Shift in hospital culture frees up time for nurses to spend with patients

A culture model pioneered by a US hospital and adopted by five NHS trusts is giving healthcare professionals greater opportunities for direct patient care

An American approach to transforming hospital culture by improving quality and safety has been running in the NHS for a year. Five trusts in England have been using the US method, which was influenced by Japanese car production techniques.

The approach was influenced by Japanese car production techniques Photo: Alamy

The Virginia Mason Hospital in Seattle, Washington, designed a system to put patients at the centre of a healthcare organisation’s work. It adapted principles originally developed by Toyota to improve patient safety, patient experience and the quality, cost and delivery of healthcare.

Six years after the hospital began its mission of striving for zero-defect healthcare, in 2002 its staff set up the Virginia Mason Institute, a not-for-profit organisation which aims to help other healthcare providers transform practices.

Last June, health secretary Jeremy Hunt announced that the institute’s experts would work on a five-year partnership with University Hospitals Coventry and Warwickshire NHS Trust, the Shrewsbury and Telford Hospital NHS Trust, Barking, Havering and Redbridge University Hospitals NHS Trust, the Leeds Teaching Hospitals NHS Trust and Surrey and Sussex Healthcare NHS Trust.

Patients' needs

The approach streamlines work so that doctors and nurses can monitor and attend to patients’ needs quickly. The Virginia Mason Hospital moved the most commonly used supplies to patient rooms so nurses had to do less walking back and forth to get them. Steps walked each day fell from 10,000 to roughly 1,200. Electronic dashboards were developed to remind clinicians to address specific issues, for example to undertake a quality review for every critical care patient.

The new system led to nurses spending more time with their patients. Virginia Mason estimated that the time nurses spent in direct patient care increased from 35% before the changes to 90% afterwards.

Charleen Tachibana, senior vice president for quality and safety at Virginia Mason, says nurses as frontline staff are key to spotting problems and developing solutions to improve care delivery. ‘Our method has eliminated time spent on non-value added activities, reduced the work burden and created greater skill-task alignment ensuring that the right people are in the right jobs.’

Since 2008, more than 5,000 professionals from 20 countries have attended training sessions at the institute. The approach requires a long-term commitment to making cultural changes that last.

Intensive support

Mark Radford, chief nurse at University Hospitals Coventry and Warwickshire NHS Trust, says that the trust has had intensive support from staff at the Virginia Mason Institute this year. Specialists from the US have helped to train 40 staff during regular visits to the trust. A team from the hospital has also visited Seattle to see how the model works in practice.

The model focuses on streamlining healthcare delivery and improving safety by developing a culture of openness and transparency, says Mr Radford. The trust initially wants to improve the reporting of safety events, efficiency in theatres, and efficiency and care in the outpatient ophthalmology department.

Each area has a value stream event, the name given to a meeting of frontline staff to see where improvements could be made. Staff use a value stream map, representing a patient’s experience and the flow of healthcare process. Produced through direct observations where the work is done, it is designed to help staff see waste so that they can direct improvements.

Changes made at the trust include giving ophthalmology patients their next appointment before they leave the department, rather than sending them a letter naming a time they may not be able to make. This has reduced the number of missed appointments.

Faster system

The time taken to report patient safety incidents has been cut from days to minutes. Mr Radford says that in the past, a member of staff would report an incident on the system and it would go through a process of being graded by a senior clinician and safety officers. ‘Now the individual entering the information grades it straight away,’ he adds. ‘It streamlines and simplifies the system and changes the culture of people reporting incidents.’

Where systems have been shown to work, they are to be rolled out to other departments to create a cycle of continuous improvement, Mr Radford says.

‘The really important thing is that change is bottom-up. It is about people who work in the system with patients designing procedures that will work,’ he explains. ‘The system is designed collectively around engaging frontline staff and supporting them with senior executive support, and making changes within a week rather than taking a long time. It is really exciting. Staff have been enthusiastic about being involved. There are always going to be people who find it more challenging, and part of the process is how we engage those people.’

Changing the culture

He stresses that the Virginia Mason approach is not a short-term fix, but a long-term plan to change the culture of the organisation. ‘We will see some results and improvements in the first couple of years,’ he adds, ‘but later we will see substantial culture shifts.’

NHS Improvement, the organisation that oversees foundation trusts and which has supported the partnership with the Seattle hospital, agrees that the approach is for the long term.

Kathy McLean, executive medical director, says: ‘The partnership we have with the Virginia Mason Institute is a five-year commitment, but the vision for the five trusts goes far beyond this. Less than a year in, we are already seeing progress – core staff have been trained and the trusts are implementing new management techniques, empowering staff across disciplines to focus on improvement from the patient’s perspective, free of the usual hierarchies.’


Model aims

The Virginia Mason Institute model aims to:

  • Measurably increase patient safety and quality
  • Streamline efficiency of time-consuming healthcare processes
  • Introduce a culture that places blame on processes, not people
  • Enable providers to spend more time with their patients
  • Increase staff satisfaction and engagement
  • Sustain successes and keep moving forward     


Leeds Teaching Hospital NHS Trust:

Patients and nurses in an orthopaedic department at the Leeds Teaching Hospital NHS Trust are already benefiting from changes inspired by the Virginia Mason programme.

Staff spent a week devising improvements to the system for booking of patients for elective surgery, pre-assessment checks and the flow of patients on the day of surgery.

As a result, two new staff have been employed to carry out pre-assessment, meaning examinations are more likely to take place on the day patients meet their surgeon, so patients can arrange their surgery date in consultation then.

Ann Emerson, nurse scheduler for orthopaedic elective services, says that in the past patients were sent a letter about three weeks before surgery. Operations were frequently cancelled because patients were not available on the date they had been allocated.

‘It has had a massive impact and has been a very positive process,’ says Ms Emerson. ‘I used to spend 80% of my time on scheduling – now it is down to 10%.’

Andrea Tobin, a staff nurse, says: ‘A lot of time used to be spent walking between patients and rooms when people were admitted for surgery. We have now put a small supply of equipment in each room so we do not have to go back to a central area. There has been a 44% reduction in staff walking, which is significant.’

The trust is about to start a ten-month training course for 40 members of staff on lean management principles, with the support of a trainer from the Virginia Mason Institute.

Erin Dean is a freelance journalist

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