good fit for spread if it isn’t aligned with the larger goals.
  1. Create a Standard Work Guiding Team, which includes stakeholders from each site, to be the gatekeepers for all of the standard work. At Virginia Mason, for instance, the Standard Work Guiding Team (SWGT) is essential in deciding which pieces of standard work will be spread to each of our primary care clinics. Process owners make presentations at the monthly SWGT meetings about standard work they are hoping to spread and give an implementation plan, allowing for the guiding team to ask clarifying questions. The guiding team then has a 30-day period to vote on which standard work will be implemented and spread.
  1. Start small and even out the nuances during the spread. It’s important to ensure that the standard work you’ve developed translates well in different clinics with different geographic layouts and staffing. Limiting the spreading of the new standard work to one or two teams at a time is ideal, so that you can capture and share best practices before spreading to other teams. Abundant communication to all stakeholders during the spread is critical!
  1. Make the process visible and accountable. In the Department of Primary Care at Virginia Mason, we do this by using shared electronic Skills Maps – a tool that allows team members to know at a glance if a team has fully implemented key pieces of standard work. The accountability for training and implementation of the standard work is transparent and shared among team members.
  1. Create a toolkit for spread. In our best work, there is a step-by-step playbook containing any tools needed to roll out the new standard work. The playbook is updated with any new learning from teams as needed.

A reminder

Standard work, developed by team members doing the work, is an excellent tool to define best practice. As the father of the Toyota Production System taught us, “Without standards, there can be no improvement.” Once you have implemented standard work, you can build upon the work and sustain best practices.

The role of the leader is to connect the dots for team members, and ensure everyone understands their roles in standard work and sees how the work connects to the patient experience. Standard work allows us to mistake-proof our processes, helping to ensure that every patient has an outstanding experience and outcome, every time.

To learn more about engaging and motivating employees while creating and spreading standard work, register for our course Engaging Staff in Daily Improvement.

To learn how your organization can create a culture of continuous improvement, read about our Transformation Services.

Ingrid Gerbino, MD, a Virginia Mason faculty member, practices general internal medicine and provides leadership in the Department of Primary Care at Virginia Mason. A Kaizen Fellow graduate, she has completed the Virginia Mason Production System certification and has led process improvement initiatives involving the patient portal, the implementation of electronic results to endorse and more. Dr. Gerbino received her medical degree from UCLA and completed her residency in internal medicine at the University of Washington.

How does standard work lead to better patient safety?

By Eli Quisenberry, Director, Kaizen Promotion Office, Virginia Mason

We’re hurting people in health care more than we think.

Providers and other health care specialists frequently balance the art and the science of medicine. While many clinical studies and evidence of best practices guide our work, we are still dependent on medical specialists and staff to use their best critical thinking, judgment, and knowledge gained through experience to deliver high-quality health care. The challenge is that health care is complex and often chaotic, and people make mistakes. What’s more, variability in our processes leads to variation in patient care—and this is a huge problem. In health care, we know that no mistake or variation should be acceptable if it leads to the potential to harm a patient.

So the question becomes this: What can we do to prevent employees from causing harm to patients? How can we mistake-proof the way we deliver health care? One way that Virginia Mason makes processes safer is the creation of standard work.

Creating standard work

The first thing to realize about standard work is that it’s about efficiency, accuracy and safety and not about making workers into robots. It’s about making sure the patient is first in every part of the health care process—and that takes creativity, teamwork, and testing. It’s about asking at every step, “What is the best way the customer wants me to do this?” It’s about making routine the elements of care that we know will benefit the patient.

With standard work, the employees who are doing the work are key players in developing the standard work process.

That’s why it’s important that health care employees learn to analyze their processes, see waste, and prevent mistakes. And that’s why standard work becomes an opportunity to help employees do a better job. Instead of learning by mistakes, new employees can enter a process and quickly learn to use the best practices of those who developed the standard work.

What is standard work?

Creating standard work involves three parts:

  1. Deciding what the standard is, then creating and testing it. This is where the team analyzes the problem, studies the current work flow, and comes up with a solution that would be better from the patient’s point of view. Then the team uses the PSDA (Plan, Study, Do, Act) method to test and refine it. Remember: this is a learning journey; it’s where the rubber meets the road. This is where you find out if five different employees can use this standard work to produce results with no defects.
  2. Getting the standard work into place, and deploying it. This is where good training, open communication and follow-up with staff are crucial.
  3. Continuously improving the work. With standard work, you never rest on your laurels. You continue to audit the work and make enhancements to make it even safer for patients.

