Designing for Health: Interview with Gary Kaplan, MD [Podcast]

Overhauling the patient experience can be one of the most challenging hurdles that a health system can undertake. Honoring the work that clinicians have done in the past, while also gaining buy-in for future transformation can be a very small needle to thread. Despite the difficulties that come with a top-to-bottom transformation of a health system, it can often lead to better outcomes for every stakeholder in the healthcare ecosystem.

On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Craig Joseph, MD, chats with Gary Kaplan, MD, CEO emeritus of Virginia Mason Franciscan Health. They discuss how Dr. Kaplan spearheaded a revolution in the patient experience at Virginia Mason, how a car company headquartered on the other side of the world inspired transformational change, and how his organization gained from openness and honesty in the face of adversity.  

To learn more about Dr. Kaplan and Virginia Mason's journey, check out the book Transforming Health Care - Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience by Charles Kenney. 

Listen here:



In Network's Designing for Health podcast feature is available on all major podcasting platforms, including Apple PodcastsAmazon MusicGoogleiHeartPandoraSpotify, and more. Search for 'In Network' and subscribe for updates on future episodes. Like what you hear? Make sure to leave a 5-star rating and write a review to help others find the podcast.

Want to hear more from Dr. Joseph? Order a copy of his book, Designing for Health.

Show Notes:

[00:00] Intros

[01:40] Dr. Kaplan’s early years as CEO of Virginia Mason

[07:18] Pivoting from a physician-centered organization to a patient-centered organization

[13:30] Learning from the Toyota Production System

[27:29] Overcoming and growing from tragedy

[33:38] Implementing the Virginia Mason Production System

[40:25] Continued partnership with Toyota

[45:08] Dr. Kaplan’s favorite well-designed things


Dr. Craig Joseph: Dr. Gary Kaplan, thank you so much for appearing on the pod, and it's really an honor to have you here.

Dr. Gary Kaplan: It's my pleasure to be here with you, Craig. Thanks.

Dr. Craig Joseph: So your history is that you're an internal medicine specialist and you were practicing in the Seattle area, progressing up the ranks and ultimately becoming the chief executive officer of Virginia Mason Franciscan Hospital or Health Center

Dr. Gary Kaplan: Virginia Mason Franciscan Health is the name of the new system. But for my 21 years as chief executive, I was the CEO of the Virginia Mason Health System. And then prior to my what some people call retirement, we merged to and formed Virginia Mason Franciscan Health.

Dr. Craig Joseph: Okay. And so what I think we're going to focus on today is something that you did when you took over that really kind of revolutionized the way that Virginia Mason provided care in your hospitals and in your clinics. So you became the CEO in 2000. Is that right?

Dr. Gary Kaplan: That's correct. I’d been at Virginia Mason really my entire career after leaving the University of Michigan.

Dr. Craig Joseph: And so can you maybe paint that picture for us around the year 2000 when you took over? There were some issues that you needed to address or that you felt that needed to be addressed and hadn't been.

