Sarah Patterson informs about Lean

#qualitysummit  Another featured speaker at the Saskatchewan Health Care Quality Summit was Sarah Patterson, executive vice president and chief operating officer of Virginia Mason Medical Center, the leading adopter and proponent of Lean (or Toyota Production System) process improvement in hospitals.  Her presentation was a masterpiece of description and discussion of the Lean philosophy.  If it is posted on the web, it will be well worth your time.  In the meantime, as I did for the Jim Easton talk, I am going to post my live Twitter feeds to give you a sense of her major points.

Patterson: Using Lean provides a common language for process improvement. Small size of province offers oppty to experiment.

We understand the important role of leadership, throughout the organization.

Other orgs often talk about inability to sustain progress. Frustration of lack of stability.

Would like Va Mason org to operate like an aircraft carrier. How to run a complex business safety.

Aircraft carrier= an airport on top of a nuclear power plant comprising a bunch of 19 year olds!

Aircraft carrier needs complete alignment with the mission. If not done well, puts others at risk.


Aircraft carrier requires an incredible commitment to adoption of standard work. Relentless focus on training.

Aircraft carrier requires enforcement of accountability.

Create jobs that are doable. Train people to do them. Hold people accountable to them.

Virginia Mason story begins in 2000, looking for way to improve and assurance of accomplishing that.

Adopted TPS=customer first, highest quality, obsession w/ safety, staff engagement, successful economic enterprise

Declaration of zero defects was unheard of in health care. Essential aspect of TPS (Lean).

"Elegant" staff engagement system is inherent in Lean.

Lean 4Ps=philosophy; process; people and partners; problem solving. Not a program! A long-term philosophy.

TPS focus on process, not on the outcomes. Build key features into processes that are waste free, continuous flow.

Grow leaders. Respect, develop, and challenge your people, but also vendors (who are partners.)

Problem solving, knowing what is going on on the front lines, when problems are fresh.

AT VM, still have problem implementing and sustaining standard work, e.g., in primary care.

92% of Rapid Improv. Event results sustained after 2 months. Not good enough. Would drop further after 6 months.

Could this be because of current management system? Too much reliance based on superheroes? Great crisis mgrs?

Sterile processing superhero, knew everything, went on vacation! Surgeons left unserved!

VMason had to go back to TPS training. What did we miss?Hadn't given middle mgrs enough training about new roles.

Middle mgrs viewed TPS as an add-on, additional work with new tools. Need comprehensive mgmt system.Back to school!

Need regular management presence where the work happens. A transparent environment. Clear and complete goals.

Mgmt by policy + daily mgmt + cross-functional mgmt = world-class mgmt system.

Management by policy = long term vision, 5 year plans, annual goals.Reflection.Share environmental scan with all.

Mgmt by policy: One stage is "Catchball." Draft of policy shared deeply in the organization. Get feedback.

Catchball staff engagement, shared with 1000 people last year. Next year, 5000.

Deployment. Need process for negotiating what is effective work, resources required, and people's commitment.

More careful scoping of projects is an imp discussion to have in the organization. Signoff by key people.

Multiple executives responsible for projects. E.g., CFO responsible for safety improvements!

Regular mtg for check and review. Short updates. Who needs our help?

Cross-functional work is essential. Where creativity really happens. Blame for silos lies with the top leaders.


(Me) Review what she says to see a fundamentally different role for leaders.


Daily mgmt: Know at a glance status of work. Satisfying customer demand? Std work being followed? Engaging staff?

If our front line staff are telling us it is bad, do we know this? Are we acting to help fix it?

Leaders' 2 jobs. 1 -- Run your business, while ensuring stability. 2 -- Improve your business.

Start with understanding your demand; and knowing your supply; standard work developed and posted.

Track your business on a HOURLY basis, or you can't understand process flaws and improvement opp'ties.

Everybody on the floor needs visual cues as to status of work and meeting customer demand. In real time!!!

Every hospital needs in-the-room nurse-to-nurse bedside handoff. Every time.

Toyota cord-pulls, happens often. 30 second response by leader to be on worker's side.

In hospitals, too, need real-time ID of problems and responsiveness by leader. At the work station!

Elements of daily management = leader standard work + visual controls + daily accountability process + discipline.

Whoa! Leader standard work, too! What a concept. Can't be "too busy" for this!

With leader standard work made visible, staff now know, "Oh that's what leaders do!"

Visual controls focus on the process and make it easy to compare expected with actual performance.

At Virginia Mason, patients can see the visual controls in the waiting rooms -- e.g., MD-specific delays.

If MD gets behind by more than 10 minutes, resources are brought to bear to provide support and get back on sched.

Other visual cue examples.Note: Not sophisticated computer reports.Just white boards with stickies! In real time!

Gives list of foundational elements of hospital nursing care. Every unit, every day. Auditing process, too!

Choreographed and sequenced system of daily accountability. All units have daily huddle.

Daily accountablity. PeopleLink Board used for 30 minute stand-up meeting once a week.

Senior leader regular gemba rounds to view one aspect of standard work.

"I'd rather have no board rather than an out-of-date board. They have to be real."

Email from Amy, "I'm just a biller, but I look forward to every Thursday morning at 7:30."

Amy, "We have a common purpose and a common language."

Audience Q:  Recruitment. Didn't want people who had all the answers. Looked for curiosity. Learners. Communication skills.

Created leadership development curriculum to develop competencies, but look for innate characteristics.

Audience Q: How to take current work off the plate? A: Take things away (reports) that are needed. But don't wait.

Things that used to take leaders a lot of time don't take time, because of connection to staff, issues tracking.

