- Email: [email protected]
An Interview with Gary Kaplan
The Joint Commission Journal on Quality and Patient Safety John M. Eisenberg Patient Safety and Quality Awards
An Interview with Gary Kaplan Interviewed by Cathie Furman, R.N., M.H.A., Senior Vice President of Quality & Compliance, Virginia Mason Medical Center, Seattle.
Gary S. Kaplan, M.D., a practicing physician, is Chairman and Chief Executive Officer of Virginia Mason Medical Center, Seattle. Please address correspondence to Gary S. Kaplan, [email protected].
What were the defining moments in your career when patient safety was not just a catch phrase? My journey as a leader in the patient safety movement really started in 1996 when I was asked to chair the American Medical Association’s Group Practice Advisory Committee. In conjunction, I was asked to be part of the founding board of the National Patient Safety Foundation. At about the same time, I participated in the first Annenberg Conference [“Examining Errors in Health Care: Developing a Prevention, Education and Research Agenda”]. All these events began to inform my deeper understanding of the issues and need to approach health care differently. Of course, patient safety has always been important, but until the Institute of Medicine’s 1999 report To Err Is Human1 revealed the astounding number of preventable errors in our system, I don’t think anyone truly felt an overwhelming sense of urgency. Another key factor was that in 2001 the Virginia Mason Board drafted a new strategic plan. As part of that work, we addressed the explicit fact that health care systems were designed for us—the providers—instead of for the patients. At that point we committed to making the patient our top priority. This strategic planning process challenged us to always ask the question “What is best for our patients?” It may seem obvious, but we recognize that what is best for our patients is to receive the highest quality of care, and the foundation of quality is safety. From there we sought a management method that would help us achieve our vision to be the quality leader. We looked everywhere in health care and visited organizations throughout the country. Serendipitously, we found the Toyota Production System through our friends at Boeing, and we modeled our management method, the Virginia Mason Production System (VMPS), after Toyota’s relentless focus on the customer, quality, and safety. 584
December 2009
Virginia Mason is well known for its work with VMPS. Can you talk about how the management method affects quality and patient safety? VMPS is really very much about quality and patient safety. At the core of our VMPS work is making the safest patient experience possible and removing the waste that doesn’t add value for our patients. When you find and eliminate defects, quality and safety are improved. VMPS is the management system we use to do our work. Virginia Mason leaders had an “ah-ha” moment around patient safety on a trip to Japan. Can you talk about that? Probably the most powerful tool we brought back from Japan, on our first trip in 2002, was the “stop the line” concept. At Toyota, every 58 seconds a car is driven off the assembly line, and every 58 seconds a car enters a workstation, and the individual worker does whatever it is he or she does. But if he can’t get his task done because a part’s missing, something’s loose, there’s a defect—he pulls a cord, and the line slows down. If he still can’t do it, he pulls the cord again and the whole assembly line stops. Think about that—350 workers, every single one of whom is empowered to stop the assembly line and shut down the factory. Then all the supervisors converge on the site and fix the problem before it’s passed on downstream. In conventional manufacturing they keep the line going and inspect the products afterward. If there’s a problem, they send it upstream and fix it, but in the meantime how many defective products have been made? The way it is traditionally done in health care is even worse. There is retrospective quality assurance. Two months after the fact, a retrospective quality audit or chart review will be done, for example, and find that something should have been done differently—two months ago. Meanwhile, how many more people have been harmed?
