99% Invisible - 99% Invisible-30- The Blue Yarn

Episode Date: July 1, 2011

In 1998 Dr. Gary Kaplan, the CEO of Virginia Mason Medical Center in Seattle received some bad news about his hospital. It was losing money. So Dr. Kaplan started studying how other hospitals were being run to see if there … Continue reading →

We get support from UC Davis, a globally ranked university, working to solve the world's most pressing problems in food, energy, health, education, and the environment. UC Davis researchers collaborate and innovate in California and around the globe to find transformational solutions. It's all part of the university's mission to promote quality of life for all living things. Find out more at 21stCentry.ucdavis.edu. This is 99% Invisible. I'm Roman Mars. In 1998, Dr. Gary Kaplan, the CEO of Virginia Mason Medical Center in Seattle, received some bad news about his hospital. It was losing money.

That voice says David Weinberg, who's doing our reporting for us today. So back to the story. The STEM losses at Virginia Mason, Dr. Kaplan, start studying how other hospitals are managed. So we started scouring the country, looking for a hospital with a management system worth adopting.

And if you're anything like me, when you hear the phrase management system, part of your brain begins to shut down and another part of your brain prepares itself for hearing a lot of either complete nonsense or common sense, tarted up with unnecessary jargon. But really, all you need to understand here is that Dr. Kaplan was looking for a hospital

that had processes and procedures that were better than what he was already using, but he never found one. So instead, he ended up in Japan at a Toyota factory. Yep, the automobile company. And think about that. This is a very smart physician who goes around the country looking for a great management system and doesn't find one.

Charles Kenny is the author of Transforming Healthcare, a book about Virginia Mason's journey to adapt the Toyota production system to healthcare. He says that when Dr. Kaplan told his staff, they would be changing everything about the way they operate, and the changes were based on a car company, and that the doctors and nurses should refer to their new teachers as Sensei,

the response was not pretty. There was a lot of anger from people within his organization led by the doctors of course. And this whole multi-year overhaul started with a ball of blue yarn. The staff met with a sensei and he took out the ball of blue yarn and a map of the hospital and he told the staff to trace the path a cancer patient would take on a typical visit for chemotherapy treatment. And then the yarn went across a couple inches and then it maybe went up approximately five inches to where they'd have to get their blood drawn and then they would go up to the

14th floor and on the cardboard that was like maybe four inches above that. Michelle Wetland is a nurse manager at Virginia Macy. And then they'd have to come and see their doctor, which was in a different location. And it was so big on our board that we just had to keep winding it around itself. And that's Dr. Henry Otero. Creating kind of this circular maze,

like we would wind a yo-yo. And when we looked at it, we were amazed at how far our patients traveled. We were asking oncology patients who are... their oxygen carrying capacity is compromised because the chemotherapy destroys a lot of red blood cells so that makes them short of breath. And here we're asking patients to do this who are short of breath to begin with. So it was appalling to us. And I think it was that mapping of the flows of medicine and the patient understanding, the patient's journey was that eye opening moment that you

realize you don't really know what's going on. The blue yarn told the story of what Virginia Mason was doing wrong. We just didn't, we couldn't conceive of it until actually until we saw it visually. And the story it told was not a good one to Dr. Otero. He thought he was providing exceptional care for his patients. They basically came into my exam room and they left. And I really said, I'm a great doctor. Look at this great care I give.

I see them, I send them out. And, you know, they just must feel like Look at this great care I gave. I see them, I send them out, and they just must feel like they have this great experience of having care here. Then he saw the twisting path of the blue yarn. Oh, how awful it is for them. How awful it must be to really wait everywhere along the way and that I was contributing to that and that,

it became an intolerance really too. I couldn't accept it anymore. Six months after that first meeting, Dr. Mecklenberg, the hospital's chief of medicine, led a group of staff on a three week trip to Japan to meet with a different sensei. And so they pulled out the schematic, essentially an architect drawing of various parts of the Virginia Mason Medical Center. And the Sensei kept pointing to these areas and saying, what is that?

