# Transforming Health Care  ## Metadata - Author: [[Charles Kenney]] - Full Title: Transforming Health Care - Category: #books ## Highlights - Dr. Jacobs emphasizes that the focus is on identifying and providing only value-added services—services the patient values most highly. Anything in the patient experience that does not add value—sitting around a waiting room, for example—would be minimized or eliminated. “The doctor’s visit isn’t shorter, it’s the same,” he says. “That’s value-added time—that’s precious time. You don’t touch that. The time spent with the nurse is value-added. You don’t touch that. The speed at which you give the chemotherapy treatment or the blood or whatever it is you’re doing, you don’t touch that either. It’s all the waste in between. It’s all the waiting, the preparation time, and so on—that you can speed up.” ([Location 1186](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=1186)) - And they’re also very nice and they simply smile and say, ‘This is going to be really great’ and then they don’t do it.” ([Location 1958](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=1958)) - Primary care is naturally a mixed model line, with unique patients arriving one after another. Pittenger huddled with Virginia Mason Chief Operating Officer Sarah Patterson one day on a bus during a Virginia Mason trip to Japan in 2008 and wondered “What are our die changeovers? How can we be instantly ready for every ‘model’ of patient?” Patterson thought about it and replied, “I’ll bet it’s your huddles.” On their return ([Location 2145](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=2145)) - “A lot of nursing has historically been extremely reactive,” Tachibana says. “We wait until the patient is done with recovery before we figure out what room they’re going to. We wait until the sick call comes before we figure out where the staff member is going to come from. We wait until patients put on their call light, thinking they’re not going to go to the bathroom. All these things could be anticipated. Patients are going to need to go to the bathroom at some time or they’re going to have a question or need help getting comfortable in their bed. Some patients are more willing and able to ask for help. Others will hold back as long as possible because they might be embarrassed and they’ll wait until they have such an urgency or such a need. To the extent that you can plan, you have more control over your work cycle and less chaos. You can help a patient just beginning to experience pain much easier than dealing with the worst pain of their life.” Tachibana, Ponischil, and their team prepared a choreography for rounds before training staff nurses. The training was carefully planned and ([Location 2811](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=2811)) - ‘Are you comfortable?’ ([Location 2820](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=2820)) - Prior to the changes nurses were spending approximately two thirds of their time away from patients. After the changes they were spending about 90 percent of their time with patients. ([Location 2844](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=2844)) - industry experts that people in health care—very smart, hard-working people—were largely clueless when it came to the concept of systems thinking. ([Location 2857](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=2857)) - “It’s hard work—hard to sustain cultural change”—which is why it is essential to keep going back and checking and working to get back on track when gains have not been sustained over time. Bedside handoff, she says, is a perfect example. ([Location 2926](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=2926)) - says. “With our usual approach to health care delivery it seemed to me that we had it backwards. We were determined to sell what we wanted to produce without understanding what our customers needed as their first priority.” ([Location 3082](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=3082)) - “If the only thing giving value is physical therapy then why don’t we start with that?” she asked. ([Location 3140](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=3140)) - people very effectively,” says Patterson. She said that sending out an e-mail to the staff explaining the process proved singularly ineffective. The same ([Location 3477](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=3477)) - Management by policy ([Location 3521](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=3521)) - Daily Management Daily management, the second of the three World Class Management categories, is clearly all about managing the work day to day. Patterson views daily management as about “creating a visual workplace where you know what’s really going on moment-to-moment. You know what the standard work is that’s been defined, you know if it’s being followed, you know the flow of patients. And if there are bottlenecks in that flow on an hour-to-hour basis, the leader, the supervisor can go in and say, ‘Whoa, we’ve got a problem.’” ([Location 3544](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=3544)) - think we realized even on that first visit how profound a change this was for us as leaders and how we spend our time,” she says. “It was very different than how we have viewed our roles and the roles of our managers and supervisors. It really made the concept of a ‘servant leader’ come to life. What if your job was to support your workers to deliver the highest quality product day in and day out and do it by being right there with them and understanding what their challenges were?” ([Location 3577](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=3577)) - That has been our system in health care—to rely on people who do it all and they keep the system together; people who can manage in a crisis. But we don’t want a crisis. We want systems and standard work to prevent a crisis. If there’s a crisis, most often it’s a failure of leadership.” Success depends not on the actions of a charismatic, heroic individual, but on the system. ([Location 3599](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=3599)) - medical specialties anywhere in the world. But brilliant clinicians do not a system make. A quality system is one that delivers superb care, safe care, efficient care, and affordable care. Applying this definition, it is clear that the belief that the United States has the best system in the world is little more than myth—and ([Location 3909](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=3909)) - “It’s about day-in and day-out focus on results,” says Kaplan. “It’s about leveraging VMPS as a management system across the entire enterprise. Rather than fixing asthma and applying those lessons to diabetes and then fixing it disease by disease, we’re saying change the management system and leverage it across the entire organization.” ([Location 3996](https://readwise.io/to_kindle?action=open&asin=B006ZAGJ5Y&location=3996))