Case study of standard work

Standard work is useful whenever a process is not 100% free of defects. Is this too high a standard? Virginia Mason’s laboratory team didn’t think so.

When team members evaluated the way they labeled specimen tubes, they looked critically at their successive check process, which is completed on the check-in bench in the laboratory’s central processing department. They discovered that in a one-month period, the process failed to catch three mistakes. With more than 30,000 patient orders per month, this meant the process had a 0.01% defect rate. The team determined that the defect rate—though deemed acceptable or even very good in other health care organizations—wasn’t acceptable for Virginia Mason’s patients, who wanted zero mistakes. They knew that a lab mistake could translate to a delay, misdiagnosis or even the wrong treatment in a patient’s care.

So the team analyzed the process, eliminated waste, introduced standard work and used the concept of TWI (Training Within Industry) instruction to ensure that all team members were fully trained in the new standard process. The standard work they developed helped the team achieve zero defects in the next six-month period, and it defined the standard way that all new team members are trained today.

Why was this implementation successful?

The department’s leader, recognizing that creativity is good for employee engagement and skill-building, involved the employees in the investigation of the existing process and the creation and testing of a brand-new process. The leader said to them: “Is there a ‘best way’ for this process? How can our team bring the concept of continuous improvement to the table?” and then encouraged them to speak up with their ideas and made sure they had time to conduct analyses and testing between meetings.

All team members knew that the goal was to make this process more efficient, and therefore, safer and better for patients. They knew that to have a defect-free process, everyone needed to follow the new process, every time, in the same way.

And after the standard work was developed, deployed and refined, the employees were freed up to use creative thinking to investigate other systems and to devise new ways to improve them. Whenever employees developed new standard work, they became more confident and better skilled—really mastering their jobs and growing in their understanding of new aspects of their work every day. And this is because every team member asked, “How can I make this work better for our patients?”

To learn how to create health care processes with zero defects, register for our course Lean Training.

To learn more about creating standard work that engages and motivates employees, register for our course Engaging Staff in Daily Improvement.

Rhonda Stewart

Eli Quisenberry, MBA, is director for the Kaizen Promotion Office at the Virginia Mason Medical Center. He partners with leaders, staff, and teams across the medical center, applying the Virginia Mason Production System principles as they work to transform health care and achieve the organization’s vision as the quality leader. Eli has worked in health care administration for over 10 years and is a certified rapid process improvement workshop leader and a Training Within Industry trainer.

“How can my organization use daily management to create a culture that puts the patient first?”

By Rhonda Stewart, Virginia Mason Institute Faculty

Engaging StaffFor leaders who want to make progress in improvements across an organization, the challenge can seem insurmountable. How can you get executives, providers and staff to adopt a mindset of continuous improvement? How do you even get started?

A good place to begin is to reflect on your organization’s culture. What would it take for you to have a culture that puts the patient first? Are you thinking it would be too hard on your organization to make the necessary changes? Are you feeling powerless to bring about a meaningful change that would make a difference? Let’s look at some key aspects of a culture that is truly patient-focused.

  • In patient-centered organizations, staff members speak up about their own near misses. In these organizations self-reporting is essential because it can expose gaps in the process where patient safety might be jeopardized. In fact, leaders encourage self-reporting because it can instigate an investigation of the process and the formation of an improvement event to protect patients.
  • Staff members speak up about others’ mistakes. Staff feel empowered—and eventually compelled—to speak up. This is true for any employee in the organization. Those who speak up for patient safety are met with support, not retribution.
  • Staff members talk to each other to uncover and resolve problems. They don’t point fingers; they don’t say to another team member, for instance, “You always bring me the patient too early.” They say, “When the patient is brought to me, I’m not ready to provide care and then the patient has to wait. What can we do as a team to make this process seamless for the patient?” Leaders support this teamwork.
  • The idea generators in your organization are staff members. In organizations that are not patient-focused, staff members won’t regularly think of ideas—or speak up about them—to improve patient safety or the patient experience. They just do the best they can with the processes they were trained to use. In these organizations, leaders want satisfied patients, but they don’t ask their staff to be a part of improving the system of delivering care. In patient-focused organizations like Virginia Mason, however, leaders ask staff members to come up with ideas to improve patient care, and then the staff members own those ideas and work independently or with a team to test them and bring them to life.
  • Within departments, work processes function similarly for all the department’s providers. In organizations that are not patient-focused, the bigger picture is lost, and medical assistants throughout the organizations say, “My provider does things differently.” Patient-focused organizations are willing to challenge the status quo to make things better for patients across the organization. They know that when variation is reduced, the service becomes not only consistent and more predictable, but also feels safer from the patient perspective.
  • Staff members listen to other perspectives and are willing to integrate them into their own thinking. They’re willing to shadow other staff members and work collaboratively to make the new process function well for the whole team. They know that health care that is truly patient-focused involves collaboration with many staff members involved in the patient visit to make patient care seamless and make it truly safe.
  • Teams make their work visible, transparent. They have production boards showcasing their health care processes so other teams can spot defects that may impact patient satisfaction. Teams know that working well with other teams is essential to an organization that wants to improve the patient care process.

