The ThedaCare Improvement System (TIS)

John S. Toussaint, MDPresident/CEOThedaCare, Inc.

Is a comprehensive, community-owned healthcare system focused onachieving measurable, better value for our customers. Our mission is to

improve the health of our communities.

Appleton Medical Center

160-Bed Acute CareMedical Center

Theda Clark Medical Center

260-Bed Acute CareMedical Center

New London FamilyMedical Center25-Bed Acute Care

Medical Center

RiversideMedical Center25-Bed Acute Care

Medical Center

Orthopedics PlusThe New Standard forQuick, High QualityOrthopedic Services

In The Fox Cities

ThedaCarePhysicians

Employing Over 118 PhysiciansAt 20 Locations

ThedaCare at HomeHome Health, Hospice,

DME, Respiratory Therapy, Infusion, Pharmacy Services

ThedaCare at WorkOccupational andEmployee Health

Services, Employee Assistance Program

Ingenuity FirstOffers Innovative

Solutions to EmployersFor Health Care Costs

Fox CitiesCommunity ClinicA Free Clinic Jointly

Owned With St. Elizabeth Hospital

The Heritage/Peabody ManorContinuing Care Campus for Older

Adults

ThedaCareBehavioral Health

Inpt and Outpt MentalHealth, Substance

Abuse Services

Gold CrossAmbulance ServiceJointly Owned With

Affinity HealthSystems

July 2006

Missionthe reason we are together

“ThedaCare’s mission is to improve the health of our communities”

Visiona picture of the ideal state to be achieved

“To always set and deliver the highest standard of health care performance in measurable and visible

ways so our customers are confident they are making the right decision in choosing us.”

Shared Valuesthe internal compasses that guide our day-to-day

decisions; the glue that holds the organization together

Compassion

Courage

Honesty

Innovation

Integrity

Respect

Teamwork

ThedaCare Goals6/30/06

Decrease Defects and Waiting Time by 50% each year

Business Engagement

Quality

Customer

Increase Productivity 10% each year

All staff and physicians participate in 2 or more RIE’s

Defects per Million Opportunities (DPMO) Performance

Industry/Process Defect DPMOCommercial large jet travel Crash 3.4

Nuclear industry Reactor malfunction 3.4

Chemical industry Spill 6,210

Road safety Death 6,210

Microlight aircraft or helicopter

Crash 66,807

Himalayan mountaineering Death 388,537

RESULTS:Collaborative Care

A vision of hospital care with nursing at its centerA new model of inpatient care delivery based on:• Change in team roles and responsibilities (people)• Innovative processes• Principles of poka-yoke; pull production and visual

management

Provided in environment designed specifically for the model, to reduce waste, to ensure safety and to promote healing.

RESULTS:

KEY ATTRIBUTE CURRENT FUTURE

Physician Role Hierarchical Partner in care team

Medical Record/Plan of Care Multiple Care Plans, developed separately by clinicians at different times.

One plan, developed by team in room with patient.

Patient Experience Disjointed. May be confusing, even contradictory.

Single plan of care developed with patient – is visible, continuously updated with patient driven schedule and goals.

Clinical Quality Admirable, but not 100% reliable. Manage errors. Dependent on heroic effort.

Reliable, standard work, using evidence-based quality and real time problem solving to prevent errors. Toll gates.

Nursing Role Task oriented. Care manager. Expanded and empowered role in decision making and patient care progression. Bedside management of quality measures.

Environment Semi-private, dated. Private. Designed for patient/staff safety, and to support collaborative processes.

Collaborative Care is the Model Which Will Transform Us From Current to Future State

RESULTS:~ Collaborative Care ~

Initial* Results

Measure Pre Desired Collaborative Care Unit

Defect Free Medication 1.5/pt .1/pt

Quality Bundle Pneumonia 38%CHF

93%86%

Patient Satisfaction 68% Top Box 84%

Length of Stay 4.35 days 2.86

Case Mix Index 1.09 1.12

Cost Per Case $9,640 $6,000

* First 12 Weeks of R&D Unit

Within 4 hours of

admission

1st 90 minutes

Full calendar day 1—may loop here

dependent on condition and LOS.

Within 24 hours of

DC—Toll 4

Within 2 hours of DC—last

Toll

Poka-Yoke Criteria to

assure defects do not pass

forward

Activities to progress care

and reach next Toll

Decision makers in

Purple

TOLL GATES

Patent Pending. © 2006 ThedaCare, Inc. All rights reserved. For More information, contact ThedaCare, Inc.

Collaborative Care Patient ProgressionTollgate

2Tollgate

4Tollgate

5Tollgate

1Tollgate

3

Pat

ient

Dis

char

ge

Are we progressing

care?

