Driving for efficiency: Saving time and money while boosting quality

Virginia Mason Medical Center in Seattle got its philosophy of a lean production system from an unlikely source -- Toyota.

By Mike Norbut — Posted Oct. 3, 2005

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Crammed into a space only slightly larger than an exam room, eight Virginia Mason Medical Center employees -- including its CEO, an interventional cardiologist and a resident -- agonize over such hospital issues as equipment set-up and phone protocols -- topics not usually subject to detailed analysis.

But at Seattle's Virginia Mason, each movement of each employee adds value or contributes to waste, and nothing is too trivial to ignore.

During this week in August, group members are looking at how to shorten the time it takes a patient who enters the hospital with a heart attack to get an emergency angioplasty. The goal is to trim it from a 100-minute average to 50 minutes.

"We actually say to the team, 'No new people, no new space and no new money,' " said Gary S. Kaplan, MD, Virginia Mason's chair and CEO. "And you cannot say, 'You can't do that.' "

Every second matters, and Virginia Mason leaders prove it by timing employee tasks. The goal is to trim away unnecessary actions, leaving a lean system that saves lives and money.

If it sounds like a strategy for factory workers, it is. Virginia Mason leaders got their inspiration from the Toyota Motor Corp., which teaches its lean production principles around the world.

Toyota's concepts were developed in the late 1940s and early 1950s by its then-assembly manager, Taiichi Ohno, at a time when Toyota was teetering on the edge of bankruptcy and couldn't afford major investments or more employees. The concepts are designed to increase efficiency and raise quality, while at the same time improving customer and employee satisfaction.

Until recently, Toyota's pupils were other big players in the manufacturing industry, but Virginia Mason and a handful of others have proven that the method can apply to health care as well.

With the patient as its focal point, the hospital strives for efficiency instead of speed, quality instead of quantity, and a bottom line that's driven as much by cost reduction as it is by revenue.

Lean production is ingrained in the hospital's culture, and it's evident in employees' everyday language. They mention lessons taught by their sensei, they call the hospital gemba, a word for a manufacturing shop floor. There are weekly kaizen meetings, workshops geared to maximize efficiency in a specific process.

"One of the things people say is, 'How dare you apply the principles of building cars to caring for patients,' " said anesthesiologist Robert A. Caplan, MD, medical director of quality for Virginia Mason. But those principles center around efficiency and quality outcomes.

The idea of the Toyota system goes beyond just being lean, said Steve Spear, a senior fellow at the Institute for Healthcare Improvement in Cambridge, Mass. It's based on developing a self-diagnosing, self-improving and self-correcting system in which the business actually learns how to perform the job better as it's doing it.

Whether the concepts become mainstream in health care remain to be seen, but you don't have to be an industry giant to implement some of these ideas, he said.

Spear told the story of one primary care practice in Boston that improved its efficiency just by tracking and eliminating some of impediments, such as poorly located equipment, and miscommunications that led to wasted time.

Over a span of a few months, the practice implemented minor changes that, combined, made a noticeable difference for physicians and patients.

"You can definitely do it on a small scale as well as a large scale," Spear said. "The key theme is letting the problems tell you where the improvement areas are."

Learning the system isn't easy. Virginia Mason, with about 350 hospital beds, 400 physicians and more than 5,000 employees, sends its leaders to Japan annually for lessons on lean operations.

The system has help put the facility, which struggled through several years of losses in the late 1990s, back on track financially. Virginia Mason, which started searching for a unique production system to match its quality vision in 2000, reported positive income years in 2003 and 2004. Lean production also has saved the hospital space and the staff wasted steps.

No problem is too small for lean operation. The hospital has a department dedicated to organizing and supporting the weekly kaizen meetings.

Sometimes the groups discuss something as minor as standardizing a desk drawer, so an employee can sit at a co-worker's desk and know where everything is. Or they can tackle issues such as emergency response team protocols.

The leaders encourage employees to be a part of the system. The hospital has a "no layoff" policy, so employees do not feel they are targets for cost-cutting, and it solicits feedback from people from throughout the medical center.

