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Transforming Culture, Transforming Care

March 23, 2011
by Mark Hagland
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Virginia Mason's Groundbreaking Journey to Healthcare Reform

In Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience, a new book published by Productivity Press, noted author and journalist Charles Kenney recounts the compelling story of how leaders at the 336-bed Seattle academic medical center took a hospital organization with pressing financial and operational challenges, and followed a unique path, embracing principles absorbed from the Toyota Corp. and translated them into healthcare-specific concepts and results.

As Kenney documents, the Virginia Mason transformation began a decade ago with Gary S. Kaplan, M.D., Virginia Mason's chairman and CEO. Kaplan led other senior leaders at Virginia Mason Medical Center (VMMC) on a journey that was both conceptual and literal, at one point flying about 30 senior leaders of the organization to Japan in June 2002 to observe the Toyota Production System in action and to determine how to begin translating its principles into what eventually became the Virginia Mason Production System. Within a few years, VMMC leaders had turned the organization around organizationally, financially, and above all, with regard to patient safety and care quality. It has won numerous national awards and recognitions for the hospital's quality, and has established an institute (the Virginia Mason Institute) for healthcare organizations wishing to follow in VMMC's path.

Recently, Kaplan spoke with HCI Editor-in-Chief Mark Hagland regarding the cultural transformation that has taken place at VMMC, and the role of information technology in facilitating clinical and operational transformation. Below are excerpts from that interview.

Healthcare Informatics: What were some of the major early insights you had, in terms of the potential for healthcare leaders to learn from the quality transformation success stories emerging from other industries?

Gary S. Kaplan, M.D.: In fact, that was one of the biggest early insights [the revelation of innovative practices that could be transferred from other industries to healthcare]. There are a lot of innovations in this [performance improvement] work, and there's a lot of out-of-the-box thinking taking place. And number one was the realization that our own industry did not have all the answers; not only that, the industry was unconsciously a part of the problem or set of barriers we needed to break through. So the lesson is to be willing to first listen and then next educate ourselves in the methods of manufacturing, and really deepen our knowledge, and realize that there were things in there that had applicability to our world and our patients and their families that was like a huge breakthrough.

Another insight, which was articulated quite well in the book-and this occurred before we discovered the Virginia Mason Production System-involved determining who really was our customer, and getting clear about what it truly means to really put the patient at the top. That's something that's ongoing, because the norm in healthcare is so deeply ingrained, and we're so acculturated, that it's an ongoing challenge, but critically important; because before we could look at other industries, we had to realize we were not the customers. Another area was the compact work. Aligning expectations, having the deep conversations, took months, but we recognized that if we wanted to lead widespread change, we had to have those kinds of challenging conversations. And another big one was declaring the Virginia Mason Production System to be our production system. It was how we were going to think, how we were going to run the place; it wasn't a ‘one-off' quality initiative. And finally, changing the minds of senior leadership as a prerequisite to change; that's why we took the whole team to Japan.

HCI: Early on in the process, long before you had established what became the Virginia Mason Production System, and the local paper published a story about your taking the team to Japan, how did you feel?

Kaplan: We were already close to closing on our bet-the-farm strategy. And it didn't feel good, but it actually allowed us to have some conversations we might not otherwise have had.

HCI: It's clear from the book that one of the challenges you faced is the underlying problem of the non-system-ness of the healthcare industry, which remains very ‘mom-and-pop' in its orientation, even as it surges beyond 17 percent of U.S. GDP.

Kaplan: That's right; that's part of the battle. And that's why I think this book could potentially provide some leverage; because we've got some serious issues in healthcare, and we need the public to understand what they are. In fact, there are plenty of people in healthcare betting on the naiveté or the impenetrability of the public to not be able to change their thinking. So I want the public, and particularly the employers, to understand not only that they have skin in the game, but that they also have lots of power.

