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Mistake-Proofing Primary Care

Virginia Mason Institute

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Virginia Mason recognized that mistakes and defects in health care not only harmed patients but eroded patient and staff satisfaction. Care teams were spending valuable time fixing mistakes and defects in primary care — such as rooming mistakes, scheduling patients for the wrong provider, medication errors and neglected tests and vaccines — instead of spending that time caring for patients.


The following improvements were designed with input from physicians, nurses, medical assistants and customer-service representatives from Virginia Mason’s Primary Care Department.

Encouraging preventive screenings

First, Primary Care designed new standard work in appointment scheduling to support preventive care. When a patient requested an appointment, a patient services representative checked the computer to identify any preventive tests the patient was due for and offered to schedule the test right at the point of service.

Next, Virginia Mason added a Health Maintenance Module to its electronic medical records to make patients’ preventive care needs more visible. While rooming the patient, the medical assistant used the module to flag tests the patient was due for in the medical record. The flag became the first note a physician viewed during the visit, and it required modification before the physician could proceed any further with the visit.

Leveling the skills of the team

Primary Care also ensured that health care team members were doing the right work for their skill level, also known as level loading, or heijunka. Several tasks that physicians previously handled were reassigned to others. For example, medical assistants began practicing at the top of their certification; their responsibilities included going through the problem list with the patient, performing more setup and prescreening, reviewing medication lists, verifying allergies, reviewing test results and administering vaccines.

Planned care

Primary Care experimented with delivering more intense care and coordination for the patients who were sickest in a primary care setting. In a pilot with The Boeing Company and Regence BlueShield, Virginia Mason set out to reduce Boeing’s health care costs by 15 percent for employees who had the most expensive health conditions — while improving patients’ health status. Part of the intervention included “planned care” for patients with chronic or complex conditions by nurse case managers, who provided phone support and coaching, as well as visits with nurse practitioners and physician assistants.

The pilot lowered Boeing’s health care costs by 33 percent and reduced hospital admissions, despite the additional expense for nurse coaching. Quality also improved: More patients with diabetes were placed on statin drugs and more diabetes patients reported healthier cholesterol levels (from 40 percent in 2000 to 68 percent in 2009). Patient and staff satisfaction also improved, with staff reporting that they knew what was expected of them.

The clinic also set up a visual system, in the form of a bulletin board, so the provider could easily see when a patient required a call-back throughout the day.


By implementing standard work that encouraged preventive care, Virginia Mason’s primary care patients received care that was more proactive and systematic, resulting in improved patient safety and patient satisfaction. Planned care also improved quality for patients with chronic and complex medical conditions, reducing hospital admissions and saving money.

Clinicians were better equipped to care for their patients because they had the information they needed right at their fingertips. Additionally, by leveling the skills across more members of the health care team, no single member of the health care team was overwhelmed and their responsibilities were clearly defined, resulting in a win for staff efficiency and satisfaction.

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