Volume 35 Number 12
Copyright 2010 Joint Commission on Accreditation of Health Care Organizations
The Joint Commission Journal on Quality and Patient Safety Our “ah-ha” moment came as we watched a worker pull the cord and stop the line. We asked the question “If Toyota does this for cars, shouldn’t we be doing this for our patients?” We wanted to have real-time quality assurance at Virginia Mason, so we put in place our Patient Safety Alert (PSA) system™–our health care version of stop the line.2 We said that every single staff member is a patient safety inspector and is empowered to stop any process or situation that might cause harm to a patient. The PSA system demonstrates to our staff their concerns will be taken seriously and therefore encourages more reporting. We can’t fix what is not known. We are dependent on everyone being inspectors and signaling when there is a problem that needs fixing. To date, we’ve had more than 14,000 PSAs. While it may seem counterintuitive, we think the more PSAs we generate, the safer care is here. Why is there such concern in health care around reporting errors? The health care culture has long been a hierarchical and blaming culture. I was taught as a resident that it was my responsibility to double-check my work and that errors were not really talked about. There was no recognition that I was working in a complex broken system that was leading me down the wrong path in some instances. Today, too many residents and nursing students are still taught that if you try hard enough you won’t make mistakes. But we know that is not true. James Reason taught us years ago that humans make on average six errors a day.3 We need to change the way students are taught from a focus on individual responsibility to a systems and team approach. Virginia Mason is currently partnering with the Institute of Healthcare Improvement Open School and the Alliance for Independent Academic Medical Centers (AIAMC) to develop a patient safety curriculum that all of our residency program participants will be required to complete. You frequently talk about seeking perfection and transforming health care. Is that really possible? When I became CEO in 2000, health care was much the same as it is today: expensive, rising costs, defect- and errorprone care and access unavailable to many. The health care industry has a defect rate of 3% or more, a rate unacceptable in any other industry. Defects really can be anything from appointment scheduling errors to wrong-site surgery. Of course, when a defect happens to me or a family mem-
December 2009
ber, the defect rate climbs to 100%. No one cares that the other 97% of patients got defect-free care. Zero is the only acceptable rate of defects. Perfect care must be our goal. I realize that our dreams are audacious. There is no perfection in human affairs, after all. And to declare that we think we can play a vital role in the transformation of the entire industry, well, it sounds very bold, to say the least. But we must be bold for true transformational change in health care. I think now is the time for new ways of thinking, and we think the work we’re doing at Virginia Mason can be a key to success. It’s impossible to talk about patient safety without citing Virginia Mason’s tragic accident in 2004 with the death of Mary McClinton, which was caused by preventable medical error. How did you make the decision to go public and apologize? When Mrs. McClinton came to us for a routine tertiary procedure, we were about two-and-a-half years into our journey with VMPS. We failed her. She died of a preventable error. It was the deepest, darkest time in my career and in our organization’s history. As soon as we found out what happened, we told our staff and then went public with the news. In addition to our local media, the story hit national airwaves on Good Morning America, and Reuters picked it up. We received lots of expressions of concerns, appreciation, and some criticism. Going public was worth it. About a month later, we received a phone call from the state Department of Health. The survey manager told us that every hospital they had surveyed since the event told them that the same situation was present. When they read about the tragic error, every single hospital made changes to labeling medication solutions. Interestingly, we learned that several months earlier the same mistake had occurred in another hospital in Seattle and that it had been kept quiet. That made it clear to us that we had done the right thing by admitting our mistake publicly. We knew if this could happen to us, where our intense focus is on quality and patient safety, this could happen anywhere. What do you think the single easiest thing every hospital or clinic could do to make significant strides in patient safety? Listen to staff. The people on the front lines know more about the potential for errors and the risks to patient safety than anyone in an office. And a close second is to get leaders out of their offices. Genchi genbutsu means “go and see for yourself.” Traditionally, leaders spend most of their time in their offices, in meetings, in conference rooms, looking at spreadsheets. At Virginia Mason, we are working to spend less time in meetings and more time on the “shop floor”—the lab, the OR, the crit-
Volume 35 Number 12
Copyright 2010 Joint Commission on Accreditation of Health Care Organizations
585
The Joint Commission Journal on Quality and Patient Safety ical care unit, the clinic—because that’s where it’s happening. Go see for yourself. And don’t go out there as the boss who knows everything. Because you don’t. It’s OK to be vulnerable. It’s OK to show you don’t know something. How do you elevate the importance of patient safety among physicians? Long before we began our work with the Toyota system, we knew that we needed to change the way we communicate. The most important change was that we needed to actually tell the truth and shine a bright light on quality, safety, processes, economics, costs, and behavior. We needed to have honest conversations with our physicians and really understand what transparency means, not just pay lip service to the concept. As physicians began to understand the magnitude of the safety issues and understand their impact on patients and their families, the focus on safety became more compelling. VMPS and the PSA system gave our physicians a way to talk about patient safety that is all about understanding the current state and then envisioning and implementing a safer future state. The cultural changes are very significant, and we spent time, even prior to VMPS, working on our physician and leadership compacts to better align our teams and our organization. A key part of Virginia Mason’s vision is to be the Quality Leader. What does Virginia Mason actually mean by quality? Q = A × (O + S) W This is our Virginia Mason Quality Equation. It says, Quality is Appropriateness times Outcomes plus Service divided by Waste. It used to be our “value” equation and the W was a C for cost. It used to be divided by Cost. The way we often manage in health care is to tell all department managers to take 2 % out of their budget. We don’t care how they do it. Well, we realized that if we just cut out cost, more often than not we’re reducing quality. What we’ve learned is that if we reduce cost by reducing waste, which is what VMPS is all about, we actually improve quality. The other side of the coin is appropriateness. We can do the best surgical procedure, we can have a great outcome, we can delight the patient and his or her family with great service, we can even do it efficiently with no waste. But if the patient didn’t need it to begin with, there is no quality. We know that this happens all too often. Virginia Mason’s board received the first Leapfrog Governance for Quality Award in 2008. How did you get the 586