Being patient-focused means that your organization works constantly to do what is best for the patient—to improve patient safety and the patient experience. It means understanding what is not value-added in patient care and working relentlessly to make the patient experience better. To leaders who say, “Where do I begin changing something like culture?” I would say, “Look at one of these key concepts. What can you do to promote this in your organizations?” Small steps in transforming your culture can make a difference—for you, your staff and, most significantly, your patients.

Learn more about leading differently to bring about change in your organization in our course Engaging Staff in Daily Improvement.

Rhonda StewartRhonda Stewart, who is certified in the Virginia Mason Production System, has led improvement events throughout ambulatory, specialty and hospital value streams, including the PACU/Recovery areas. In her former role as Virginia Mason’s director of finance, she led improvement events in accounting, analytics, billing, payroll and supply chain.

“We’re moving to a new space. How do we make things better?”

Using teams to create a new patient experience

By Chris Backous, MHA, Virginia Mason Institute faculty

A team encouraged to test ideas can create entirely new ways to improve patient care.

A team encouraged to test ideas can create entirely new ways to improve patient care.

You just found out your health care team has the opportunity to move to a new space. How do you make it work? Is it possible to make it better?

If you’re like many health care teams, being told you’re moving to a new space creates a challenge. Your current space works because you’ve made it work—because you’ve had to make it work. And for most health care employees on the team, the space was inherited, along with some processes, too. In many ways, it’s not a very functional space, and for years patients have been waiting in the waiting room for longer than they want to—longer than you want them to, even on the best of days—and there hasn’t been anything you could do about it.

“Furniture is what people buy. Flow is what people create and what adds value to your organization.”

– Chris Backous, MHA

But now you get to start over in a new space. It could be a brand-new space; it could be a repurposed space with a different shape, and a different look and feel. How can you make this space an opportunity to change the way you and your team work together and to change the way you all work with patients?

  1. First, and most important, challenge yourself to think differently. Imagine what it would be like to really change things with breakthrough ideas.
  1. Then ask, how does the current space function from the patient perspective? What are the opportunities for improvement in the new space? What are the unnecessary wastes and processes? Should health care workers be doing different types of work, or the same work in new and different ways? What if, for instance, medical assistants had more responsibility so that physicians could spend more time with their patients?
  1. Use the 3P method—production preparation process—to allow you to invest your time wisely and think differently.
  1. As a team, identify and eliminate waste. Ask, “What wastes should we focus on first?” or “Where are the biggest rocks in our shoes?”
  1. Involve your team and get them excited. Help people move from their usual ways of doing things to inventing something new. For example, if you know that patients wait a long time in waiting rooms, talk about what you can do to change your process. What if your organization didn’t have waiting rooms at all? What if it was illegal to make patients wait? How could your team create a process in which “no need for waiting rooms” became a reality? Once the team can imagine this, then they have a new process to reinvent, and it becomes exciting. Without imaginative thinking, the best you might hope for is just a smaller waiting room in the new space. Your team can do better.

    When I work with organizations using the 3P method, at first the team struggles to come up with one or two ideas. It can be hard to come up with original thinking and say these ideas out loud. People worry, What if my colleagues think my ideas are ridiculous? But every time, as the class progresses and the confidence builds, the team develops a ton of ideas. Before long, they’re testing out their new ideas within minutes using Legos and they’re doing simulations. It’s amazing!

