The Blue Yarn

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

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

David Weinberg (DW): It was losing money.

RM: 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 started studying how other hospitals are managed.

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

RM: 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 started up with unnecessary jargon. But really all you need to understand here is that Dr. Kaplan was looking for a hospital that has processes and procedures that were better than what he was already using. But he never found one. So instead, he ended up in Japan.

DW: At a Toyota factory.

RM: Yep. The automobile company.

Charles Kenney (CK): 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.

DW: 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.

CK: There was a lot of anger from people within his organization, lead by the doctors, of course.

RM: 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, ‘trace the path a cancer patient would take on a typical visit for chemotherapy treatment.’

Michele Wettland (MW): 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 maybe four inches above that.

RM: Michele Wettland is a nurse manager at Virginia Mason.

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

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

RM: And that’s doctor Henry Otero.

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

MW: 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 and 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.

HO: 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 that you don’t really know what’s going on.

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

MW: We just didn’t- we just couldn’t conceive of it intellectually until we saw it visually.

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

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

HO: 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.”

RM: Then he saw the twisting path of the blue yarn.

HO: 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 that it became an intolerance, really, too. I couldn’t accept it anymore.

DW: 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.

HO: 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”

HO: And as this was happening.

“Well that’s a waiting area”

HO: 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 the 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’s team, says to them, “aren’t you ashamed?” And Dr. Mecklenburg said at that moment he was ashamed. He was absolutely ashamed.

RM: 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.

DW: 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.

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

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

DW: 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.

RM: But in order to give the patients these rooms, they had to take them away from the doctors whose offices had been there.

HO: It wasn’t something that was really difficult for me because I think we were always in the right direction with the patient. I think for others, who 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?

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

HO: 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 that decision was made and it totally was the right decision. There’s not even a question about it.

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

MW: 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.

RM: 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.

DW: From 2007 to 2009, Virginia Mason was so much safer than 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.

MW: 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 patients.

DW: 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.

RM: 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.

DW: 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.

HO: 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.

RM: Then you start making automating looms and improve the machinery

HO: 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. But we’ve got a long way to go to mistake-proof healthcare and do it in a cost-efficient manner.

RM: 99% Invisible was produced this week by David Weinberg, with help from me, Roman Mars….

Comments (7)


  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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