What does Lean mean for RHA board members in Saskatchewan?

A conversation with Carolyn Corvi, Board Chair of Virginia Mason Health System

On January 31st, board members from Saskatchewan RHAs, 3sHealth, eHealth Saskatchewan, Health Quality Council and Ministry of Health executives had an opportunity to chat via teleconference with Carolyn Corvi, board chair of Virginia Mason Health System and Virginia Mason Medical Center since 2009. Before joining Virginia Mason, Ms. Corvi was a VP at Boeing where she spearheaded their Lean cultural transformation. Here, in Question and Answer format, is a summary of Ms. Corvi’s free-flowing conversation with Saskatchewan’s health care governors.

Question: Does the Board at Virginia Mason pay close attention to the results your health system is achieving?
At the beginning of our Lean journey, Virginia Mason had lots of data, but they weren’t doing anything with it. We have, over time, developed metrics that are focused on outcomes. The dashboard we havenow has evolved over the years. At every Board meeting, we review our dashboard. This information is part of our board package; it’s posted to our Board website. On a monthly basis, we are actively using it and asking questions about how well we are achieving our objectives around quality and cost.

Question: How have your organization’s high-level quality metrics changed over the years?
We have refined these over time. We had a sub-team working on this; it involved board members and the executive – including a statistician. The board worked closely with that team on this. We think our current dashboard is representative of all the work we’re trying to do. We have now a set of metrics that are very useful for us; they wouldn’t necessarily be right for another health system or hospital.

Question: Does your Board ask tough questions of the senior leadership at Virginia Mason?
I don’t think our Board is afraid to ask questions. At first, we needed some education around the metrics. But once we all understand why the metrics we receive are relevant, then it is a very open dialogue. Gary Kaplan (CEO of Virginia Mason) calls it a partnership. Our metrics have helped facilitate the dialogue. So much of this (managing health care with Lean) is about leadership. You can have the best intentions and put the right tools in place, but without leadership – at the Board and at the executive level – you will not achieve success.

Question: What do board members do when they’re not happy about some of Virginia Mason’s results?
That’s why we serve. That’s our job as board members. If we’re not speaking up, we’re not doing our duty. On our board, there’s no reluctance to express dissatisfaction with something. We’re continually setting the bar higher for our leadership. For example, we will send a PSA (Patient Safety Alert) back to the executive when we don’t feel the solution that’s been proposed has actually solved a problem.

Question: What orientation do you provide for new Board members?
Part of our work to improve our governance is to provide better orientation for new members before their first meeting, and then to give them ongoing orientation. The package we provide to new members includes information about the Virginia Mason Production System. We give them a “buddy” on the board for one year; this is someone who has already been to Japan.

Question: What Lean training do Board members receive?
Every Board member goes to Japan for 2 weeks with staff, usually in the second year of their term. There is lots of reading and classroom work that they do in advance. They also have the opportunity to participate in Rapid Process Improvement Workshops (RPIWs) and 3Ps, which most do, and they also take part in leadership rounding.
Question: Do you see value in having board members participate in Rapid Process Improvement Workshops (RPIWs)?
Absolutely. I learned by doing. You need to go to the gemba, to watch the work. Hands-on participation is very important for leaders and board members. By helping to plan and then doing the work in the week, you learn about the processes and process improvement. It gives you a whole different level of understanding of how much opportunity there is to improve. I would encourage your board members to do this, even though it’s big time commitment (1 week).

Question: Are Board members required to get Lean Leader Certification?
No. But we provide them with enough training so they can perform their role as Board members, and ask the right kinds of questions.

Question: Do you apply Lean to your Board processes?
We haven’t done any of our own RPIWs, but when Board members go to Japan they do a value stream map on one of our governance processes. We have also worked over the years to improve our dashboard and our metrics. We formed a joint team involving some executives and some Board members and they used kaizen tools to identify the best metrics and how to display them. This team spent 8 or 9 months working on this.

Question: At what point did your Board start to see returns on its investment in Lean, both in terms of quality but also costs?
I joined the Board a year and a half into Virginia Mason’s Lean journey. At that time, there were lots of questions each month about our financial statements; Board members traditionally looked at the financials first. I kept telling them to be patient, that this is an incremental process. I reminded them that the patient was our focus so we needed to stay focused on quality metrics. Financial performance tends to trail these. You must have patience because this is deep cultural change. Your surface metrics will change sooner than your culture. We started to see returns, but they were slow at first. The key is to focus on quality, and your financial improvements will flow from that.

Question: Was there ever a point where the Board felt that Lean was not working?
I don’t think there was ever a time when anyone on the Board wanted to throw in the towel on the Virginia Mason Production System. There was always a strong commitment right from beginning. There were times when people want to see results faster. I was biased going in because of my experience at Boeing. At Boeing we tried many different ways to improve. This is the only one where, if you stick with it, it will serve you well and pay off.

Question: What have you learned about how Boards work with the senior executive?
It’s about trust. The CEO sets the tone for this. At Virginia Mason, there is a genuine commitment to learning together. It’s a trust-based partnership. A critical part of our success is that the board is engaged at all levels. For example, Gary Kaplan (VM’s CEO) invites board members to accompany staff to national conferences. We are treated as part of the system, rather than separate from it.