Dr. Gary Kaplan: Yeah, it was a very interesting time in the history of our organization. We were one of a small group of organizations that were founded by doctors from the Mayo Clinic, what I call the Mayo Clinic diaspora. In the late teens and early twenties, a lot of the Mayo Clinic physicians who were the first, as you know, the first group practice in the United States, they I think I jokingly say, decided that they didn't want to live in Rochester, Minnesota, in the wintertime. And they fanned out to form these group practices across the country to beautiful places like Cleveland, Ohio, Boston, Massachusetts, New Orleans. And so Virginia Mason was one of those clinics like Geisinger, Ochsner, Cleveland and others that were born of the Mayo Clinic model. And we were a place that became a major referral center for the Pacific Northwest. We were the first group practice in the Pacific Northwest, and I came there in 1978 as an internal medicine intern and really fell in love with this organization, the multi-specialty group practice model, and never left. And so I was fortunate. I was part of leadership for many, many years. I was vice chairman of the medical center from 1995 until the year 2000 and then the year 2000. I was chosen as the seventh CEO in now 103 years. Each of us has been a practicing clinician and I was part of leadership when I became CEO. But it didn't take long before I realized that we really needed to change, to change in a big way, in several major ways. And that was hard, because I was a product of the organization, product of the past. But for me it became how do you honor the traditions and the legacy and then still lead large-scale change? And it was very interesting. It started with a question from our board. So here I was a new CEO, but part of the prior leadership structure and the board asked us who is our customer? And like everybody in healthcare, I said, well, of course it's the patient. But what happened next really kind of threw me for a loop because the board said, “Well, if that's the case, why do things look the way they do?” And in fact, that began a deep dive on our processes. And we came to see that they were really designed all around us. The doctors, the nurses, the pharmacists, social workers, everybody working in healthcare. And this was long before, you know, people started talking about patient-centered care. It became the buzzword. The IOM had just put out their first report: To Err Is Human. And we began to see that we needed to change our ways and redesign care around our patients. A great example I use is waiting rooms. I mean, what are waiting rooms but places for patients to hurry up, be on time and then wait for us? We spend millions of dollars still today in this country building these spaces so patients can wait. But what if we could actually create flow and eliminate waiting rooms? And it was a great, it is one of hundreds of examples of how care was designed around us and not around our patient. So we got very clear that we wanted to be, to move from what I was proud at the time, to call a physician driven organization to being a patient driven organization. We then went through a strategic planning process led by the board, our leadership team, but really broad based and involving our doctors, many from our communities, many people from our community. And we set ourselves a vision. And our vision was really all-around quality and it was evolved to be the quality leader. Now that for most people would sound like apple pie and motherhood, of course, it took us months to come to that because it was at a time when most health systems were looking for market share dominance, you know, those kinds of things. And we said, we're going to double down and bet the farm on quality. That became our driving force.

Dr. Craig Joseph: Let me ask you a question about kind of pivoting from what you, what everyone would say in healthcare, which is where we're focused on the patient. You said, well, actually, when you look around or actually your board did. It looks like you're really focused on the physician and the people that work here. And that was it sounds like back in the day, that was one of the major reasons that was a very important thing for Virginia Mason to do. Right. Focus on the physician and the nurse in terms of recruiting and retention. And so, you know, what happened when you kind of made that, when you had that aha! moment and there was a switch and hey, hey, doctor and nurse and therapist and pharmacists, we're going to switch things up here a little bit.

Dr. Gary Kaplan: It was actually very controversial in many ways because, like I said, I was proud to talk about Virginia Mason as a physician-driven company, but we pivoted in a sense, saying that we can actually be a great place for physicians and nurses and team members by virtue of being a patient-driven organization, because that's why we all went into healthcare to begin with. However, there were skeptics. I had doctors in my office. I had one doctor came into my office, pounded his fist on the table and said, if you don't flip what we called our strategic pyramid, which was an iconic depiction of our strategic plan that had the patient at the very top, If you don't flip that and put the doctor back on top, I'm leaving. I showed him the door and we lost a few people who were saying, this isn't the place I wanted to or had come to, or that it's always been. And yet soon it became a rallying cry. The people were so proud that and as I said, long before people were talking about patient centeredness, that this was a place that was truly going to be about the patient. And it became embedded in our decision roles. Whenever we had choices, we would always err on what was in the best interest of the patients. And that soon then became a magnet for attracting staff, attracting doctors. And when you couple that with what we haven't talked about yet, which is the Virginia Mason Production system, people gravitated to Virginia Mason because they wanted to be in a place where they were empowered to work on their work and to actually have a way forward, to make things better. And so that refocus of the patient, putting the patient at the top, was the first step. The vision of becoming a quality leader was a huge step forward for us. I remember Paul O'Neill, former secretary of the Treasury, who became very interested and CEO of Alcoa. He became very interested in healthcare in his later years, became a good friend, visited us many times at the Institute for Healthcare Improvement annual meeting in 2002, he said little Virginia Mason up in the Pacific Northwest has embarked on a bet the farm strategy around quality and now, I didn't know was at the time that it was bet the farm I knew it might have been, bet the career but I didn't know it was bet the farm. And it was also a focal point for people who really wanted to be serious about providing the very best of care excellence. The next thing that happened, which was very interesting, was I realized that in a physician-driven organization like Virginia Mason, we needed to recast what I would call the deal between the doctors and the organization. That the old compact, which was entitlement protection and autonomy, was a really sweet deal. And that was the deal when I joined Virginia Mason. I was entitled to patients. I was protected by the business leaders and the physician leaders like I became, and I was autonomous. Nobody could tell me what to do. I was a doctor and only I knew what was best for my patients. So, we embarked in 2001 on a process of putting together a new compact between our doctors and the organization. What did every doctor have every right to expect from the organization? What did the organization have every right to expect from its doctors? And in fact, that compact took a year and touched every doctor in the organization and is alive and well even today, over 20 years later. But that was the foundation also. And that allowed us to even consider introducing a management system that was all about manufacturing, that had never been done before in healthcare. So, we had a vision, a new vision. We redesigned care around our patients. We were focused on becoming a quality leader. We had a new compact with our doctors, and soon thereafter, by the way, our leaders and even our board, they wanted a new compact. And then it was how are we going to possibly do this? And I personally went looking at the great health systems in the United States, and nobody had a management system, and that's when we heard from Boeing what was going on there. And we began to explore the Toyota Production System and we can talk more, if you'd like, about it, became our management system and is still today our management system, and we're sharing that, those learnings around the world.