December 2009
board engaged in quality? Great question! This work must start in the boardroom. Many of us in health care have a public board of community members. In their role, they commit to representing the voice of our patients and the community. Our board at Virginia Mason has really taken this to heart. During our strategic planning work in 2000, it was our board members that helped define our business strategy for the pursuit of quality. To this day, they continue to be supportive and engaged in this work. Our board dedicates at least a third of its time on quality and patient safety. Having shared experiences helps tremendously too. Most of our board members have traveled to Japan with us, learned VMPS tools alongside us and worked with us to improve the patient experience at Virginia Mason. Another key to our success with the board has been open, honest dialogue. How many organizations truly share their successes and failures with their public board members? Our board members actively participate in the review of patient safety alerts. So much so that any major alert must be presented and the resolution explained to the board’s quality oversight committee before the matter can be closed. I am so thankful for the board we have at Virginia Mason. When I talk about our journey, the conversation starts with the fact that our board challenged us to think about the patient first. Our board knows there is nothing more important. You’ve said before that this journey has only begun. How do you maintain gains in patient safety and quality and how do you keep patient safety and quality a priority? Our journey is about building deep organizational capacity for change, capacity for leadership and managing through VMPS. Every single one of our staff—all 5,000 people–is trained in the fundamentals of VMPS. It is a long journey, and we have made huge progress. We still have a long way to go. It requires a constancy of purpose at all levels of the organization—from the boardroom, the leadership, and the staff. The willingness to listen to the voice of the patient is what keeps us moving forward. J
References 1. Institute of Medicine: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999. 2. Furman C., Caplan R.: Applying the Toyota Production System: Using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf 33:376–386, Jul. 2007. 3. Reason J.: Human Error. New York City: Cambridge University Press, 2000.
Volume 35 Number 12
Copyright 2010 Joint Commission on Accreditation of Health Care Organizations
An Interview with Gary Kaplan Interviewed by Cathie Furman, R.N., M.H.A., Senior Vice President of Quality & Compliance, Virginia Mason Medical Center, Seattle.
Gary S. Kaplan, M.D., a practicing physician, is Chairman and Chief Executive Officer of Virginia Mason Medical Center, Seattle. Please address correspondence to Gary S. Kaplan, [email protected].
What were the defining moments in your career when patient safety was not just a catch phrase? My journey as a leader in the patient safety movement really started in 1996 when I was asked to chair the American Medical Association’s Group Practice Advisory Committee. In conjunction, I was asked to be part of the founding board of the National Patient Safety Foundation. At about the same time, I participated in the first Annenberg Conference [“Examining Errors in Health Care: Developing a Prevention, Education and Research Agenda”]. All these events began to inform my deeper understanding of the issues and need to approach health care differently. Of course, patient safety has always been important, but until the Institute of Medicine’s 1999 report To Err Is Human1 revealed the astounding number of preventable errors in our system, I don’t think anyone truly felt an overwhelming sense of urgency. Another key factor was that in 2001 the Virginia Mason Board drafted a new strategic plan. As part of that work, we addressed the explicit fact that health care systems were designed for us—the providers—instead of for the patients. At that point we committed to making the patient our top priority. This strategic planning process challenged us to always ask the question “What is best for our patients?” It may seem obvious, but we recognize that what is best for our patients is to receive the highest quality of care, and the foundation of quality is safety. From there we sought a management method that would help us achieve our vision to be the quality leader. We looked everywhere in health care and visited organizations throughout the country. Serendipitously, we found the Toyota Production System through our friends at Boeing, and we modeled our management method, the Virginia Mason Production System (VMPS), after Toyota’s relentless focus on the customer, quality, and safety. 584
December 2009
Virginia Mason is well known for its work with VMPS. Can you talk about how the management method affects quality and patient safety? VMPS is really very much about quality and patient safety. At the core of our VMPS work is making the safest patient experience possible and removing the waste that doesn’t add value for our patients. When you find and eliminate defects, quality and safety are improved. VMPS is the management system we use to do our work. Virginia Mason leaders had an “ah-ha” moment around patient safety on a trip to Japan. Can you talk about that? Probably the most powerful tool we brought back from Japan, on our first trip in 2002, was the “stop the line” concept. At Toyota, every 58 seconds a car is driven off the assembly line, and every 58 seconds a car enters a workstation, and the individual worker does whatever it is he or she does. But if he can’t get his task done because a part’s missing, something’s loose, there’s a defect—he pulls a cord, and the line slows down. If he still can’t do it, he pulls the cord again and the whole assembly line stops. Think about that—350 workers, every single one of whom is empowered to stop the assembly line and shut down the factory. Then all the supervisors converge on the site and fix the problem before it’s passed on downstream. In conventional manufacturing they keep the line going and inspect the products afterward. If there’s a problem, they send it upstream and fix it, but in the meantime how many defective products have been made? The way it is traditionally done in health care is even worse. There is retrospective quality assurance. Two months after the fact, a retrospective quality audit or chart review will be done, for example, and find that something should have been done differently—two months ago. Meanwhile, how many more people have been harmed?