  1. Look at other spaces for ideas. Borrow shamelessly, but make it your own. Health care leaders and providers from around the world tour Virginia Mason week after week, every year, to find out how we’ve transformed our space to improve patient safety and the patient experience. We encourage them to get inspired by our use of space for our patients, and we want them to do the same for their unique patient populations. We want their space to be as great for them as ours is for us.
  1. Give your team time for out-of-the-box thinking. It’s not natural or easy. It takes work; it takes practice; it takes time.

Remember, designing a new space is not about new furniture that pleases your staff and patients. Furniture is what people buy. Flow is what people create and what adds value to your organization. If you can’t design for new flow processes, your new design becomes just a different—but not better—patient experience. You can do better for your patients and your staff. You can create a design that works for your patients, your staff and you, one that your team owns and values, one that enhances everyone’s experience. I encourage you to make it happen!

Do your teams struggle to break out of current thinking about space? What helps?

Learn more about creating a patient-centered design in our Lean Facility Design Seminar.

Learn more about improving flow in our course Creating Flow in the Ambulatory Setting.

Chris Backous, MHA

Chris Backous, MHA

Chris Backous, MHA, is certified in the Virginia Mason Production System and 3P facilitation. Before joining the Virginia Mason Institute, Chris was a member of the Virginia Mason Kaizen Promotion Office, where he led numerous improvement activities on facility design. Chris has influenced and inspired individuals, organizations, and national health care systems to integrate lean processes into their improvement and transformation efforts, to engage teams to use innovative thinking and to create new processes and spaces.

Using the Nemawashi gauge to guide improvement in patient safety

By Celeste Derheimer, RN, CPHQ, MBA, Transformation Services Sensei

A culture in support of safety is inextricably linked to a culture where continuous improvement thrives. Leaders drive values, values drive behaviors, and the collective behaviors of the individuals in an organization define its culture. These same leaders must be involved in creating the transformational change that is required to develop and sustain a culture of safety. Then they must implement and maintain a system that continuously engages staff. The Nemawashi gauge is a tool that can help leaders succeed in improving patient safety and engaging staff to contribute to continuous improvement.

Defining the Nemawashi gauge

Nemawashi is a Japanese term that means “to prepare the soil for planting or transplanting a tree so that it will live,” and it speaks to the adaptive aspects of change. In recent years, Virginia Mason identified five foundational elements needed to support improvement and developed the Nemawashi gauge to assess an area’s readiness for change:

    1. Leader preparation
    2. Genba presence
    3. Daily management
    4. Creating a line of sight
    5. Staff readiness and engagement

The Nemawashi gauge can help leaders discover the blend of technical and adaptive change required to successfully create and sustain a culture in support of patient safety.

How can leaders use the Nemawashi gauge to engage their staff?

To create and support an improvement culture, leaders and staff need to define the problems and participate in solving them. It’s just as important to move beyond complaints and generate new ideas. With these points in mind, readers can engage staff in the following ways:

  • Encourage your staff to speak up, and then reinforce that message. If a staff member believes that there is a process or an obstacle creating a barrier to patient care, the team needs to know. Also let staff know that you would like them to come to work with ideas for improvement, and then reinforce this by asking the team for ideas during huddles, genba walks and meetings.
  • Now that you have enabled your staff members to speak up about problems and new ideas, be sure to allow and reward courageousness. Staff need to know that their ideas are important, and that it is OK to feel vulnerable and take chances.
  • Be sure that the people who do the work improve the work. Let it be clear that an idea won’t languish in a suggestion box, waiting for someone else to act on it. Ideas need to be tested by the staff who will potentially implement the new ideas in their daily work.
  • Support staff as they test their ideas. Check in with them at the genba as part of daily management. Create a line of sight at weekly huddles, too, so staff can report on their progress to the team.
  • Remember that staff who see their ideas implemented become more engaged and more likely to continuously generate more ideas. Engaged staff are the ones who regularly seek improvement and make your organization better and your patients safer.

How has the Nemawashi gauge been received at Virginia Mason and other organizations?

At Virginia Mason, the Nemawashi gauge has helped leaders assess the readiness of their teams for change. As a result of using this tool and other patient safety tools and methods, we have seen a steady increase in continuous improvement, especially in clinical engagement. Most notably, we have seen an increase in our staff’s reporting of safety concerns—in fact, our Patient Safety Alerts (which are part of our system for empowering all team members to report any perceived threat to patient safety) have increased significantly because staff are paying close attention and feel empowered to speak up.