Dr. Craig Joseph: So, Dr. Kaplan, you were looking for a management system. You went to the ends of the Earth, or at least the ends of the U.S., looking at great healthcare systems and how they managed the work that they were doing. But ultimately you landed on a place I think most of us would, never guess in a million years. It was the Toyota Motor Company, the Toyota Car Company. And so how did you kind of find out what they were doing and then figure out that you wanted to learn a lot more about it?

Dr. Gary Kaplan: Well, we went exploring, you know, as I said, for a management system, didn't find it in healthcare and very serendipitously heard about Boeing's work with the Toyota Production System where they were you know, Boeing being here in Seattle, just down the street. They actually went from taking 21 days to build a 737 to 11 days, and they built it. It’s ironic today with some of the challenges they're facing as a company. But this was back, you know, in the nineties and they were building planes of better, higher quality, safer, faster and at lower cost. And we said, wow, maybe there's something here for healthcare. Because that was what we needed. We needed higher quality, safer care. But we also had cost challenges even then and as we do today. And so we began to explore. We dabbled, went to Boeing, we visited, we dabbled in the production system, did a couple of projects, studied it. And in December of 2001, we took the entire management, not management team, but the executive team, about 30 people. And we went to a company called Wiremold in Hartford, Connecticut, and they were one of the leading so-called lean companies in the United States. And it kind of blew us away. These frontline blue-collar factory workers were saying, finally, people care what I think. I had solutions to some of the challenges but had no way to bring them to the fore. And they were empowered. They were on fire. They became a great company. And we came home saying, you know, this is really, there's something here. And the Boeing people said, well, look, if this were a new medical procedure, you would go to the source, you would go to the place that this was developed, and you should go to Japan. And that's when we decided to go. And I said to the entire executive team, if you want to be on this team, you're going to come with us. Yeah. I had never been there. I had no idea what to expect. And that was a transformative two weeks where we worked in the factory. And actually, I just got back from helping to lead our 20th trip with doctors, nurses, frontline team members working to practice the tools that we had been learning about and then bring them back and apply them to taking care of patients. And it was quite remarkable.

Dr. Craig Joseph: So the Toyota Production System is, I think what we're talking about and you took your entire executive team flew them first to the other side of the country and then to the other side of the world. And what did you end up with? You ended up with the Virginia Mason Production System, right? VMPS. And how long did it take to kind of to you felt like, hey, we really do have something that we can put a name on? Was that a year? Was that two years? How did that process go?

Dr. Gary Kaplan: Well, we came back from Japan, and in our last team meeting in Japan, we collectively made the decision that this was going to be our management system. This was how we were going to run the company. And so, we didn't delay. We came home and began to put in place the kinds of things we would need to do, particularly the training that was required. And particularly and first and foremost, we actually put in place what Toyota is famous for in their stop-the-line approach to patient safety, we applied it to patient safety. We came home and said we want to take care of our patients and do for our patients at least what Toyota's doing for cars. And so, we began almost immediately to put this in place, came home. People thought we had lost our minds. You know, we started talking about standard work, which today is the buzzword. You know, we need to standardize nonvalue added variation. In those days I remember standing up in our auditorium in front of all of our doctors and saying we need standard work so that we can eliminate variation that adds no value and make care safer and eliminate the waste that care is filled with. And people said standard work, that's standard mediocrity. Cookbook medicine, stifle innovation. And actually, nothing could be further from the truth. And just a few years ago, we had a professional staff meeting, which we have every month, and the theme was from our doctors. We need more standard work, and we need it now because it really did make care better. It made it easier to do the things we all want to do for our patients when you can take the waste out of processes. So, you know, it took two or three years before we began to reach a tipping point. Some people said, ‘this is not for me’. I jokingly was asked at one point how many people left and that wasn't a joke. It was a serious question. But what I you know; I said not enough. But frankly, what I meant by that was, you know, I spent a lot of time. These were my friends, my colleagues, my mentors, and I wanted to bring them along. And it wasn't until, you know, I realized that not everybody could come that we were able to really accelerate because, you know, I wanted everybody to buy in and to feel comfortable, but not everybody could. And that's okay. You know, then people had to go their separate ways. But as I said today, it's the way work is done. It's been that way now for almost 20 years and over 20 years. And there's tremendous alignment and it's become a magnet for people.

