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Virginia Mason Medical Center nurse leaders retool patient care

RNs realize both patient and work benefits of turning Toyota manufacturing process into hospital production system

Monday January 13, 2014
In a simulation of bedside shift reporting, Kellie Meserve, RN (left) and Charilyn Andres, RN, demonstrate an in-room handoff between the nurse coming on shift and the nurse going off shift at Virginia Mason Medical Center. A colleague is posing as a patient.
In a simulation of bedside shift reporting, Kellie Meserve, RN (left) and Charilyn Andres, RN, demonstrate an in-room handoff between the nurse coming on shift and the nurse going off shift at Virginia Mason Medical Center. A colleague is posing as a patient.
(Photos courtesy of Virginia Mason Medical Center)
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Charleen Tachibana, RN
By Karen Schmidt, RN

How can the way a car is built improve how nurses care for patients? At Seattle’s Virginia Mason Medical Center, nursing leaders have retooled care based on production methods they observed at Toyota plants in Japan.

As a result, nurses spend about 80% of their time with patients, walk thousands of fewer steps in the course of their shifts, and have direct input in solving patient-care problems.

“It actually has taken a big cultural shift,” VMMC CNO Charleen Tachibana, RN, MN, said about implementing the Virginia Mason Production System. “At that point, it hadn’t been applied to healthcare,” Tachibana said.

In 2001, Tachibana and about 30 other executive team members traveled to Japan to observe the working of the Toyota Production System, which reduces waste while streamlining production. The team, including three other nurses, then spent about 18 months studying the TPS.

Bringing changes mean less steps

The changes at VMMC, including nurses’ workflow, have been gradual and systematic. “We didn’t change nursing, but we looked at how and where nurses gave report, did charting, how assignments were made, how far [RNs] had to walk.”

By rearranging and reorganizing workflow, she said, nurses were able to get back to the bedside. Now nurses give shift reports at the bedside, engaging patients and families. Tachibana said the result is an improved patient care experience.

“It’s more transparent and patients are more engaged in their care,” she added. This is something they hadn’t experienced before.”

Also different is how assignments are made. VMMC’s long hallways meant nurses used much time travelling between patient rooms. Now, assignments group patients closer together. “Nurses don’t cross more than half the hallway in their assignment,” Tachibana explained.

RNs are paired with a patient care technician who’s assigned the same patients, improving communication. The result: more time spent with patients and less stress, as nurses now walk only about 1,200 steps per day compared to the previous 10,000 steps.

Other small but significant changes, such as stocking frequently used supplies such as bandages, 2x2 gauze and tape in patient rooms, add up to less time and effort wasted.

The geographic assignment change was the result of a Rapid Process Improvement Workshop, one tool in the VMPS. Focusing on a single problem at a time, staff involved in that specific problem worked together to help to improve how work is done.

“Once nurses understood this [RPIW] concept and got involved in the workshops, they felt the benefit,” Tachibana said, and many started to jump onboard the changes.

Safety alerts

The patient safety alert system also stemmed from that initial Toyota visit when the executive team stood on a catwalk, observing the factory floor below.

The system enables a staff member to call for help at the point of a problem or breakdown. “Leaders immediately respond to resolve problems right at the start,” Tachibana said.

At VMMC, through hundreds of safety alert calls each month, nurse leaders see where a process or system is broken, so it can be remedied.

Measurable improvments

The VMPS, which Tachibana said continues to be refined, has improved quality of care. Falls declined from 3.33 per 1,000 patient days in 2006 to approximately 1.83 per 1,000 patient days in 2013 (January-November). A Press Ganey patient satisfaction survey at Virginia Mason Hospital for January through June 2013 placed the hospital in the 78th percentile for overall patient satisfaction. This figure has risen steadily since 2005.

Success also has brought recognition. In 2008, the non-profit Virginia Mason Institute opened to train others on the production system. Change hasn’t been easy, but now nurses seek work at VMMC because of the change.

Money is not the solution, Tachibana said. “We had to become creative and innovative in the way we do things.”


Karen Schmidt, RN, is a freelance writer. Post a comment below or email editorWest@nurse.com.