"Just tell them to do it. Don't be afraid. It won't be perfect. Try it. Fail. Try it. Change. Keep going."

Jim Easton inspires

#qualitysummit Jim Easton, national director for improvement and efficiency of the National Health Service, was the keynote speaker last night at the Saskatchewan Health Care Quality Summit.  (You see him here with Bonnie Brossart, CEO of the Health Quality Council.)  His was one of the most engaging and inspirational speeches I have ever heard on the topic.  I think it might be available on line in the future, but I wanted to present a summary here.

I think I'll do it, though, by just reposting my Twitter comments as the speech was delivered.  (You can also see them by searching using the hashtag above.)  While not doing full justice to Jim's eloquence, you'll get the drift.

Jim Easton tells Sask that they are doing great work - truly remarkable. But that's just the beginning. It's hard work!

It is tough to change attitudes and practice. Despite the commitment of people, a paradox.

Universal system really matters to UK and Sask. We need to remind people that we are protecting that. A leadership responsibility.

Improvement of health delivery system is the most important task in society. 

Cost reduction. Quality revolution. Patient empowerment. Three aspects of paradigm shift.

We the people running health care are killing it (costs) so we have responsibility 2 change it.

We have a responsibility to fix the unsustainability of the health care system

Easton aiming to save 20 billion pounds by 2014 for NHS! 

The cost problem is an ethical issue. Money is medicine.

Quality revolution. Examples of success exist but health care is still not a self-improving industry.

Shameful not to share clinical quality information.

Quality improvement driven by front-line is powerful. But we need to improve the improvement, to make it better.

We have ethical obligation to share information about how well health care system is performing.

We need to spread and increase the rate of improvement. Rate of both is 2 slow.

We love to hear from patients when they praise us! Easton. But we need to hear criticism better.

Criticism can be attributed to "difficult people." We are still early in this journey of listening.

How 2 accelerate change? Need to use all levers in a coordinated fashion. Leadership for change is one. Need skills.

Leadership is not an amateur sport! Need disciplined development.

Two: you need a plan for spreading innovation.

Three: have an improvement method like Lean. Common language. Skills will spread.

Four: engagement to mobilize. Communication. Have to tell the story of change right.

Tell the story over and over. 100 percent of ur time. Relentless communication.

Five: use system drivers and align with the desired changes. Money, salaries, investment. People spot those things.

Six: transparent measurement. Morally right. Powerful tool for change.

Seven: rigorous delivery. E.g. Waiting time. Link this to quality improvement.

Need to improve ourselves as leaders. Be intolerant of mediocrity, to hate it. Reject normative levels of harm.

It is not ok to be in the middle of the distribution of the number of people we are killing.

It is uncomfortable to be the person saying we are not doing well enough.

Easton says he's been called bully for saying good enough isn't good enough when it comes to quality, safety.

Be a personal champion of spread.

Harness the good difficult people. Deal with the bad difficult people. Don't allow blockers to block. Tackle this.

Staff always responds well in a crisis. Need to give value to calm ordered care.

Runs of routine success are what matters.

Reward ordered routine care.

Improving ourselves as leaders: This is hard. Get support.

A visit to gemba at Royal University Hospital

Regular readers know of my practice of going to gemba when I am visiting a hospital.  It is my way of looking at work processes in different places.  If you are interested in process improvement, you can never see enough examples of this.  In turn, I like to present summaries to you, my readers, not to draw negative conclusions about the institutions involved, but rather to demonstrate the common need for process improvement across the hospital world.

This week, while I was in Saskatoon for the Health Care Quality Summit, my hosts graciously arranged for me to spend some time shadowing Therese, a unit clerk in the emergency room of Royal University Hospital, an excellent institution operated by the Saskatoon Health Region.  The SHR, along with the rest of the province, has made a strong commitment to the Lean process improvement philosophy.  Lean will be rolled out over the coming years.  Given the early stages, it has not yet been fully adopted everywhere, and so I got to see the "before" view of things in the ER.

Therese is a dedicated and hard-working person who faces a large variety of tasks in the ER.  She handles telephone inquiries of all types.  She helps coordinate the collection of specimens and their delivery by pneumatic tube to the laboratory.  She compiles patient records.  (These are paper records, as an electronic system has not yet been put in place.)  She also takes care of linen changes and wiping down of the patient care bays in her section of the ER.

As I sat with Therese, I was amazed at her energy and sense of organization.  She truly holds the place together in many ways.  And yet the underlying work flows that she must carry out offer prime examples for the kind of redesign that will surely come when Lean arrives.

Here's an example.  When a patient is discharged from the ER, a copy of the patient's record -- known as the back copy -- is kept in the ER for two weeks in the event the patient returns.  If and when the patient returns, Therese flips through the accumulated stack, looking for that record, and then attaches it to the current patient file.  Also, if a bacterial culture has been taken for a patient, the lab result generally is returned after the patient has left.  Therese has to find the back copy, onto which she attaches the lab report, leaving it for a doctor to review in the event a change in treatment (e.g., a new anibiotic) is called for.

If Therese cannot find the back copy, she has to call to the medical records department and ask them to fax a copy to her.  The problem is that the back copies are stacked up in an unpredictable order, so Therese has to flip through them to try to find the correct patient record.  This ends up taking an inordinate amount of her time -- 2 to 3 minutes each time -- unless she is interrupted by a phone call or something else, at which points she has to start over again.  This little video gives you a sense of the current process.


When you add up those multiple 2-3 minute tasks and calculate how much cumulative time is spent on this alone, you can see how -- some Lean day in the future -- this and other parts of Therese's life in the ER will be improved.

If you cannot see the video, click here.