Dr. Craig Joseph: Well, that's great. Let's talk about that first thing that you mentioned, the stop-the-line. And so, what you had mentioned, I think one of the things you saw in Japan at Toyota was the ability for almost anyone working in the factory line, on the production line, to identify a problem that they could not resolve themselves and they could pull a cord and literally stop the production for the entire factory until that thing gets resolved. Because they were taking quality that seriously. How did you, well, healthcare might be kind of a factory. There's not a beginning and an end that's easily identified. How did you apply those principles at Virginia Mason?

Dr. Gary Kaplan: Yeah, I think that what we saw there, which was really amazing to most of us, was that here were blue-collar factory workers, every single one of which empowered to shut down the factory. That in and of itself was an eye opener. It wasn't after the car got through the assembly line that they inspected and find the problem, but that they would really actually stop and fix the problem rather than pass the defect to the next operator. What do we do in healthcare? Traditionally, retrospective quality assurance, you know, a month after the fact, the QA committee says how many people were readmitted within ten days of discharge and we find the reason it's usually a systems issue, not a person issue. We fix the system, but how many more people will be harmed by delay and retrospective quality assurance? And so we said we want real time quality assurance. So, we set up a system where we asked every single team member to be a patient safety inspector. And that meant that every single team member not only was empowered to report a defect, an error, a near miss or frankly, anything that concerned them, but they were expected to. Now that doesn't mean that everybody embraced that or believed it right away. We called it a PSA system, a patient safety alert system. And there were you know, people used it as a verb. They would say things like, you're not going to PSA me, are you? Or you're not going to report me. And it became you know, there's that's very much part of the fabric and culture of medicine, you know, is peer protection, peer review. We will do all the various types of quality meetings under cloak of secrecy. But we started celebrating that, you know, people that reported these defects were heroes because they were basically saying, you know, this is I'm concerned about this. It may lead to nothing. And the commitment from management was just like the supervisors at Toyota. When someone pulled that cord, the line stopped, and the supervisors converged to help the worker fix the problem. We said we will respond 24 hours a day, seven days a week to your concerns as staff members and people didn't believe that either. And then it started to happen and suddenly people said, wow, they're serious, they mean it. And what that led to was Virginia Mason becoming, in many ways the safest hospital in the United States. But it wasn't until tragedy struck that we really realized what it was going to take to truly change the culture and to truly be focused on creating what I call a perfect patient experience, or what some people called zero defects. And that's when Mary McClinton came to us for a tertiary procedure, but one that we do every week at Virginia Mason. And we failed her. She died of a preventable medical error. When we realized what happened, the patient safety alert was called. We took steps to ensure that what occurred, happened to Mary would never happen again. And we went public, which until that time had never been done before. With one exception. Betsy Layman, who was a Boston Globe reporter who died from a chemotherapy overdose at the Dana-Farber Cancer Institute. And so, we went public. We were fried in the media. We were on Good Morning America. I got letters from Europe saying you should be put out of business you don't deserve; you killed that woman. And it was the saddest time in our history. But I knew we had done the right thing. When one of our team members came forward a couple of weeks later and she said, Dr. Kaplan, the same exact thing happened at X hospital down the street and was swept under the rug. And if that had been put out into the public domain, maybe Mary McClinton would have lived so from that point on, you know, at that point we said we're only going to have one goal in this hospital medical center, to keep our patients safe and free from avoidable injury and harm. And for the next three years, we had only one organizational goal solely focused on patient safety and accelerated the development of VMPS and the cultural evolution that led to us proudly being named Top Hospital of the decade by Leapfrog.

