9 Weeks to Health – America…Lean but not Mean

Can you imagine a general practice without a waiting room?  What would a primary care facility look like if it had over 80 staff?  How would you organise to serve 25,000 or even 60,000 patients?  To see the answers you need travel no further than Virginia Mason in Seattle.

The most revolutionary of their primary care facilities is in Kirkland, one suburb past the headquarters of Microsoft.  This is a middle class haven but the re-thinking which has occurred within their five year old facility could be applied much more broadly.

When patients arrive, they spend less than a minute with a receiver. Here they are checked in and given a radio frequency identity tag (RFID).  They are also given a laminated page which contains the name of the wing they will be visiting.  On that is their room number. The patients then navigate to their room and wait for their Medical Assistant to arrive.  No sharing germs or having children run around the chairs in this facility!  Generally the Medical Assistants arrive in under three minutes and begins taking a history and vitals.

When the Medical Assistant is done, they leave the room by the back door (the one they entered).  If necessary, they write a note on the whiteboard on the outside of the sliding door.  This notation is not clinical.  It is to avoid re-opening emotional wounds, to list any other family members in the room and generally instruct on the “must achieves” for the medical part of the consultation.  If a procedure is required, the right trolley is moved into a cupboard with dual entries. When the doctor arrives, they open that cupboard from the front and the right equipment is all to hand.  This process means everyone comes to the patient.  Such an approach reduces patient confusion and waiting time.

Best of all, the nursing, allied health and medical teams all share computers in corridors behind the consultation rooms.  This improves communication and team spirit.  In between consults, in other words whilst patients are rooming themselves or whilst the Medical Assistants are rooming patients, the doctors attend to their electronic in-boxes.  Computers in each consult room are there to take patient notes and display these to the patient.  They are not the desks of any particular clinician.  Computers in the corridor are for non-contact patient work and coordination.  RFID tags worn by the clinicians identify where everyone is in the facility with the computer providing prompts when staff need to move to their next room.

Even the cupboards in the consultation rooms containing clinical consumables have been designed using lean principles.  Every item has a two container system.  When one container is used up, it is placed on the bottom shelf of the cupboard, in front of a glass opening window.  From the clinical corridor you can see through the glass to what needs replacing so this can occur in real time.  The process reduces inventory, eliminates the need for daily re-stocking and ensures efficiency as every room has exactly the same layout and supplies.

Lean manufacturing was pioneered by Toyota and adopted by many industries.  The healthcare sector has long resisted kanban and the other elements required to keep things flowing and eliminate waste. Virginia Mason has standardised protocols, uses lean methodologies to negotiate changes to services and has driven down the cost of providing care whilst improving health outcomes and satisfaction across the board.  They are attracting high quality staff from across the United States who want to work in their system…because it is a system which works.  It might be lean and do everything it can to cut waste and re-work, but their system has created a humming and satisfying place to work and receive care.  That is why patients in the North West are flocking to the Virginia Mason sites across Seattle making them some of the largest in the city.

Tracey Johnson, General Manager, Inala Primary Care

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