1. Virginia Mason Production System
第 二 組
余憲忠 曾國成
陳建良 翁根本

2. Production Models in Health Care
Several management models drawn from production industries, including critical pathways, total quality management (TQM), and six sigma. Of these TQM was particularly noteworthy.

3. Toyota Production System TPS
Virginia Mason Medical Center had utilized TQM in the 1990s.
They executive felt that TQM tended to emphasize top-down management.
Both TQM and Six Sigma were failed in this center.
Toyota Production System (TPS): Toyota’s system was primarily about flow-information flow, physical flow of parts, overall production flow- via standardized processes and continuous improvement.
Virginia Mason Production System (VMPS):
Safety and perfection are paramount.
Even a small defect rate is not acceptable.

5. Virginia Mason Production System (VMPS)
Encourage staff to contemplate and change their processes.
A no-layoff policy: the only way to accomplish lower labor costs is not to hire replacements when people leave. -- It’s a real challenge given technical skill sets.
For example, we ended up redeploying one of our best audiologists to a project manager in the operating room, with equal pay, and she’s very happy there.
VMPS depended on the use of specific methods as mechanisms for action. These activities were borrowed from TPS and tailored to fit the health-care model.
這是一套管理方法，而不僅是個偶爾拿出來解決問題的工具

6. Virginia Mason Production System (VMPS)
Value-stream mapping
RPIW: rapid process improvement workshop.
5S: a visual system for organizing the workplace.
3P: production, preparation, process (redesign space according to flow)
Everyday Lean idea system
Patient safety alert (PSA) system.
Bundles: best practices instituted “bundles” into VMPS.

7. Value-stream mapping
Unless you understand the steps, you cannot see the waste, you cannot see the opportunity, you cannot see the defects.
For example: oncology unit.
對癌症患者而言，時間最寶貴，而我們卻在浪費他們的時間
利用3P (Production Preparation Process, 生產準備程序)及 魚骨圖找出改善機會
無數次的RPIW /護理人員的抱怨/醫師的反彈: 標準化
最後是精彩的成功案例
不增加人力，滿意度卻高達九成
主要優點是病患優先

9. RPIW: rapid process improvement workshop.
A five-day event design.
1-3 days: observing, measuring, brainstorming.
4th day: establish new or improved existing standard work
5th day: reported out to the organization.
Often completing multiple RPIWs on the same topic within the same unit
同一單位同一主題的持續改善
From 2002 to 2005, VMMC participated in over 350 RPIW.

12. 5S and 3P 5S: a visual system for organizing the workplace.
Stood for sort, simplify, sweep, standardize, and self- discipline.
3P: production, preparation, process
redesign space according to flow
For example: oncology unit  a circular unit
In the same amount of space, a 57% increase of patient visit and a 76% decrease of patient travel.
Reduce the waiting time from 2 hours to minutes (藥局) and 20 minutes to 1 minute (lab data).

14. Everyday Lean idea system

16. Everyday Lean idea system
VMMC held monthly contests to recognize the top three employee ideas.
Judges reviewed ideas base on applicability, ease of implementation, and how well the standard process was followed.
Between June and September, 2005: 87 lean ideas, 80% of which were implemented.

17. Patient safety alert (PSA) system.
The key concept behind “stopping the line” (andon cord in action) at Toyota was that a mistake could be corrected in real time.
The PSA process was a commitment by all employees to “pull the cord” when any safety hazard or mistake was identified.
一位護士舉報的勇氣
一名醫師認錯的勇氣 (Atenolol, 25 mg QD)
注射流感疫苗
麥可柯林頓女士之死
認錯與修正，讓醫療責任保費大幅降低

18. Bundles
The best practices or evidence-based interventions instituted “bundles” into VMPS.
For example: ventilator-acquired pneumonia (VAP) in ICU.
4 practices known to dramatically reduce incidence of VAP:
Elevation of the head of bed between 30 and 45 degree.
Daily sedationand assessment of readiness to extubate.
Peptic ulcer disease prophylaxis
Deep vein thrombosis prophylaxis.
Checklists of bundled care in ICU
In 2002, 34 VAP, $ 500,000  in 2005, 1 VAP, $15,000 .

19. VMPS Infrastructure Kaizen promotion offices (KPOs)
Overall, VMPS decided 20 full-time employees (18 KPO staffers plus two central operations managers) to the planning, implementation, and maintenance of VMPS.
The goal was to achieve zero defects – no one should die because of something we could prevent.

20. VMPS
275 RPIWs from 2002 to 2004 reduced staff walking distance by 38%, or 34 miles, and the travel distance of parts by a whopping 77%, or 70 miles.
Lead time within the medical center decreased by 708 days (53%), which translated to over two years.
44% gain in productivity, the equivalent of 77 full-time employees redeployed within the center.
3P efforts saved between $12 million and $ 15 million in budgeted capital.
3P reduce the utilized number of square feet by 24%.
By redesign of several units, planned additions and relocations were no longer necessary.

22. We don’t make cars, we treat patients
People left because they knew they wouldn’t fit into the new culture, or they weren’t comfortable with VMPS, or they just didn’t like the change.
You have to say good-bye and this is a good thing. You can’t keep everyone happy.

23. 精實醫療
謝謝聆聽 請多多指教