Dr. Craig Joseph: So, let's dig in a little deeper on what happened to Mary McClinton, because I think it's obviously sad but very instructive and one of the things that you had said before a little earlier is that you identified a problem, but it was not an individual problem, was a system problem. And I think that doesn't get enough attention. A lot of times we look at the last person who kind of touched the patient. We said, well, this is their fault. And they're the ones that get named and shamed and often lose their job and maybe even their license to practice, even when it's a system problem. So, as I understand it, Mary came in for an operation and something happened in the OR that wasn't identified until days, hours, two days later. Can you kind of give us that story?

Dr. Gary Kaplan: Yeah, Mary came in for an interventional radiology procedure, cerebrovascular interventional procedure. And what happened was the saline that was injected or presumed to be saline turned out to be another clear and colorless, colorless fluid that was chlorhexidine and that was the defect. That's what happened. There was lack of labeling. And this was at a time when it was, you know, this wasn't realized as a potential error. And it was quite remarkable and, you know, very sad. And it was that, you know, the operator was handed the syringe to flush the line and it had been drawn up from a beaker there and colorless fluid. And it was a mistake that led to Mary's injury and subsequent death. Labeling was part of the systems issue, recognizing that clear, colorless fluids are a defect prone situation waiting to happen. They don't even make the stuff anymore so that you can make that error there. It’s put in the swabs so those were the systems issues that were identified. And when we went public health systems across the country began to put in place changes to prevent this from ever happening as remotely possible. You know, as a rare occurrence that it might be. So yeah, systems issues I think your point is well taken even today and I'm very involved as you may know, in the patient safety world and we have not yet gotten to this no blame kind of culture that we need to now stop focusing on people and focus on systems that have occurred. We still have scapegoats. We still have people being punished and we don't have enough of what is called just culture, where we understand at a deep level human error. We understand at risk behavior, and then we also understand reckless behavior. And where we can see reckless behavior, we have to deal with that. But we also have to recognize that human error occurs every day and that we need to find ways to mistake-proof. The Japanese, it's called poka-yoke, to mistake-proof our processes so that you can't possibly make the mistake. And there are actually many, many opportunities in healthcare to truly mistake group processes. And so we've learned a lot about those things. But unfortunately, while the conversation is evolving in the profession and in the industry, far too many people are still working in environments where blame is the norm. And the result of that then is that a lot of the concerns go underground. We've had hundreds of thousands of patient safety alerts at Virginia Mason because people know that what's expected of them, and you can't improve what you don't know about. You can't mistake proof, which you don't know about. And so rather than drive that underground and continue to propagate errors and wasteful processes, I think more transparency is clearly required and more focus on training just cultures within our healthcare institutions.

Dr. Craig Joseph: Yeah, I'm fascinated by that design principle of making things error proof. And this was a really great example and taking that clear liquid and changing it so that it's no longer a liquid, it's actually now a swab and putting the chlorhexidine on a swab that's now it's now impossible to confuse that and you've taken that design is so much more, it's safer, it's more usable, it's more obvious. And instead of what would normally have happened, I think and still would often happen is that the person that drew up the liquid and then instilled it, that person would normally be the one that was blamed. And we wouldn't say anything about system. And to me like that's the flag that you're waving and I'm so glad you waved it 20 years ago and are still waving it today.

Dr. Gary Kaplan: While we talk about systems just to step back for a minute, one of the first steps in putting in place the Virginia Mason Production System or TPS, Toyota Production System, is a deep understanding of one of the processes, and I used to think I understood my work, but it wasn't until I asked somebody to time me over the course of a day that I realized I was spending an hour and a half every day looking for things. I thought I had a steel trap filing system and, but I was wasting my time. And so, when we came home from Japan that first trip, we asked every single major area of the medical center to map out a value stream map and understand their process. And when you do that, that's where you begin to see the waste. You begin to see the interconnectedness of the systems of how the silos that we traditionally built in healthcare are not how patients access our care. They go across those silos and, understanding the value stream of care through the lens of patients. And that step really puts some, you know, meat, specificity to the notion of, well, it's a systems issue which some people think when you say that you're just trying to get out of blaming somebody, but really what you're trying to do is actually get to the root cause and the core of what's causing it. So we have a deep, I think, understanding of our processes and that can lead to all kinds of things to improve processes, improve throughput, eliminate bottlenecks. And I'd say most importantly, make care safer and higher quality.