HCI: There's a lot in comprehensive healthcare reform that speaks to what you've achieved at VMMC.

Shown above is Virginia Mason Medical Center chairman and CEO Gary S. Kaplan, M.D., (right) on the factory floor in the Hitachi Air Conditioning Systems plant in Shizuoka, Japan. Kaplan and about 30 of the top leaders of VMMC flew to Japan in June 2002 to learn about the Toyota Production System (TPS), and see its principles demonstrated in action. With Kaplan is TPS sensei (master) Chihiro Nakao.
Virginia Mason Medical Center

Shown above is Virginia Mason Medical Center chairman and CEO Gary S. Kaplan, M.D., (right) on the factory floor in the Hitachi Air Conditioning Systems plant in Shizuoka, Japan. Kaplan and about 30 of the top leaders of VMMC flew to Japan in June 2002 to learn about the Toyota Production System (TPS), and see its principles demonstrated in action. With Kaplan is TPS sensei (master) Chihiro Nakao.

Kaplan: I'm a very big supporter of healthcare reform; Don Berwick [federal Centers for Medicare and Medicaid Services administrator Donald M. Berwick, M.D.] was just here visiting. And I'm on the board of IHI [the Cambridge, Mass.-based Institute for Healthcare Improvement, which Berwick founded and led for many years]. And I think reform in general, and particularly the CMS Innovation Center, really is potentially about the ‘beef' here, about creating alignment with the incentive world, that we need to do.

CHANGE FROM A PHYSICIAN VANTAGE POINT

HCI: You're a physician by background. How has that influenced the strategic path you've helped lead the organization on?

Kaplan: I'm a physician by daily work, still practicing as an internal medicine doc. I see patients Monday and Thursday mornings; that's important to me. It helps me to be a better leader, for sure. It gives me additional credibility with the other physicians, particularly over issues like putting in a new CPOE [computerized physician order entry] system, and so on.

HCI: Physicians have historically been trained in a lone-wolf medical culture. How have you and the other senior leaders at Virginia Mason helped to change that culture, as you've moved towards systems thinking and continuous performance improvement?

Kaplan: We built this in a culture that had some traditional elements in it, but that also had a history of collaboration and teamwork, which helped.

HCI: Looking industry-wide, where are we in terms of physicians accepting the new reality of healthcare, which involves more accountability, transparency, systems thinking, and collaboration?

Kaplan: Two or three years ago, we were at a 1 on a scale of 1 to10; now we're at about a 3. And a lot of the handwriting is on the wall; a lot of the payment is changing. So some will be kicking and screaming; but I see a lot more attention from the AMA [American Medical Association] and from state medical societies to the changes. And, for the first time in their history, at their 22nd annual meeting, the IHI had a track specifically devoted to Virginia Mason, for those interested in clinical transformation. We had 13 presentations and posters. So there was a lot of interest. So what I hope is that the book, and our journey, and the Virginia Mason Institute, will show what's possible. I sent a copy to President Obama. I hope our work shows what's possible and can be an inspiration to others, while we continue to make changes.

THE IRREDUCIBLE IT COMPONENT

HCI: You can't sustain important, systemic change without the facilitation of data and of information technology, correct?

Kaplan: Yes, that's correct. And I see IT as a critical tool that allows our redesigned processes to truly flow, and allows our desire to sustain zero-defect processes to continue to thrive. But you can't automate bad processes; you have to redesign your work first.

HCI: But the data will help you as you determine where the flaws are, and then create a continuous feedback loop, don't you agree?

Kaplan: Yes, the data comes first; and IT can help eliminate manually based errors.

HCI: What would you say to the Doubting Thomases out there about creating this kind of change?

Kaplan: I would say that you have to realize that the status quo is unsustainable, and that we as leaders have an obligation. And that management courage, leadership courage, is probably the single most important thing you need to have. And that leaders can become champions.

Healthcare Informatics 2011 April;28(4):44-46


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