In my work as sensei at organizations worldwide, I know that daily management is crucial to sustaining the improvement culture, so I reinforce the constancy of purpose with every leader. At Virginia Mason, we know from our years of experience that discipline is necessary, even with all the other competing priorities and the surprises that come our way in health care. We also know that the resulting culture of engaged staff—and improvement of patient safety—is worth the effort.

To learn more about the Nemawashi gauge and other ways to improve patient safety, register for our course Creating a Culture of Patient Safety.

To learn more about how leaders can create and sustain an improvement culture, register for our course Engaging Staff to Drive Improvement.

Celeste Derheimer, RN, CPHQ, MBA, is a Transformation Services sensei at Virginia Mason Institute. A Kaizen Fellow graduate, with certification in the Virginia Mason Production System, she has led multiple kaizen activities to improve safety, quality and administrative processes. Prior to joining Virginia Mason Institute, she served as administrative director for Corporate Quality and Safety at Virginia Mason, where she was responsible for organization-wide quality improvement and patient safety. She has held leadership positions in numerous health systems in Washington and Oregon and has served as an examiner for the Malcolm Baldrige National Quality Award since 2006.

How Change Can Energize and Motivate an Organization

By Diane Miller, Executive Director, Virginia Mason Institute

Introducing the Virginia Mason Institute Team to Our Blog

Diane Miller

Diane Miller

I’d like to introduce the Virginia Mason Institute team to readers. In the coming months, more faculty members will be featured on the Virginia Mason blog, sharing their experience and explaining the ways that lean concepts can successfully be used in health care. A collection of lean thinkers and teachers, rigorously trained in the Virginia Mason Production System (VMPS), the team officially began transforming health care in organizations outside Virginia Mason in 2008. Today’s team comes with a variety of skills—in ambulatory flow, primary care and specialty medicine, nursing, patient safety, lean financial processes, lean architecture, and kaizen promotion—and they enjoy being lifelong learners and teachers.

Through the years, we’ve grown in number and in scope, so that now we’re training leaders on site in the United States, United Kingdom, Denmark and more. In our classrooms in Seattle, we’re training leaders from Maine to California, from the Netherlands to Japan and from Iceland to Brazil. In every one of our courses, we’re asking providers and organizations, one by one, to learn from Virginia Mason’s successes and failures and find the courage to change the culture and put patients first in all that they do.

Why is change necessary?

Change, as we know from experience, can be a rough road to travel. Health care providers naturally want to provide the best care, at all times, to their patients. Asking them to change processes may seem foreign or unnecessary—something they and their colleagues don’t have time for. But we know from years of experience that using Virginia Mason Production System tools and a new management method can not only change the way an organization operates, but also dramatically alter the patient and staff experience in a positive way. With the concept of continuous improvement embedded in our culture, we know that change can energize and motivate providers—providing multiple opportunities for innovation, teamwork and accomplishments that weren’t possible with an old management system.

Virginia Mason Institute team members in our new training facility

Virginia Mason Institute team members
in our new training facility

Here at Virginia Mason Institute, we’re undergoing a new change of our own as we take our model of continuous improvement to heart. First, based on feedback from attendees at our classes in Seattle, we’re building new classrooms. With seating arrangements that allow for more teambuilding, windows that allow natural light in all the spaces, corridors that enable thoughtful time between sessions and streamlined check-in processes and refreshment stands, the new space will better serve the national and international clientele who travel here to learn from and engage with us.

We’re also updating our courses to incorporate new case studies and simulation exercises to help the lean concepts we teach continue to powerfully resonate with health care providers and leaders. In every class, we pledge to deliver an extraordinary learning experience and be sure attendees leave with a greater capacity to reduce waste, improve patient safety and increase patient and staff satisfaction. All of our work is exciting to us, and this feeds our mission to energize and motivate health care teams around the world.

What to look forward to

In addition to introducing new voices to our blog and opening new classrooms, this year we’ll be redesigning our website and debuting more ways to interact with us on social media. We want you to learn from the lean journey that we have experienced for more than a decade and that we continue to experience every day. Our enthusiasm for transforming health care knows no bounds, and we’re proud to develop more and more connections to the broader community that wants to transform health care, too. Please connect with us to let us know what you’d like to see—in the blog, in our classrooms, in our courses—as we work to continuously improve the learning journey.

The beauty of intrinsic motivation

Charleen Tachibana, RN

Charleen Tachibana, RN

“For me, leadership here is a vocation and I think that’s true for many of us.”