Dr. Craig Joseph: One of your colleagues wrote or a couple of your colleagues, I think, wrote an article in the Joint Commission Journal talking about why patient safety alerts, as you've called them, the system that you've created that have even made a verb of PSA-ing, why it works, how it works. And the four bullet points that I think they called out was one and you've talked about this executive leadership is essential from the CEO. I think you were only two or three as the CEO. You were only two or three steps away from, you know, from being called to action for a PSA. Another thing, another one of the essentials was making it easy to report. And I see a lot of healthcare systems really not jump on this. You know, if someone sees something, can they send a message? Well, sure. You know, you just have to go to the website and then click five different places and then you have to fill out all of these required boxes. And so you're not really incentivizing folks to tell you about things. And then hence you shouldn't be shocked when you don't get those reports.

Dr. Gary Kaplan: Exactly. So, it's perfectly designed to get the results it gets.

Dr. Craig Joseph: Exactly right. I regularly find folks who are like, well, they could just email. We made it easy to email. And I'm like, well, you know, most clinicians or our folks in operations are spending their day in a specific system like the electronic health record or somewhere else, and they're not going to these other places. And so, you're not going to get these updates or even whether they're safety or any other types of recommendations. And finally, having to once you identify a problem, fixing it. Right. And that's, again, where a lot of folks I can imagine with Mary McClinton, a fix that some other healthcare systems might have made was to get rid of the person that made that mistake and problem solved. No that's not the fix. And so I think there's, it sounds pretty easy when I'm listening to you, but it's certainly not, it was a lot of work and a lot of culture change.

Dr. Gary Kaplan: Right. And I think that's right. And that point number one about the executive presence. And it wasn't about me, it was about our team. We had a very aligned executive team and, you know, which then created an aligned frontline management team. And, you know, I used to tell my direct reports, we'll go over your list in my office for 20 minutes and then we're going somewhere. We're going to the ICU, to the OR, to the laboratory. We're going to go where the action is. And all of us made executive rounds, really almost every day. And many of the leadership meetings, I personally every Tuesday morning at 7 a.m., let's stand up where the improvement work of the week was reviewed. I asked, you know, pointed questions. We tried to have some teachable moments, but the real, the real intent was to send the signal that this is our work, too. When a lot of CEOs were looking at M&A or new facility development, which, you know, I had to do philanthropy, I had to do all that stuff, but you had to be visible, and you had to walk the talk and you had to stay focused on the vision. And I think that was really critical to the culture evolving in the way it did.

Dr. Craig Joseph: I'm fascinated by some of the stories I've heard when you brought some of the Toyota Production System and other folks from other industries kind of brought them back to help you from time to time to offer their perspective. They knew nothing about healthcare. I was reading in a book that we’ll make sure to put in our notes for this episode, Transforming Healthcare, about how you made some of these changes. And there was one anecdote about someone explaining a waiting room, as you referenced a little earlier, like, this is the waiting room. And the person kept asking, well, why is there a waiting room and just kept whatever the response was, just kept getting to the whys and ultimately said, aren't you ashamed? Aren't you ashamed that your system is not good enough, that you are, as again, as you referenced earlier, that you've got patients waiting for you, even though they've done everything that you've asked them to do. That perspective and that outside perspective seems amazing because that's not something you or I would ever I think I would say I'll speak for myself; I would never have thought of that in that way.

Dr. Gary Kaplan: And I think that you referenced Sensei Nakao, Mr. Nakao is one of only two living students of Taiichi Ohno. Taiichi Ohno was the founder and inventor of the Toyota Production System, and he had these six students and Nakao was one of them. And he really adopted us as his healthcare client. I actually personally became his physician for a period of time and even today, we have the Sensei from Japan come to Virginia Mason. They keep us honest. They keep us from getting overwhelmed by our own press clippings and ask questions like that. I mean, I remember and they're appreciative inquiries, Sensei-like approach to learning is fascinating. And we had early on one of our leaders was talking about a sterilization process that she was trying to improve. And she said, you know, I just don’t understand exactly how the autoclave works. And so, Sensei Nakao said to her, well, get in the autoclave. And, you know, first of all, the autoclave is not big enough for a person. Of course. But what he was really saying is, don't ask me, ask the machine. If we're on the assembly line at Hitachi air conditioning and somebody says, I don't get how that machine works. The Sensei will say, go ask the machine. And they're basically saying, big eyes, big ears, small mouth, and use your powers of observation and listening. And these are important skills. So, we still find it valuable to bring in outside expertise. Today, people are coming from all over the world to Virginia Mason Just like we went to Japan, and we say, you know, we've got to continue to grow and learn or we have nothing to really teach. So, it's been an interesting process now over 21 years.

