Leading a Lean Healthcare Transformation

John S. Toussaint M.D.

CEO Thedacare Center for Healthcare Value

Lund Sweden 03/16/10

Purpose Process People

Results using Lean Group Health of Puget Sound reduced E.R. visits by

29% using their medical home redesign in addition to an 11% reduction in hospital admissions

Bolten U.K reduced Stroke mortality by 23% ThedaCare Collaborative care unit redesign achieved 0

medication reconciliation errors for 2 years running and the cost of inpatient care dropped by 30%

St. Bonifice Winnepeg Ca. has the best cost/weighted case for an academic medical center in Manitoba, and is second in all of Canada

Source: Health Affairs 2009, Volume28, No: 5:1343-1350 , America Journal of Managed Care, September 2009

Thedacare’s Financial Improvement Since Starting

Lean More than doubling operating margin from 2003 to 2009(2.5 % to 6.0%)

25 million dollars in documented improvement

Moved from Moody’s Bond rating A2 in 2003 to A1 in 2008

Increased cash on hand by 105 million dollars

Isolated CABG Mortality

0

1

2

3

4

5

6

2003 2005 2007 2009

% O

per

ativ

e M

orta

liti

es

2009 TARGET: $318.57% Improvement: 5.9%

2008 Baseline: $338.432009 YTD: $324.27

4.2%1,022,000$

d

2009 STPD Monthly Scorecard

YTD % Improvement

Roll-Up of Total Clinical Labor Costs/UOS (Excluding OB & Psych)

YTD Cost Savings

*MTD Target and YTD Target are the same

Goal = $318.57 / UOS

$290.00

$300.00

$310.00

$320.00

$330.00

$340.00

$350.00

$360.00

$370.00

J an Feb Mar Apr May J un J ul Aug Sept Oct Nov Dec

Co

st

/ U

OS

MTD

YTD

Target

2008Baseline

G o a l = 1 1 .8 9 / U O S

11.00

12.00

13.00

14.00

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

G o a l = $ 3 2 7 .4 8 / U O S

1 1 .0 0

1 2 .0 0

1 3 .0 0

1 4 .0 0

Ja n F e b M a r A p r M a y Ju n Ju l A u g S e p t O c t N o v D e c

MTD

YTD

Target

2008Baseline

Purpose:Deliver Measurably Better

Value to Customers

Reliable Quality (3.4 defects per million opportunities)

Reliable Service (wait times for any service less than 15 min.)

Lowest Cost

Process:What’s True North?

Decrease Defects and Waiting Time by 50% each year

No. of Suggestions Implemented

Increase Productivity 10% each year

Business Engagement

Quality

Customer

Process

Consistent methodology that is codified, transparent, and understood by everyone in the organization

Process:Hoshin Kanri

Hoshin• ho – method or form• shin – shiny needle or compass“method for strategic direction setting”

Kanri• control or management

Strategy Deployment = Hoshin Kanri• process to embed strategy• Target and Means

Process:Strategy Deployment

CEO/Board

VP

Manager

Supervisor

Staff

Process:A3

As a standard process, it becomes easier for you • to persuade others, and• to understand others

It fosters dialogue within the organization It develops thinking problem-solvers It encourages front-line initiative Teaches scientific method

Background

Why are you talking about it ?

Current Situation

Where do we stand ?

What’s the problem?

Analysis

- What is the root cause(s) of the problem?

- What requirements, constraints and alternatives need to be considered?

Goal Where we need to be?

What is the specific change you want to accomplish now?

Plan

What activities will be required for implementation and who will be responsible for what and when?

Recommendations

What is your proposed countermeasure(s)?

Follow-up

How we will know if the actions have the impact needed? What remaining issues can be anticipated ?

A3 or PDSA: What Are Talking About?

Title: System Safety A3 (Hospitals, TCP, Senior Svs. Support Areas)

2. Current Conditions1. Background• Our paradigm tolerates risk & errors.

• Healthcare nationally harms 5 million pts/yr and kills nearly 100,000 pts/yr-minimal change since original IOM report (To Err is Human) released in 1999.

• Our employees are at risk in the workplace.

• Sub-optimal safety = avoidable cost ($$$) to ThedaCare and the national healthcare system.

• Our expectations r/t safety are unclear.

