The Blue Yarn

Roman Mars:
This is 99% Invisible. I’m Roman Mars.

Roman Mars:
In 1998, Dr. Gary Kaplan, the CEO of Virginia Mason Medical Center in Seattle, received some bad news about his hospital.

David Weinberg:
It was losing money.

Roman Mars:
That voice is David Weinberg, who is doing our reporting for us today. So, back to the story. To stem losses at Virginia Mason, Dr. Kaplan starts studying how other hospitals are managed.

David Weinberg:
He started scouring the country, looking for a hospital with a management system worth adopting.

Roman Mars:
And if you’re anything like me when you hear the phrase “management system,” part of your brain begins to shut down and another part of your brain prepares itself by hearing a lot of either complete nonsense or common sense tarted up with unnecessary jargon. But really all you need to understand here is that Dr. Kaplan was looking for a hospital that had processes and procedures that were better than what he was already using. But he never found one. So instead, he ended up in Japan.

David Weinberg:
At a Toyota factory.

Roman Mars:
Yep. The automobile company.

Charles Kenney:
And think about that. This is a very smart physician who goes around the country looking for a great management system and doesn’t find one.

David Weinberg:
Charles Kenney is the author of “Transforming Healthcare,” a book about Virginia Mason’s journey to adapt the Toyota production system to healthcare. He says that when Doctor Kaplan told his staff they would be changing everything about the way they operate, and the changes were based on a car company, and that the doctors and nurses should refer to their new teachers as “sensei?” The response was not pretty.

Charles Kenney:
There was a lot of anger from people within his organization, led by the doctors, of course.

Roman Mars:
And this whole multi-year overhaul started with a ball of blue yarn. The staff met with the sensei and he took out the ball of blue yarn and a map of the hospital, and he told the staff to trace the path a cancer patient would take on a typical visit for chemotherapy treatment.

Michele Wettland:
And then the yarn went a couple inches and then it maybe went up approximately five inches to where they’d have to get their blood drawn, and then they would go up to the 14th floor and on the cardboard that was maybe like four inches above that.

Roman Mars:
Michele Wettland is a nurse manager at Virginia Mason.

Michele Wettland:
And then they’d have to come and see their doctor, which was in a different location.

Henry Otero:
And it was so big on our board that we just had to keep winding it around itself-

Roman Mars:
And that’s doctor Henry Otero.

Henry Otero:
Creating this kind of this circular maze, like you would wind a yo-yo.

Michele Wettland:
And when we looked at it we were amazed at how far patients traveled. We were asking oncology patients, whose oxygen-carrying capacity is compromised because the chemotherapy destroys a lot of red blood cells so that makes them short of breath, and here we’re asking patients to do this who are short of breath to begin with. So it was appalling to us.

Henry Otero:
And I think it was that mapping of the flows of medicine and understanding the patient’s journey was that eye-opening moment that you realize you don’t really know what’s going on.

Roman Mars:
The blue yarn told the story of what Virginia Mason was doing wrong.

Michele Wettland:
We just didn’t… we just couldn’t conceive of it intellectually until we saw it visually.

Roman Mars:
And the story it told was not a good one to Dr. Otero.

David Weinberg:
He thought he was providing exceptional care for his patients.

Henry Otero:
They basically came into my exam room and they left. And I really said, “I’m a great doctor, look at this great care I give. I see them, I send them out, and they must feel like they have this great experience of having care here.”

Roman Mars:
Then he saw the twisting path of the blue yarn.

Henry Otero:
Oh, how awful it is for them! How awful it must be to really wait everywhere along the way, and that I was contributing to that. And it became an intolerance, really. I couldn’t accept it anymore.

David Weinberg:
Six months after that first meeting, Dr. Mecklenburg, the hospital’s Chief of Medicine, led a group of staff on a three week trip to Japan to meet with a different sensei.

Henry Otero:
And so they pulled out the schematic, essentially an architect’s drawing of various parts of the Virginia Mason Medical Center, and the sensei kept pointing to these areas and saying, “what is that?” And Dr. Mecklenburg would say “well, that’s a waiting area.” And this happened over and over again.

[Well that’s a waiting area.]

Henry Otero:
And as this was happening-

[Well that’s a waiting area]

Henry Otero:
The sensei seems to him to be getting increasingly angry. And he says to Mecklenburg, “Why are there so many waiting areas throughout this facility? Who is waiting there? What are they doing? What are they waiting for?” And Dr. Mecklenburg says “Those are our patients. They’re waiting for us.” And the sensei, long pause, looks quite furious, looks directly at Dr. Mecklenburg and in front of Mecklenburg’s team, says to them, “Aren’t you ashamed?” And Dr. Mecklenburg said at that moment he was ashamed. He was absolutely ashamed.