Dr. Craig Joseph: A similar application of taking kind of the area of a defect in care and applying that from a defect in production to healthcare that I thought was very interesting that I read about was a call light on the inpatient side. Right. So, if a patient for those who have never been in the hospital for if a patient needs something and they're in bed, they can press a button and it will either call their nurse or call a clerk who can try to address that. And that this person at Virginia Mason was saying, we see that as a defect. If you had to click that button and call us, then we didn't, we're being reactive, and we don't want to be reactive. We want to be proactive whenever possible. So, if you're calling us because you need to use the restroom, when was the last time we asked you if you needed to use the restroom? Can we have made that better? And again, it's just a very different way of looking at things.

Dr. Gary Kaplan: Yeah, I think that's right. What you're describing is the result of a rapid cycle improvement, rapid process improvement workshop that are in acute care inpatient nurses did themselves, they said you know we’re spending the majority of our time, not at the bedside. We don't want the new hospital floor to have nursing stations where we can go and hang out with our fellow nurses. We want to be at the bedside. And so they designed cellular nursing where basically bed assignment was based on geographic design. And the patients did a lot of their work, I mean, the nurses did a lot of their work inside the patient rooms. And so there was never a need to push the call button because historically in healthcare, you know, you're visiting your family member in the hospital. That IV pump starts beeping. You can't get it to shut off. I know being a doctor I guess I felt like I could do it, but I pulled the plug to get the thing to shut off because nobody responded to the nurse button, or it took so long. So if you can eliminate that by having the physical presence, care gets better, patient's needs are met more quickly. And I think it has importantly, the work is much more rewarding to the nurses and to the patient care technicians who are spending their time at the bedside, which is why they went into healthcare to begin with.

Dr. Craig Joseph: Typically, we often end this podcast with me asking you, are there things, are there one or two things in your life that are so well-designed that they're notable or they bring you joy?

Dr. Gary Kaplan: Well, that's an interesting question. I mean, one of the things, we built a home in Seattle about 14 years ago, and it's got a large cathedral ceiling and radiant heat in the floor and nobody, you know, for many years, Seattle was the venue with the lowest penetration of air conditioning in the country because it never got hot enough. But as we know, with climate change, things are changing. And we've actually had days in the hundreds here. And so, my wife and I decided that we were going to get the air conditioning, but because we don't have ducts in our house, we had to get these units that you put on the wall. And what was a fabulous byproduct is they also produce heat. And so while we got them so that we would have air conditioning in the summer, it turns out that our heating system became much more efficient and much more comfortable since we put these units in place. And so they're just, I didn't realize that they were designed to produce both heat and air conditioning and it's just something I'm actually appreciating today because we had a power failure last night, as I mentioned to you earlier, and it was colder than I had hoped it would be when I got home from the Michigan victory in the National Championship game last night.

Dr. Craig Joseph: So. wait, was there a football game?

Dr. Gary Kaplan: You know there was. And I was in an interesting position being a Seattleite for 46 years with the University of Washington, a couple of miles from my house. But I bleed blue and it was a wonderful experience.

Dr. Craig Joseph: Well, thank you again. Thank you for sharing that. I will send out my positive energy to you that you're safe living in Seattle and being a Michigan fan for the next year because I doubt that you'll mention to anyone in Seattle that you bleed blue and that you're a Michigan fan that probably will never come up.

Dr. Craig Joseph: I'm just guessing.

Dr. Gary Kaplan: Oh, it will, that plane ride home last night was very interesting.

Dr. Craig Joseph: Well, go blue. I will say that. And that's the state of my birth. So, I feel for the state institution. Yeah. So, again, thank you for your time and sharing your messages with us. Really appreciate it.

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