Volume 35 Number 12
Copyright 2010 Joint Commission on Accreditation of Health Care Organizations
The Joint Commission Journal on Quality and Patient Safety Our “ah-ha” moment came as we watched a worker pull the cord and stop the line. We asked the question “If Toyota does this for cars, shouldn’t we be doing this for our patients?” We wanted to have real-time quality assurance at Virginia Mason, so we put in place our Patient Safety Alert (PSA) system™–our health care version of stop the line.2 We said that every single staff member is a patient safety inspector and is empowered to stop any process or situation that might cause harm to a patient. The PSA system demonstrates to our staff their concerns will be taken seriously and therefore encourages more reporting. We can’t fix what is not known. We are dependent on everyone being inspectors and signaling when there is a problem that needs fixing. To date, we’ve had more than 14,000 PSAs. While it may seem counterintuitive, we think the more PSAs we generate, the safer care is here. Why is there such concern in health care around reporting errors? The health care culture has long been a hierarchical and blaming culture. I was taught as a resident that it was my responsibility to double-check my work and that errors were not really talked about. There was no recognition that I was working in a complex broken system that was leading me down the wrong path in some instances. Today, too many residents and nursing students are still taught that if you try hard enough you won’t make mistakes. But we know that is not true. James Reason taught us years ago that humans make on average six errors a day.3 We need to change the way students are taught from a focus on individual responsibility to a systems and team approach. Virginia Mason is currently partnering with the Institute of Healthcare Improvement Open School and the Alliance for Independent Academic Medical Centers (AIAMC) to develop a patient safety curriculum that all of our residency program participants will be required to complete. You frequently talk about seeking perfection and transforming health care. Is that really possible? When I became CEO in 2000, health care was much the same as it is today: expensive, rising costs, defect- and errorprone care and access unavailable to many. The health care industry has a defect rate of 3% or more, a rate unacceptable in any other industry. Defects really can be anything from appointment scheduling errors to wrong-site surgery. Of course, when a defect happens to me or a family mem-
December 2009
ber, the defect rate climbs to 100%. No one cares that the other 97% of patients got defect-free care. Zero is the only acceptable rate of defects. Perfect care must be our goal. I realize that our dreams are audacious. There is no perfection in human affairs, after all. And to declare that we think we can play a vital role in the transformation of the entire industry, well, it sounds very bold, to say the least. But we must be bold for true transformational change in health care. I think now is the time for new ways of thinking, and we think the work we’re doing at Virginia Mason can be a key to success. It’s impossible to talk about patient safety without citing Virginia Mason’s tragic accident in 2004 with the death of Mary McClinton, which was caused by preventable medical error. How did you make the decision to go public and apologize? When Mrs. McClinton came to us for a routine tertiary procedure, we were about two-and-a-half years into our journey with VMPS. We failed her. She died of a preventable error. It was the deepest, darkest time in my career and in our organization’s history. As soon as we found out what happened, we told our staff and then went public with the news. In addition to our local media, the story hit national airwaves on Good Morning America, and Reuters picked it up. We received lots of expressions of concerns, appreciation, and some criticism. Going public was worth it. About a month later, we received a phone call from the state Department of Health. The survey manager told us that every hospital they had surveyed since the event told them that the same situation was present. When they read about the tragic error, every single hospital made changes to labeling medication solutions. Interestingly, we learned that several months earlier the same mistake had occurred in another hospital in Seattle and that it had been kept quiet. That made it clear to us that we had done the right thing by admitting our mistake publicly. We knew if this could happen to us, where our intense focus is on quality and patient safety, this could happen anywhere. What do you think the single easiest thing every hospital or clinic could do to make significant strides in patient safety? Listen to staff. The people on the front lines know more about the potential for errors and the risks to patient safety than anyone in an office. And a close second is to get leaders out of their offices. Genchi genbutsu means “go and see for yourself.” Traditionally, leaders spend most of their time in their offices, in meetings, in conference rooms, looking at spreadsheets. At Virginia Mason, we are working to spend less time in meetings and more time on the “shop floor”—the lab, the OR, the crit-