Charleen Tachibana, RN

A lot has been written lately about burnout among health care workers in the United States. Too much stress in too many dysfunctional organizations has clinicians and administrators on edge.

Health care is an inherently stressful business. The work flow is constant and the very nature of the work is unlike any other professional pursuit. Every minute of every day in our clinics and hospitals, patients’ lives are at stake. Every day, the people we care for come to us with challenges large and small. Many arrive in our clinics worried, fearful for their own health, or that of a loved one.

We have a profound responsibility to do our very best for each and every patient − always. And we do. From a certain perspective, this is a heavy burden. The work is difficult and relentlessly challenging. But at Virginia Mason we never see it as a burden – we see the challenges as a gift. The gift is the opportunity to care for people who truly need us. The gift is the deep trust they have in us.

This is not to suggest that we are entirely immune from the stress and pressures endemic to health care. We feel the pressure. We struggle with the challenges.

Julie Morath

Julie Morath

But we also have something within our DNA that sets us apart, and that is a deep desire on the part of our people to stay focused on the most elemental mission to help human beings who are suffering, fearful and vulnerable.

Charleen Tachibana, RN, hospital administrator and chief nursing officer, says that for most members of the leadership team the mission is about values.

“We have aligned people’s beliefs with those of the organization,” she says. “People have passion about their work. Their job is a personal mission to make a difference; to change things for the better. Some people internally describe it as a moral imperative. I can’t not do this. There is a synergy there that ignites the connection between clarity of values of the organization connected to people’s personal values.

“For me, leadership here is a vocation and I think that’s true for many of us. It’s a calling here. It’s such a gift to do it with others who are in vocations with you and want to travel there with you. For me it’s a very spiritual journey here. I can’t imagine doing it elsewhere because the risk of losing that component of it. But I would say leadership here, for most people, is a vocation. It’s a calling.”

Joyce Lammert, MD, Chief of Medicine, holds a similar view. “I think most of the leaders here are intrinsically motivated,” she says. “They’re values-driven. We have something that gives meaning to what we do every day − the opportunity and ability to comfort and heal and guide.”

Getting to a place of intrinsic motivation doesn’t happen overnight. It is developed over many years and requires a clear vision, with a mission and set of values that ring true throughout all levels of the organization. It becomes ingrained as part of the culture and is modeled and exemplified by top leadership every day.

Joyce Lammert - Virginia Mason Chief of Medicine

Joyce Lammert, MD
VM Chief of Medicine

Julie Morath joined the Virginia Mason board in January 2009. From the start, she observed the intrinsic motivation that Dr. Lammert and Tachibana describe.

There is alignment but it is not a transactional business model alignment,” she says. “It is alignment to fidelity of purpose; to deep respect for people. There is real clarity of vision and purpose. It’s a highly relational alignment based on common purpose and constancy of purpose – a real passion around that. It is different from a lot of places where alignment works because of incentives. This has a little higher order to it; higher order because people give discretionary energy. They’re not just doing the job. There is always this sense of inquiry − getting better as a way of life. When we look at the Triple Aim* and hospitals under siege, we know patients and families deserve more, society deserves more than we have been delivering in terms of value. Virginia Mason is leading the way.”

Says Dr. Lammert, “I think our people are truly aligned with our mission and vision. We have an opportunity for growth in a culture that allows you to be involved in something significant, something that makes a difference. Our vision is to transform health care. We take that very, very seriously every day. What a wonderful motivator!”

What motivates you and your teams to do the very best work every day?

* The Institute for Healthcare Improvement’s belief that new designs must be developed to simultaneously pursue three dimensions, which it calls the “Triple Aim”: improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Cutting cost of care while improving quality (part two)

“From my perspective, we all have a common purpose, and that is to return healthy and satisfied employees to work faster and more affordably.”

– Robert Mecklenburg, MD

Note: This is the second of a two-part installment looking at the Center for Health Care Solutions at Virginia Mason. This post focuses on how identifying standardized, evidence-based care for common conditions is proving to be beneficial for purchasers and the State of Washington. Part one looked specifically at how patients benefit.

