Continence Coach: Lean Manufacturing for Patient-Centered Continence Care

Without standards, there can be no improvement. — Taiichi Ohno, former Toyota executive

  Recently, I made a site visit to Virginia Mason Medical Center (VMMC), Seattle, WA, as part of the process of determining its designation by the National Association For Continence (NAFC) as a Center of Excellence in Continence Care. I never expected to find myself hearing about car manufacturing philosophies.

But VMMC has adopted the Toyota Production System (TPS) — known in this country as lean manufacturing — and applied it to the pursuit of the perfect patient experience. VMMC CEO Gary Kaplan, MD, has equated the process of perfecting car production with perfecting patient care services throughout his institution.¹ In doing so, he and the health system’s leadership have successfully placed the patient at the center of VMMC’s universe.

   The transformation began when patient safety was threatened because the organization’s process of delivering services, in quality control terms, was faulty. Lives were being lost and financial assets were eroding. The institution’s image and brand were severely marred, jeopardizing the entity’s existence. Ironically, now nearly a decade after implementing this program, leaders from prominent Japanese hospitals are visiting VMMC to see how it has applied the principles of TPS to healthcare to learn how they might improve their own institutions

.   Throughout America’s healthcare system, we risk losing sight of why we exist because we may “discount” the patient or render him/her invisible — ie, absent from view, priority, or consideration. Virginia Mason put the patient back in the equation, right at the top of the pyramid from which the institution’s vision, mission, values, strategies, and foundational elements emanate. As a result, VMMC’s organizational attitudes about safety, waste, and management practices now revolve around the patient’s best interests, needs, and satisfaction. During my visit, I was struck by how in harmony everyone was in speaking about patient care. No one has rank above the patient and anyone can “stop the line” if the patient’s safety and well-being are undermined in any way. Every VMMC employee has a sense of empowerment and job security when it comes to doing the right thing for the patient.

  What does this have to do with continence care? Everything. Just as for all Virginia Mason patients, it takes a team to deliver what the patient deserves in continence care. Clinical performance measurement is one of the most pervasive and permanent aspects of healthcare delivery; the trend toward standardization is growing. By establishing standards, or benchmarks, we have a point of reference for comparison as well as a starting point for change — ie, continuous improvement — until we reach perfection. As such, the NAFC recently launched an initiative to establish national product performance standards for adult absorbent products paid for by state Medicaid agencies for people cared for privately in their homes under waivers from nursing home placement.² State departments of health, collapsing beneath the weight of Medicaid spending for long-term care of the indigent, need help selecting products because volunteer caregivers are bewildered by product options. In addition, product quality and performance characteristics vary widely. As a result, patient skin integrity and quality of care are compromised. Procurement costs are uncontrollable and medical costs are soaring because of the need for intervention in the case of skin excoriation and breakdown. Urged by our own state (South Carolina) to assume leadership in tackling this crisis, the NAFC subsequently formed a national council of the leading manufacturers, selected state agencies, clinicians, and patient and caregiver advocates. The goal is to define needed performance characteristics and the standards to meet them. It’s not a branding showdown —it’s all about what the patient and his/her caregiver need most. Price is off the table.

  The NAFC’s effort represents only a beginning, a benchmark from which quality can evolve and spin upward. Armed with performance standards and the Toyota production model, healthcare in general and continence care specifically can develop the road map for improved care provision and better patient outcomes.

 The National Association For Continence is a national, private, non-profit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound Management peer-review process.

1. Kenney C. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. New York, NY: Productivity Press, a Taylor & Francis Group;2011.

2. NAFC Launches Council to Establish National Performance Standards for Adult Absorbent Products. December 16, 2010. Available at: www.nafc.org/news/147/318/NAFC-Launches-Council-to-Establish-National-Performance-Standards-For-Adult-Absorbent-Products/. Accessed January 13, 2011.