Question: Have you ever had problems with board members not being prepared for meetings, or not fulfilling their role?
Sometimes people have stuff going on in their lives. As the chair, I sit down with them one-on-one to discuss how they’re doing. These are volunteers after all. We may be unique, but I would have to say that our members always come to meetings well prepared. At the end of every meeting, they fill out a survey that asks about whether they felt they were prepared and had received the right information in advance. We try to use this feedback after every meeting to improve things for next time. We have actively been using this feedback form for past the past 8 or 9 years. There’s really no excuse for saying you didn’t get what you needed, because we are always asking about this. The feedback we’ve received through this has helped us structure our board agenda. It’s a good tool that gives board members the chance to write down their thoughts before they leave the meeting, while things are still fresh.

Question: How important is it that board members are “visible”?
People look to the board for leadership. The board needs to lead by example. At Virginia Mason, they are visible at walls, at report outs, at education opportunities. The more conversant they are in the language of Lean, the better equipped they are to behave in a manner consistent with the approach. Being visible is one of the best ways to demonstrate that the board is committed to making changes in how you govern and manage health care services.
In 2004, we killed a woman. We made a mistake that resulted in her death. This was 2 or 3 years into our Lean journey. CEO Gary Kaplan came to our board immediately and said he wanted to go public. We supported him in this. We decided that, if we were really committed, we needed to go public. This was transformational. It was really a catalyst for our board and the executive around our commitment to the Virginia Mason Production System. A big part of transformation is transparency. After the story had been out in the media for a few days, we started to get calls commending us for going public. Now, we honor this patient every year; we honor her death by celebrating the team that has most improved a care process.

Question: What is your advice on the one thing we can’t fail at as boards?
You must have unwavering commitment to do this. Deming talked about constancy of purpose. If the board has unwavering commitment to improving health outcomes and patient safety, this is the most important message you can send to your management.

Question: Is the board worried about sustaining all of this improvement if you lose key champions of Lean?
Yes, we worry and talk about this all the time at the board. If Gary (Kaplan, CEO) were to leave, is this all dependent on him or will it stand on its own? We talk about our succession planning process. Are the roots deep enough that we can sustain this? I’m not sure if there are any data you can look at that answer that question. Our board is of the opinion that if Gary were to leave, we would not bring in someone without the same depth of understanding of the Toyota Production System. You simply can’t learn this on the job. It would take us longer to find right the right person, but we but firmly believe this is the right approach.

Question: How well has Boeing sustained its use of Lean?
They have, in certain areas. At Boeing, it never took firm root everywhere. The 737 progream is doing great because Lean became part of the culture. In other parts of the company, that’s not so much the case. It comes back to leadership. If you’re not demonstrating commitment, it won’t succeed. Leadership must allow the people on the ground to do the work. At Virginia Mason every employee gets to bring their brain to work every day.

Question: You have already made many significant improvements. What does your board see as current challenges?
Continuous improvement is our culture. We are always looking at ways to improve our governance: how can we implement more rigorous processes for everything we do? At our core, we never lose sight of our quality and safety work. Over the past few years, we have been trying to expand our definition of quality to include Virginia Mason employees; we recognized we’d maybe lost sight of the importance of this.

Question: Where is Virginia Mason in terms of eliminating waste, 10 years into your journey?
There is always more waste to get rid of, but yes, we’re making progress. We see improvement in feedback on our staff satisfaction survey. In all the things we measure, we see progress, even in our financials – despite the current economic downturn. Our metrics are telling us that we’re continuing to make progress.

Question: If you could go back in time, what’s one thing you would change?
I don’t go back in time. This process is all about moving forward. It doesn’t help to look back. That’s one of the great things about the process you’re adopting: the system enables you to always keep moving forward. Looking back is not in my DNA.

Question: What are you most proud of?
I am most proud of the resolve of Gary Kaplan and our board to go public with Mary McClintock’s death. Those of us working in health care know that deaths happen all time, but most other people don’t. Mary’s son speaks at our annual event. Last year, when he got up to speak, he talked about his own knee replacement. He had a choice to make: get it at Virginia Mason where his mom was killed or go somewhere else. He said he thought about all the annual meetings (to mark his mother’s death) and about the commitment he saw to improving quality and safety, and in the end he decided to have his knee done at Virginia Mason.
Questions: We are in our early days with Lean here in Saskatchewan. Can you offer any advice to our leadership?
Be resilient. There will be disappointments, but stay committed. Get the right metrics in place, but don’t be afraid to change them if you find there not working for you; this is about improving. Demonstrate disciplined use of the tools, they’re there for a reason. People don’t like the rigor, they want to jump ahead to the end of the process. But you can’t find waste if you don’t do the work of spaghetti diagrams or value streams. This work doesn’t happen overnight.

There’s a quote I like from Taiichi Ohno (one of the fathers of the Toyota Production System): “Having the spirit to endure the training is the first step on the road to winning.” People often say they don’t have time to do this. But you create the capacity for doing the right thing, through doing this. You need to believe that this is true.



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