It's not about making people, including physicians, do more work. Instead, it's about giving them the tools to use their time more efficiently, Dr. Kaplan said. "We're reducing the burden of work. We're creating time for them to get home early for dinner, spend time on research with a colleague or spend more time with their patients. We're trying to create value-added time."

The turnaround has not come without its own morale costs, however. Leaders at Virginia Mason acknowledge that convincing physicians to embrace the philosophy has not been easy. Some doctors, including section heads and other high-placed medical leaders, have left Virginia Mason.

Others are sticking with it, with mixed results. Gastroenterologist Drew B. Schembre, MD, who has been with Virginia Mason for seven years, has seen the medical center gain efficiency in many areas, but "paradoxically, I'm busier now."

"When you get more productive, there's always more to do," Dr. Schembre said. "I don't always get home for dinner."

The concept of standardization causes some physicians to bristle, although many realize that "relinquishing some autonomy and some ego" is "ultimately for the greater good," he said.

That good comes in the form of data, improved quality and a safer facility. For example, by implementing a set of standard intubation procedures, Virginia Mason has been able to cut its cases of ventilator-acquired pneumonia. It reported 34 in 2002 at a cost of about $500,000, compared with only four cases and a cost of about $60,000 in 2004.

Of course, these cost savings represent patients getting healthier more quickly and more safely. Although patient safety has been at the forefront, there is still progress to be made.

Physicians at Virginia Mason say if the Boeing Co., another major Seattle-area employer, were held to the same safety standards common in health care, people would be afraid to fly. But in health care, safety is not a result of properly installed widgets. It's an ongoing process based on constant communication, technological advancement and a certain human, caring touch, they say.

"There's this mythology that you get what you pay for, and if you pay more, you'll get better quality care," Dr. Kaplan said. "It turns out, when you cut out the costs by reducing waste, quality and safety go up."

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How lean production works

At Virginia Mason Medical Center, a wide range of lean concepts have been put into practice.

Operating room shadow boards: Anesthesiologists place a disposable shadow board on their equipment tray that has full-size images of tools necessary for each procedure. It's a standard set of photos, so the physician doesn't have to spend time trying to remember minute details when he or she should be concentrating on the work at hand, said Robert A. Caplan, MD, an anesthesiologist and medical director of quality for Virginia Mason.

"Imagine an anesthesiologist getting up at 3 a.m. and trying to remember everything," he said. "Setting these things up for a case is not a skill that takes a doctor. It's better for the physician to spend his or her time with the patient."

Center for Hyperbaric Medicine: The center, which uses oxygen therapy to treat patients with carbon monoxide poisoning, decompression sickness and chronic wounds, among other conditions, uses a kanban system, where patients guide themselves through the registration process. By posting colored, laminated cards, patients can tell when they have arrived, when they're ready for a physician or if they are in treatment.

Floyd & Delores Jones Cancer Institute: The new center, which opened earlier this year, was designed with the lean production system in mind. It employs a pod concept, so the exam room, physician office and scheduling desk are near each other. And rather than sending patients to different departments when they come for chemotherapy treatment, the hospital brings all the services to the patient.

"Fatigue is a common symptom of chemotherapy treatment, so it's important for patients to minimize the amount of time they spend hiking around," said Andrew D. Jacobs, MD, chief of Virginia Mason's Dept. of Cancer Care.

Also, instead of tying up millions of dollars by purchasing chemotherapy drugs months in advance, the medical center uses a just-in-time inventory approach, cutting its supply to a fraction of what it once was. The system requires employees to be disciplined when it comes to signaling that the cancer institute is running low on a certain drug, and it asks suppliers to be responsive and make more frequent deliveries.

Ticket home: The hospital's Acute Care for the Elderly, or ACE, unit used to experience communication problems, in which physicians, nurses and others would be asking patients the same questions. And no one, including the patient, knew exactly when he or she would be able to go home. So the hospital installed a dry-erase board in each room with a checklist of medical and functional goals, such as self-feeding and bathing, to put everyone on the same page. The goal is to get patients home as quickly as possible. "We have 16,000 discharges a year and a full hospital," said A. James Bender, MD, an internist and medical director of hospital services for Virginia Mason. "If we can shave one hour off each discharge, that's 16,000 hours. That's a number of patients."

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