The ability of Seattle’s Virginia Mason Medical Center to respond to the COVID-19 pandemic was forged some 18 years ago with the creation of the Virginia Mason Production System, which has resulted in almost two decades of sharp focus on improving patient safety, quality and value.
“We are a learning organization, and what that means is that you have rapid-cycle improvements, rapid-cycle change management where some things work and some things don’t. Then you leverage the learning and do it again,” said Gary S. Kaplan, MD, an internist who has been with Virginia Mason for 42 years—including the last 20 as chairman and CEO of the health system.
Virginia Mason, an AMA Health System Program Partner, patterned its process from the Toyota Production System and includes their front-line workers and patients in an environment of constant improvement. It was put to use on Feb. 28 when the first COVID-19 patient was seen at the medical center. Since then, Virginia Mason has treated more than 275 COVID-19 patients at its Seattle and Yakima hospitals.
Work included creating a command center, a specific COVID-19 unit, designing and mapping special workflows and moving from “dabbling” in telehealth to providing thousands of virtual visits per week.
“We were able to do that very effectively and efficiently because of our Virginia Mason Production System work,” Dr. Kaplan said. “It allowed us to be nimble and make changes not only on a weekly basis, but—in some cases—on an hourly basis.”
For COVID-19, this meant adapting to shifting supply-chain metrics and guidance from the Centers for Disease Control and Prevention. Virginia Mason also raised its patient capacity as part of a regional pandemic response, only to have most of that growth go unused.
“I had one team member say to me: ‘Dr. Kaplan, are you speaking out of both sides of your mouth? Yesterday you told us one thing and today you’re telling us something that’s totally different,’” Dr. Kaplan recalled. “I said, ‘Yep, that’s true. What we know today is different from what we knew yesterday.’ I have often said ‘I reserve the right to be smarter today than I was yesterday.’”
A much-in-demand speaker, COVID-19 curtailed Dr. Kaplan’s ability to travel, which he now calls a “silver lining” that emerged from the pandemic.
“I came to again appreciate the importance of leadership presence and visibility,” he said, adding that he saw how well the Virginia Mason team performed under stress and how team leaders became better at managing and tolerating change—which he thinks will make for more effective leadership in the future.
Dr. Kaplan said the COVID-19 experience has changed the health care industry, though much of the impact won’t be known for months and the opportunity it created for positive change won’t stick unless its leaders leverage and harness what they learned.
One very visible impact on Virginia Mason that will bring lasting change is the explosive growth of telemedicine. The system had been on a “multi-year trajectory” of implementing the technology, but rapidly ramped up its efforts.
“We have televideo deployed across the enterprise, everything from primary care, specialty care, to surgical and procedural care,” Dr. Kaplan said. “This has been embraced.”
Telemedicine has also been fully integrated into surgical care with pre-op screening and post-op visits.
“I envision in the future that the demand for this will continue and it will be continue to be very much a part of our work here,” Dr. Kaplan said, adding that he foresees telehealth accounting for about 35% of patient visits.
For physicians looking to expedite telehealth implementation during the pandemic, the AMA created this quick guide to telemedicine in practice.
Value journey that began with back pain
Virginia Mason’s commitment to value was highlighted some 15 years ago when it worked with local payers and employers on a project to boost worker health and reduce absenteeism.
Back pain was identified as a leading cause of missed days from work, and a review of the Virginia Mason treatment plan revealed that one of the first—and most expensive—parts of that plan, an MRI, yielded little clinical value for most patients. So, it discontinued the tests and emphasized physical therapy instead—even though, at the time, the MRIs provided the only profit margin in the back-pain pathway.
“That was an important statement for us to make as an organization,” Dr. Kaplan recalled. “Even though we were a fee-for-service delivery system, we could still be serious about eliminating costs that didn’t create value even if, on the surface, it would appear to disadvantage us economically.”
The loss of revenue was offset in other ways, including getting insurance companies and employers to pay more for physical therapy (which led to expansion of the service), delaying new capital expenses because the machinery lasted longer, and improved patient satisfaction because wait times were shortened for patients who would benefit from an MRI.
“We didn’t end up losing substantive amounts of money, but what we did do is cement the lens for team members around creating value,” Dr. Kaplan said. This led to working with the Pacific Business Group on Health and several companies to become a center of excellence for spine surgery, total joint replacement and heart surgery.
“This all evolved from those first use cases around backpain and MRIs,” he said. “It was a seminal moment for us on our value journey.”
Patients play role in innovation
Patients have been invited on this journey and have become an integral part of Virginia Mason’s continuous-improvement process.
Examples of patient-generated programs include “peer partner” rounding for patients undergoing joint-replacement where volunteer patients who underwent the same surgery provide support to current patients.
“It’s a fabulous resource,” Dr. Kaplan said. “The volunteers have a wealth of information, a wealth of perspective, and our patients love it.”
The “Know Me” form was created by patients with pancreatic cancer. It lets the care team get to know them on a deeper level and find out what the patients feel is important.
Patients and family members have also helped created innovations for dealing with delirium in the hospital, alcohol withdrawal, end of life care and delivering bad news—an exercise that included role play with patients.
“It was very powerful, and they helped us realize what things resonate with patients and family members,” Dr. Kaplan said. “Physicians have a variety of styles when it comes to delivering bad news and they have a lot of variation and comfort levels. So, what this did, was make it much more objective and compassionate.”
Recruiting and hiring for fit
The commitment to continuous improvement doesn’t come as a surprise to Virginia Mason staff. They know what they are getting into.
“It’s something we recruit for, we hire for fit,” Dr. Kaplan said. “I think it’s very much in our DNA—that’s not to say there doesn’t have to be consistent messaging. But it’s part of what we do and how we lead—as opposed to it being one thing on a list with some days it’s there and some days it’s not.”
The rapid-cycle approach to improvement in day-to-day activities prepared Virginia Mason staff for the rapid-cycle response needed for the COVID-19 crisis.
“It’s a mindset,” Dr. Kaplan said. “It’s leaning into change instead of fearing change. I think we need more of that in health care.”