Robert Mecklenburg, MD

Robert Mecklenburg, MD

Virginia Mason believes every patient should receive the best evidence-based care every time. Toward that end, it has identified 10 conditions where standardized, evidence-based care means superb quality at the lowest cost:

  • Abdominal pain
  • Asthma
  • Chest pain
  • Depression/anxiety
  • Diabetes
  • Headache
  • Hyperlipidemia
  • Hypertension
  • Acute respiratory infection
  • Urinary tract infections

For purchasers
Analysis has shown that these 10 conditions also have a negative impact on companies paying for their employees’ health care. Workers suffering from these conditions miss work, which creates an economic disruption for the employer.

Virginia Mason teams led by Robert Mecklenburg, MD, medical director, Center for Health Care Solutions, have worked closely with a variety of companies to define what constitutes quality from an employer’s perspective. This work, which Dr. Mecklenburg has been leading for 10 years, looks at care delivery not only from the patient’s point of view, but also from the perspective of the employer paying for care. The breakthrough here is the alignment of interest − defining quality so the interests of workers and employers are met simultaneously.

“From my perspective, we all have a common purpose, and that is to return healthy and satisfied employees to work faster and more affordably,” says Dr. Mecklenburg. He and his colleagues leverage primary care teams to reliably meet five performance specifications:

  • Appropriate evidence-based care
  • 100 percent patient satisfaction
  • Same-day access
  • Rapid return to function
  • Affordable price for the provider and purchaser

“The goal is to have primary care teams use a systems-based approach to clinical care for frequently seen conditions with zero defects in quality,’’ says Ingrid Gerbino, MD, faculty member, Virginia Mason Institute. “Using the clinical value streams can help restore our patients to fully productive lives in a manner that is patient-centered, efficient and effective.”

Ingrid Gerbino, MD

Ingrid Gerbino, MD

Near the top of every employer’s wish list is the ability to provide quality health care for their employees at an affordable price. Far too often this seems like a futuristic aspiration. But this approach at Virginia Mason has made it a reality, demonstrating to employers throughout the Puget Sound region and beyond that this goal is achievable today.

Another way Virginia Mason provides the finest care at the most affordable price is through its warranty for knee- and hip-replacement surgeries.

John Levesque, managing editor at Seattle Business magazine, wrote in November 2014: “Rarely does a medical institution say it will stand behind its work and not charge patients for return visits if something goes wrong.”

Levesque’s article quoted Gary S. Kaplan, MD, Virginia Mason Chairman and CEO: “Under the current reimbursement system in our country, hospitals are often paid more for surgery that does not go well than for surgery that is completely successful. We find this unacceptable and contrary to the needs of patients, employers and insurers paying the bill.”

Levesque commented that “to hear [this] being uttered by the CEO of a hospital is refreshing, rewarding and remarkable.”

For the State of Washington
The approach discussed here works well for patients and employers, and these principles have now been extended to the State of Washington through the work of the Robert Bree Collaborative. This collaborative, established by the state legislature, seeks to ensure “public and private health care stakeholders would have the opportunity to identify specific ways to improve health care quality, outcomes, and affordability.” As explained by the Bree Collaborative:

Each year, our members identify up to three health care services with high variation in the way that care is delivered, that are frequently used but do not lead to better care or patient health, or that have patient safety issues. For most topics, we form an expert workgroup to develop evidence-based recommendations.

Dr. Mecklenburg serves as chair of the work group that has developed bundled payment models and warranties for total joint replacement and lumbar fusion. The work group recently started creating a bundle/warranty for coronary artery bypass graft surgery.

“A warranty provides significant value for purchasers,” says Dr. Mecklenburg. “It means a fixed price for a transparent, standardized patient pathway and builds appropriateness standards into the bundle to avoid unnecessary surgery. Also built in is accountability for nine avoidable complications resulting in readmission to the hospital. The fixed price and warranty mean purchasers are not accountable for paying for avoidable mistakes. Virginia Mason can offer the warranty created by the Bree Collaborative because of our confidence in evidence-based, appropriate care backed up by reliable systems.”

One of the most powerful trends in health care nationwide is toward increased transparency in relation to quality and cost, and the work of the Bree Collaborative is an important step in that direction. Says Dr. Mecklenburg, “What Bree has achieved is a standard for production, purchasing and payment for the State of Washington, a standard in the public domain that is available to any provider group, purchaser or health plan, a standard created by multiple stakeholders and a multitude of contributors.”

Virginia Mason has committed to the quality standards created by the Bree Collaborative. It believes the Bree work over time will result in better, more affordable care for purchasers and patients throughout our state.

How is your organization building in standards that ensure higher quality and lower cost of services?


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