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Virgina Mason Medical Center Case Study

Complicated Versus Uncomplicated Problem Solving

In the book, Transforming Health Care, author Charles Kenney describes one of the many improvements Virginia Mason Medical Center (VMMC) undertook to reduce costs and increase profitability. One of their payors, Aetna, was threatening to drop VMMC because they cost too much for comparative quality of care. Rather than jump into crisis mode, VMMC chose to use their adaptation of the Toyota Production System (Virginia Mason Production System [VMPS]) to analyze and solve the problem.

Voice of the Customer

VMMC embarked on understanding the Voice of the Customer. One of Aetna's customers, Starbucks, had issues with the costs and delays in back pain treatment. It took too long to answer the phone. Employees often waited up to 45 days for an appointment. By then the back pain took longer to treat and cost more.

Complicated vs Uncomplicated

An improvement team of companies, insurers and VMMC used Value Stream Mapping to analyze and remove waste for these types of complaints. An important first step was to separate uncomplicated and complicated back pain. Uncomplicated back pain accounted for 80% of patient issues and could be treated directly by physical therapists. Complicated back pain would require the attention of doctors and surgeons.

In the existing process, all were seen by a doctor who often ordered a $1,200 MRI even when the patient’s symptoms did not require one and provided little or no value. And “it wasn’t just the MRI that had no value—it was just about every other step in the process.” The only thing that showed evidence of providing value was physical therapy.

The improvement team decided to go for same day appointments which eliminated missed appointments. The patient would meet with a physical therapist initially and a doctor would join them to separate the uncomplicated from the complicated back pain patients. Uncomplicated back pain patients (80%) would receive an immediate physical therapy session. Complicated patients would be scheduled for imaging and other tests as needed.

The shift to same day scheduling took three months to implement. “The hardest part was convincing doctors that no backlog was a good thing.” The skill-task alignment of physical therapists to uncomplicated back pain freed doctors to focus their skills on the complicated pain. Because of the no-wait access, VMMC averaged four sessions of physical therapy to solve the back pain problems, far below the national average of 11 days. 94% of patients were returned to work the same or next day. This reduced costs to Starbucks and doubled patient volume and increased patient satisfaction.

Doctors kept scheduling MRIs, so IT implemented a block that prevented doctors from ordering an MRI if there was no evidence of the need for one. MRI usage fell from 43% to 8%.

Most hospitals worry that if they reduce the cost of care, they’ll fail to meet their financial goals. VMMC found that by organizing their work around the needs of the patient, insurer and company, they generated margins three times higher than the previous model.

This kind of change was found in many other clinics and specialties within the hospital. Teams continued to find that 80% of patients had uncomplicated problems that could be handled with less than physician-level skill and yielded better patient outcomes, faster service and improved profitability that comes from seeing more patients. Patient and physician satisfaction improved dramatically.

Implications for Lean Six Sigma

In my 25 years in quality improvement, I have found that a similar situation exists with virtually all operational problems:

80-90% of quality problems are uncomplicated and can be solved with the Seven Tools of Breakthrough Improvement. These can be solved with Yellow Belt or even just Excel skills, and QI Macros for Excel.
10-20% (or less) of the problems are complicated and require other tools like hypothesis testing, DOE, and other Green/Black Belt tools.

Unfortunately, the Six Sigma community has fallen into an obsession with Green Belt and Black Belt certification, not results. Haven spoken to hundreds if not thousands of newly belted change agents over the years, I have found that teaching all of the tools in the GB or BB body of knowledge often leads to confusion about where and how to start. It's a form of overproduction: too many tools = confusion.

I have found that people who master the Seven Tools of Breakthrough Improvement can then more easily add other tools as needed to solve increasing more complex problems.

My suggestion: Master the fundamental Seven Tools of Breakthrough Improvement. Start solving the uncomplicated problems that abound in any business. Then, and only then tackle the complicated problems that remain. Solving uncomplicated problems often eliminates what previously seemed like a complicated problem.

While not every problem can be solved with Lean Six Sigma, you can learn how to use the Magnificent Seven tools to solve most of them. Be a Money Belt www.lssmb.com