And Dr. Mecklenberg would say, well, that's a waiting area. And this happened over and over again. Well, that's a waiting area. And as this was happening, the Sensei seems to him to be getting increasingly angry. And he says to Mecklenberg, Why are there so many waiting areas throughout this facility? Who's waiting there? What are they doing? What are they waiting for?

And Dr Mecklenberg says, Those are our patients. They're waiting for us. And the Sensei long pause looks quite furious, looks directly at Dr. Mecklenberg and in front of Mecklenberg's team says to him, aren't you ashamed? And Dr. Mecklenberg said at that moment he was ashamed, he was absolutely ashamed. If I told you to picture a waiting room, you probably picturing a doctor's office. This is what we are trained to do when we go to the doctor. We are trained to wait. But to a sensei, who's been trained in the Toyota production system, waiting is a form of waste.

And the number one tenant of the TPS is to eliminate waste. The staff completely redesigned the Cancer Center, and they hired an architect who had first-hand knowledge of cancer treatment as a patient. He designed the journey differently to really be patient first. The new design put patients on the outer edges of the building, in these rooms with big windows that led in natural light and provided views of the pujits sound. But in order to give the patients these rooms, they had to take them away from the doctors who had their offices there.

It wasn't something that really was difficult for me because I think we were always in the right direction with the patient. I think for others who maybe didn't go through that process, they saw it as a takeaway. I had the great office, the great window. Now you're putting me in this cubicle. I'm the guy who does all the work. It shouldn't I had the great office, the great window. Now you're putting me in this cubicle, you know, and I'm the guy who does all the work, you know, you know, it shouldn't I, it shouldn't I have the the big office. Some doctors were so angry they quit, but Dr. Otero says that everyone who stayed realizes it was the right thing to do for the patients. When I go there and I see them there and I see them looking out and I recognize that's a much better place than be. I'm gratified that decision was made and it's totally was the right decision. It's not even a question about it. Relocating patients was just the beginning.

Today the New Cancer Center has been dubbed the Cancer Spa. It was designed to create an environment of healing so it has, it's a real pretty pale yellow color. We use colors of nature so yellow for sunshine and we have browns to simulate in greens to simulate nature and we have a water wall. There's two of them actually. And just so you don't think that this new management system resulted only in natural colored walls and big windows. The whole reason why this blue yarn was unspooled to begin with was to save the hospital money, and it did, and it also made it a safer place. From 2007 to 2009, Virginia Mason was so much safer that their insurance expenses declined

by an astonishing 37%. While simultaneously increasing the number of patients they treated, all without having to hire any additional staff. And yet some people still scoff at the idea of Toyota inspired management. I was on a boat once and someone said to me, so are you guys still building Toyota's in your basement? And that was a real, I mean I was offended because I knew that what we're doing here is really good.

And I said to him, you know, you can say what you want to make fun of what we're doing, but we're trying to do the best by the patient. This complete upheaval of the medical industry, which stemmed from a single thread of blue yarn, became especially poignant when the staff visited Japan for the first time, and saw an exhibit at the Toyota History Museum. It was an automatic loom. That was where the team learned that the Toyota production system was in fact born quite literally from a single thread of yarn.

Might have even been blue. Toyota was originally a textile manufacturer and in 1902, Sakichi Toyota invented a self-correcting loom that would stop when a thread was broken or woven incorrectly. The museum is a story of continuous process improvement. You start with back breaking work on a manual loom that is producing defective product and you put in the first components of ergonomics, putting the person sitting up instead of sitting on the floor.

Then you start making automatic looms and improve the machinery. Then you start developing mistake-proofing into the process that if any of the weave or the weft breaks, the machine stops and prove the machineries function as time goes on. Add speed and velocity. I see that at Virginia Mason, we're still just, we've just gotten off the floor sitting on the chair. We've got a couple of mistake-proofing things in the iron and some day we might be an automatic loom, but that might be 30, 40 years from now.

But we've got a long way to go to mistake proof healthcare due to in a cost-efficient manner. 99% Invisible was produced this week by David Weinberg with help from me Roman Mars. It was made possible with support from lunar Making a difference with creativity. It's a project of KALW 91.7 local public radio in San Francisco, the American Institute of Architects in San Francisco in the Center for Architecture and Design. To find out more, go to the website, it's 99%Invisible.org. you