Volume 35 Number 12
Copyright 2010 Joint Commission on Accreditation of Health Care Organizations
585
The Joint Commission Journal on Quality and Patient Safety ical care unit, the clinic—because that’s where it’s happening. Go see for yourself. And don’t go out there as the boss who knows everything. Because you don’t. It’s OK to be vulnerable. It’s OK to show you don’t know something. How do you elevate the importance of patient safety among physicians? Long before we began our work with the Toyota system, we knew that we needed to change the way we communicate. The most important change was that we needed to actually tell the truth and shine a bright light on quality, safety, processes, economics, costs, and behavior. We needed to have honest conversations with our physicians and really understand what transparency means, not just pay lip service to the concept. As physicians began to understand the magnitude of the safety issues and understand their impact on patients and their families, the focus on safety became more compelling. VMPS and the PSA system gave our physicians a way to talk about patient safety that is all about understanding the current state and then envisioning and implementing a safer future state. The cultural changes are very significant, and we spent time, even prior to VMPS, working on our physician and leadership compacts to better align our teams and our organization. A key part of Virginia Mason’s vision is to be the Quality Leader. What does Virginia Mason actually mean by quality? Q = A × (O + S) W This is our Virginia Mason Quality Equation. It says, Quality is Appropriateness times Outcomes plus Service divided by Waste. It used to be our “value” equation and the W was a C for cost. It used to be divided by Cost. The way we often manage in health care is to tell all department managers to take 2 % out of their budget. We don’t care how they do it. Well, we realized that if we just cut out cost, more often than not we’re reducing quality. What we’ve learned is that if we reduce cost by reducing waste, which is what VMPS is all about, we actually improve quality. The other side of the coin is appropriateness. We can do the best surgical procedure, we can have a great outcome, we can delight the patient and his or her family with great service, we can even do it efficiently with no waste. But if the patient didn’t need it to begin with, there is no quality. We know that this happens all too often. Virginia Mason’s board received the first Leapfrog Governance for Quality Award in 2008. How did you get the 586
December 2009
board engaged in quality? Great question! This work must start in the boardroom. Many of us in health care have a public board of community members. In their role, they commit to representing the voice of our patients and the community. Our board at Virginia Mason has really taken this to heart. During our strategic planning work in 2000, it was our board members that helped define our business strategy for the pursuit of quality. To this day, they continue to be supportive and engaged in this work. Our board dedicates at least a third of its time on quality and patient safety. Having shared experiences helps tremendously too. Most of our board members have traveled to Japan with us, learned VMPS tools alongside us and worked with us to improve the patient experience at Virginia Mason. Another key to our success with the board has been open, honest dialogue. How many organizations truly share their successes and failures with their public board members? Our board members actively participate in the review of patient safety alerts. So much so that any major alert must be presented and the resolution explained to the board’s quality oversight committee before the matter can be closed. I am so thankful for the board we have at Virginia Mason. When I talk about our journey, the conversation starts with the fact that our board challenged us to think about the patient first. Our board knows there is nothing more important. You’ve said before that this journey has only begun. How do you maintain gains in patient safety and quality and how do you keep patient safety and quality a priority? Our journey is about building deep organizational capacity for change, capacity for leadership and managing through VMPS. Every single one of our staff—all 5,000 people–is trained in the fundamentals of VMPS. It is a long journey, and we have made huge progress. We still have a long way to go. It requires a constancy of purpose at all levels of the organization—from the boardroom, the leadership, and the staff. The willingness to listen to the voice of the patient is what keeps us moving forward. J
References 1. Institute of Medicine: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999. 2. Furman C., Caplan R.: Applying the Toyota Production System: Using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf 33:376–386, Jul. 2007. 3. Reason J.: Human Error. New York City: Cambridge University Press, 2000.
Volume 35 Number 12
Copyright 2010 Joint Commission on Accreditation of Health Care Organizations