ProblemSolve

NO

PTCare

Are we progressing

care?

ProblemSolve

NO

Pat

ient

Adm

issi

on

PTCare

Are we progressing

care?

ProblemSolve

NO

PTCare

Are we progressing

care?

ProblemSolve

NO

PTCare

Are we progressing

care?

ProblemSolve

NO

PTCare

PTCare

Collaborative Care Value Stream Metrics

ThedaCare Orthopedics PlusMSC Care – January 2006

RESULTS:

PCPs -Growth (increased providers, locations)-Enhanced quality-Standard work

LATs-more schools ED

SA-more athletes

Tier 1

Tier 2 “Mayo-like”

Sports Med PT Occ MedRheum LAT Behavioral MedPhysiatry Imaging

Tier 3Orthopedic Surgery1 surg case/10 patients,More focused referrals from larger referral base

Hand

Delays minimized

Delays minimized

EMR doc--------

Service& ClinicalQuality

•1/27 – Injured (R) knee pivoting on it getting into the shower.Musculoskeletal Care Journey

RESULTS:

•1/31 – 0827 Called to make an appointment.•1/31 – 1415 Seen by Sports Medicine Physician, evaluated,

X-rays done, MRI ordered.•1/31 – 1451 Initial note completed , encounter closed,

charges dropped.•2/1 – 0630 MRI knee completed.

•2/1 – 0847 Radiologist report transcribed, report available in EMR.

Musculoskeletal Care JourneyRESULTS:

•2/1 – 0905 Patient called by Sports Medicine Physician, informed of positive MRI results.

•2/1 – 1200 Orthopedic Surgeon sees patient, surgery scheduled for 1530.

•2/1 – 1655 Anesthesia start in OR.

•2/1 – 1746 Out of OR.•2/1 – 1915 Patient returns home.

RESULTS:Door to Balloon

Cardiologists benchmarked in a collaborative in Wisconsin2 week long RIEs involving ER and CathlabPhysician champion emerging to drive competition

Kim/PPT/John/HealthForumSF0706

Mean Time to PCI – AMC(Door to Balloon)

020406080

100120140

Jan

Mar

May Jul

Sept

Nov Jan

Mar

May

Jan 05-Jun 06 Goal

Key Events:

2-6-06 Door to Balloon RIE

2-15-06 Standing orders AMI

2-27-06 Code STEMI initiated

RESULTS:

“CODE STEMI”Date: 6-4-07

Arrival Time: 1613 Via walk-in/EMS

EKG Time: 1618

ASA: 1622

Beta Blocker: 1627

Time to CVL: 1634

Xylocaine: 1642

1st Balloon Time: 34 Minutes

DOOR TO BALLOON TIME: 34 MINUTES

RESULTS:

RESULTS:

RESULTS:

The 7-Week Cycle of an R.I. Event3 weeks before – Value Stream review, Event Selection, Select Team Leader/Co-Leader and team members estimated financial, quality and staff impact1-2 weeks before – RI Checklist, preparation .. Cell Communication, aim statement, measures

day 1 - current conditionsday 2 – create the futureday 3 - run the new processday 4 - standard workday 5 - presentation

1st week after - Capture the savings2nd week after – Update Standard Work3rd week after – CFO validation

•Step 1 “Identify” waste

•Step 2 “Eliminate” waste

Accomplishments:

“6S”GET RID OF WHAT'S

NOT NEEDED

R.I. EVENT GOALS: IMPROVE AUDIT SCORE BY 20 POINTS

1: SORT OUT

2: STRAIGHTEN

3: SCRUB

4: SAFETY

6: SUSTAIN

5: STANDARDIZE

6-S APPLIES TO ALL AREAS

AUDIT AND IMPROVE

ORGANIZE WHAT IS NEEDED(VISUAL MANAGEMENT)

CLEAN UP(SEE AND SOLVE)

ADDRESS UNSAFE ACTS, CONDITIONS, MOTIONS

ESTABLISH WHO / WHAT / WHEN

FOR UPKEEP

SELF-DISCIPLINEAND CARE

Accomplishments:

6S is a Productivity tool not a workplace clean up campaign

Kim/PPT/John/NewEmployeeOrientation0307

Accomplishments:

Created the TIS Internship1% of workforce have full-time jobs in improvementWe can effectively manage 3 week-long events each weeksStandard work for executive GEMBA done weekly6S in all units

Accomplishments:

TIS Leadership Internship

PurposePrepare participants for role transition to leading in a continuous improvement environment, integrating TIS tools, processes, and thinking

Logistics & Design

Accomplishments:

8 weeks, 50% of work time (160 hrs)Weekly schedule/focusReading/pre-workCoaching with ManagerLearning methodologies• Fieldwork• Application to department work

Linking with PDPOperational managers of participants involved in the learning processEvaluation-show and tellPDSA FrameworkO: ThedaCare Improvement System/TIS Internship for Leaders

Accomplishments:

Outcomes1. Lead successful improvement activities relevant to

scope of responsibility. 2. Evaluate the impact of improvement strategies on the

people and processes in your work area and formulate an action plan to support continuous improvement efforts.