Roman Mars:
If I told you to picture a waiting room, you’re probably picturing a doctor’s office. This is what we are trained to do when we go to the doctor. We are trained to wait.

David Weinberg:
But for a sensei, who’s been trained in the Toyota production system, waiting is a form of waste. And the #1 tenant of the TPS is to eliminate waste.

Roman Mars:
The staff completely redesigned the cancer center, and they hired an architect who had firsthand knowledge of cancer treatment as a patient.

Henry Otero:
He designed the journey really differently to really be patient-first.

David Weinberg:
The new design put patients on the outer edges of the building, in these rooms with big windows that let in natural light and provided views of the Puget Sound.

Roman Mars:
But in order to give the patients these rooms, they had to take them away from the doctors who had their offices there.

Henry Otero:
It wasn’t something that really was difficult for me because I think we were always in the right direction with the patient. I think for others, who maybe didn’t go through that process, they saw it as a takeaway. “I had the great office, the great window, and now you’re putting me in this cubicle,” you know, and “I’m the guy who does all the work, you know? Shouldn’t I have the big office?”

David Weinberg:
Some doctors were so angry they quit. But Otero says that everyone who stayed realizes it was the right thing to do for the patients.

Henry Otero:
When I go there and I see them there and I see them looking out and I recognize that’s a much better place to be. I’m gratified that decision was made and it totally was the right decision. There’s not even a question about it.

David Weinberg:
Relocating patients was just the beginning. Today, the new cancer center has been dubbed “the cancer spa.”

Michele Wettland:
It was designed to create an environment of healing so it has a really pretty pale yellow color. We use colors of nature so yellow for sunshine and we have browns to simulate and greens to simulate nature. And we have a water wall. There’s two of them, actually.

Roman Mars:
And just so you don’t think this new management system resulted only in natural-colored walls and big windows, the whole reason this blue yarn was unspooled to begin with was to save the hospital money. And it did. And it also made it a safer place.

David Weinberg:
From 2007 to 2009, Virginia Mason was so much safer that their insurance expenses declined by an astonishing 37%, while simultaneously increasing the number of patients they treated. All without having to hire any additional staff. And yet some people still scoff at the idea of Toyota-inspired management.

Michele Wettland:
I was on a boat once and someone said to me, “So are you guys still building Toyotas in your basement.” And that was a real… I mean, I was offended because I knew that what we’re doing here is really good and I said to him, “You know you can say what you want to make fun of what we’re doing, but we’re trying to do the best by the patient.”

David Weinberg:
This complete upheaval of the medical industry, which stemmed from a single thread of blue yarn, became especially poignant when the staff visited Japan for the first time and saw an exhibit at the Toyota History Museum. It was an automatic loom.

Roman Mars:
That was where the team learned that the production system was in fact born quite literally from a single thread of yarn. It might have even been blue.

David Weinberg:
Toyota was originally a textile manufacturer, and in 1902, Sakichi Toyoda invented a self-correcting loom that would stop when a thread was broken or woven incorrectly.

Henry Otero:
The museum is a story of continuous process improvement. You start with back-breaking work on a manual loom that is producing a defective product and you put in the first components of ergonomics — putting the person sitting up instead of sitting on the floor.

Roman Mars:
Then you start making automating looms and improve the machinery.

Henry Otero:
Then you start developing mistake-proofing into the process, that if any of the weave or the weft breaks, the machine stops. Improve the machinery’s function, as time goes on. Add speed and velocity. I see that at Virginia Mason we’ve just gotten off the floor, sitting on the chair. We’ve got a couple of mistake-proofing thanks to the yarn. And someday we might be an automatic loom, but that might be thirty, forty years from now. We’ve got a long way to go to mistake-proof healthcare and do it in a cost-efficient manner.

Roman Mars:
99% Invisible was produced this week by David Weinberg, with help from me, Roman Mars. It was made possible with support from Lunar, making a difference with creativity. It’s a project of KALW 91.7, local public radio in San Francisco, the American Institute of Architects in San Francisco, and the Center for Architecture and Design. To find out more, go to the website. It’s 99percentinvisible.org.

  1. Charlie

    As a public servant, I really thank you for telling this story.
    I will always keep it in my mind and never forget to make this world better.

  2. My personal favorite so far!

    After your Ted talk I’ve started listening from the first post

    (btw, it’s very hard to get to the first posts)

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