Several volunteers from Lean Portland and a few nonprofit partners took a tour on November 21st, 2018 to learn how the Vancouver Clinic (VC) performs their daily management system for escalating problems.

Tour attendees were John Ashcraft (Free Geek), Drew Koessler and Malynnda Harwood (Habitat for Humanity ReStore), and Maria Grzanka and Brion Hurley (Lean Portland). The tour was hosted by Matt Horvat, who works as the Expansion Program Manager and Process Improvement at VC. VC is a multi-specialty outpatient (under 24 hour stay) medical group in Vancouver, Washington (close to Portland). 

We started off with a quick overview of the VC Management System, which is based on the Shingijutsu model, which is derived from former Toyota Japanese consultants. VC is focused on Phase 1 (Readiness and Problem Escalation) along with Phase 2 (Continuous Improvement). The goal with their system is to get problems escalated within 2 hours, where it used to take multiple days with many emails back and forth, and often the issue would not get fully resolved or tracked.

The nonprofit partners in attendance were doing some form of daily huddles each morning with their staff and volunteers, but they mentioned it wasn’t as consistent or effective as they hoped.

We visited two Tier 1 huddles live in progress. One in Rheumatology, the other in Cardiology. They have 3 tiers total.

  • Tier 1 – Front line staff
  • Tier 2 – Multiple sites
  • Tier 3 – Executive level

The huddle is setup based on the Toyota Kata improvement routine, which you can learn more about from the book of the same name, Toyota Kata (book review). We received copies of their kata question card, which you can find on Mike Rother’s Kata website.

In Rheumatology, their huddle starts at 8:10 AM each day. Their challenge was to process refills within 3 days. They have made great strides in their goal, improving from 33% up to as high as 93%, and now stabilizing around 83%.

The routine of the meetings were as follows:

  • Situational Awareness
  • Staffing/Access
  • Methods
  • Associates
  • Equipment
  • Supplies
  • Recognition
  • Financial

Team members take turns facilitating and leading the meeting, to give them an opportunity to better understand the morning huddle process. They also are invited to attend Tier 2 and Tier 3 meetings, to observe how the problems that they escalate are resolved at the next higher level. It also helps educate the staff about the organization beyond their area. They hear about the other challenges going on in different departments, and can share their own successes, or take ideas back to their team.

They ended their meeting in about 10 minutes. Very quick, to the point, and efficient.

Two issues were brought up to the team during the meeting. One related to paperwork being left in the wrong place, and the other was focused on a missing portable cart used by scribes that assist physicians. They were discussing ways to be label and 5S the carts so they are no longer missing.

They use the safety plus sign for their visual management, which is part of the QDIP methodology. Each huddle reviews any safety or HIPAA issues, and records a green (no issues), red (some issues) or black (day off) mark in the day of the month on the safety plus sign graphic.

We next moved to Cardiology at 8:35 AM. They also went through a similar routine for their meeting, but included some discussion on financial performance. Due to the upcoming holiday break, the meeting was only 5 minutes in length, as they had a smaller staff.

After the huddle, we went to Laurie’s office to review the challenge board for her area, and practice the kata questions. Their challenge is to achieve 100% patient care plans at checkout after each appointment, and they are currently at 85%.

Drew and Malynnda observe as Laurie and Zac go through the kata questions on their challenge board.

The discussion with Laurie was very enlightening to everyone. At first, she was not very excited about the new daily management system. She said the primary benefits of the kata questions is that she realizes how much they used to jump to conclusions, instead of taking the next step to test out ideas and solutions. They were also not setting any expectations of each action, so they weren’t able to learn from what worked and what didn’t work.  When conducting PDCA learning cycles or experimenting record (see image below), it forces her to really think about the problem, and made her slow down and “go to the gemba” more frequently to better understand and talk to the people dealing with the issues. She said it has forced her to become more humble, and she quickly realized that she doesn’t know everything that’s going in her area like she thought.

This extra effort and slowing down is allowing them to solve more issues permanently, and has improved employee satisfaction and increased recognition and appreciation for staff. They have also seen less emails, and much quicker response when they escalate to their leadership. They also feel that there is more transparency of what’s going on with issues within the organization, as their problems are not being lost. Even though it feels like they are “moving incremental pieces of sand,” it is getting results and she is now bought into the approach.

Our last meeting was the Tier 3 review with top leadership. This meeting is held at 9:30 AM, and is done remotely to connect in people who are off-site or not in the office. 

They performed roll call to make sure all departments were represented. They tracked their action items with a wiki tools inside of Confluence, so that escalated issues are addressed. They also gave out recognition for successes, discussed new problems to document and assign, and performed a financial review. They also reviewed some metrics on hiring shortages. The entire meeting was also less than 10 minutes long.

We would like to thank the numerous staff that helped with the tour along the way. Thanks to the entire VC team for opening up their work to us, and sharing their journey for our volunteer consultants and nonprofit partners!