3. Demonstrate communication and facilitation skills to build and lead effective teams.

4. Apply Plan-Do-Study-Act methodology using clinical data to facilitate continuous process improvement and daily problem solving.

5. Demonstrate behaviors appropriate to the role of leader within our TIS culture.

TIS Leadership Internship Outcomes

Accomplishments:

74 participants to dateRetention rate-94.5% Participant Mix• 5 Managers• 34 Supervisors• 19 Facilitators• 16 (Lead, Educator, Coordinator, Analyst)

Accomplishments:

Manager Assessment of Participant2

.0

3.3

2.3

3.3

1.6

3.3

2.3

3.6

1.9

3.9

1.0

2.0

3.0

4.0

5.0

Pre- Post- Pre- Post- Pre- Post- Pre- Post- Pre- Post-

Lead Improvement Leading Effective Teams PDSA Leader in TIS Culture People, Processes &Action

1

Establish a sense of urgency for Change Form a powerful

guiding coalition

Create the new vision

Communicate the VisionEmpower others to

act on the Vision

Plan for and create short-term wins

Consolidate Improvements

ThedaCare Change Model – Draft 2

Endings

Chaos

NewBeginnings

Collective/Group Cycle(Intellectual Change)

Individual Cycle(Emotional Change)

FundamentalSupporting Processes:•Leadership Development•Rigorous Assessment•Development of Core Processes•Capacity for Intervention•Communication/Indoctrination

We are getting exactly the results we are designed to achieve! To get something different, we must change our approach!

Sources: “Leading Change” – John Kotter“Managing Transitions” – William Bridges“Making Sense of Change Management” Cameron & Green

Institutionalize new approaches

Lessons Learned:

RIE Participant SurveyLessons Learned:

I would recommend this organization to a friend as a good place to workOverall, I think this is a great place to workMy manager or someone at work seems to care about me as a personMy manager shows appreciation for the work I doAt work, my opinion seems to countPeople here are willing to give extra to get the job doneMy manager provides me with sufficient opportunities to improve myselfI am satisfied with my job securityPeople are encouraged to balance their work and personal lifeManagement has kept promises made to us

Lessons Learned:

SummaryStatistically significant differences in satisfaction for those involved in 2 or more RIEs

Lessons Learned:

HabitsSafety• Does the staff member understand and know the safety concerns of his

or her business unit?• Is work being stopped and remedied if a safety issue is identified?

Taking responsibility for results• Does the staff member know what is expected?• Does he/she follow standard work?• Does he/she effectively communicate the need to change to the

manager/supervisor?• Does the staff member seek help from colleagues, managers and

supervisors in implementing desired change?

We improve something every day• Does the staff member use and support PDSA in the workplace?• Does the staff member measure and share results with the team?

We work as one• Does the staff member know the system measures?• Does the staff member ask for help?• Does the staff member anticipate patient/customer needs across the

continuum?• Does the staff member anticipate the impact of actions on team members ?

Our customers come first• Does the staff member ask our customers if we are meeting their

expectations?• Is the staff member designing business models to meet our customer/patient

demand?

We capture learning• Does the staff member celebrate successes and failures in big ways and in

small?• Does the staff member recognize changes within people that drives changes?• Is the staff member coaching/willing to be coached?• Is the staff member helping people to be successful?• Does the staff member forgive people if they make a mistake

We are candid and respectful• Is the staff member open to new information? • Does the staff member have regular, open, honest communication with

others?• Does the staff member put all issues on the table right away?• Does the staff member use the 5 whys?• Does the staff member get data that clarifies?• Does the staff member work to develop common understanding with the

right people?

Lessons Learned:Create Pull for Physicians

Radiology transcription dataOutpatient surgery center/under arrangement partnership (partnership with physicians)

Radiology Transcription% of Days Goal Met

17%19%

55%

60%58% 57%

71%

83%

43%

77%

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07

Lessons Learned:

Future Plans

TIS Leadership Education (Learning to See)Cell lead & training visit to Ariens3% of work force full-time on improvement through re-deployment

Issues With Suggestion

Managing change related to professional staff• Fear of loss of autonomy of decision making in

our professional staff will only be mitigated with the data that standard work works

• Lack of trust of administration will only be improved by getting wins in the departments

Change the people or change the people- Dan Ariens