• We lack a true culture of safety limiting our awareness of the problem and effective interventions…..”not my problem”.

• Safety resource needs unclear.

• ThedaCare leadership’s behaviors and actions do not always align with safety as a top priority.

3. Goals and Targets

4. Analysis (Initial thoughts) Safety A3 Gap Analysis•

9

1

2

3

4

5

6

7

8

Te

am:

Page A© 2007

5. Proposed Countermeasures

7. Follow-up•

6. Plans:

Revision #4, Date: 03/30/09

Sponsor: Leader: Greg Long, MD, CMOFacilitator: Sensei:

Culture of Safety Report Card!

1) Realize anyone can make a mistake! D

2) Create safe environment to report errors. C-

3) Create collegiate interactive healthcare teams.C+

4) Barrierless communications. C-

5) Teams with mutual human caring & support. B-

2009 Safety A3 Initiatives Division Initiative Baseline 2009 Target (50% improvement)

AMC/TC INR (% percentage of pts in safe range 64.60% 82.30%OSHA recordables lifting/handling) AMC-2.45 AMC - 1.22

TC-2.92 TC-1.56Medication Reconciliation TBD 50% improvement Safe Patient Care NA Nat'l Patient Safety Goals Met Care Giver Communication

Physician Services INR (% percentage of pts in suboptimal range 7.60% 3.80%OSHA recordables lifting/handling) 1.29 0.55

Sr Services Falls 180 90OSHA recordables lifting/handling) 10.2 5.09Medication incident reporting 168 252

New London INR (% of pts in safe range) 40% 70%Riverside INR (% of pts in safe range) 40% 70%

7%6%5%4%3%2%1%

2009 Target = 3.8%

UNSAFE INR

2007 20084 Known Deaths in 2008

10987654321

Target 2009

OSHA RECORDABLES

AMC/TC TCP SR SV2008Actual 2008

Thanks! This environment

is not judgmental

so I feel safe in reporting!

Great job recognizing that safety

problem and telling

someone!

Cause Countermeasure Description ResponsiblePatient 1) Involve patient & family in creating safe environment 1) Create standard work that actively involves the patient &

their family in creating a safe environment1)

People 1) Staff competency & training 1) Develop competency of staff related to risk assessment & anticipation

1)

2) Culture of Safety within ThedaCare 2) Educate & train, modify behavior toward culture of safety of all staff & physicians; anticipate safety/error issues

2) Roger G. JMichael G.

3) Problem solving daily by all 3) Train all manager level and above employees in TIS problem solving (eg., A3 & A4 use)

3) Roger G Katie B

4) Embrace standard work 4) Performance to standard work is assured as it becomes a way of life for all staff (purposeful variation is acceptable)

4)

Process 1) Standard work creation & compliance 1) Develop, imbed, sustain standard work, including evidence-based medicine pertaining to safety

1) Division leaders

2) Failure Mode Effect Analysis (FMEA) 2) Apply FMEA to key processes 2)

3) Standard work for assessing safety issues 3) Align assessment results with appropriate intervention. 3)

4) User-friendly reporting 4) Devise user-friendly reporting tool & process that insures maximum, non-judgemental reporting by all employees

Policy 1) Safety assessments 1) Operational staff assess safety each shift with celebration of defect-free performance

1)

2) Amend bylaws & TC policies 2) Amend and enforce hospital bylaws & TC policies outlining expected behaviors r/t safety

2) Humana Resources Robin Wilson

3) Align gainshare with safety 3) 3)

4) Add safety to target state in TIS events

Plant 1) Safety in new building 1) Continue to build/design safety into the environments 1)

2) Reduce sprains & strains to TC employees 2) Assess causes of injury to our staff & "invest" in training, tools, techniques to eliminate injuries.

2) Matt Digman

3) Safeguard our facilities 3) Assess & implement tools & techniques to eliminate pt/staff injuries…invest $ if needed.

3)

People Process PatientNo clear expectations for safety Don't involve patients & families in safety efforts

We don't know w hat an error-free environment looks like Physician data not shared Patients don't take ow nership of promoting safety

Lack culture of safety No easy, effective reporting

Leadership inconsistent in safety message Standard w ork/guidelines not alw ays follow ed

Providers/staff don't buy in Not anticipating /proactive

We don't give + feedback for positive behaviors Rely on lagging indicators

No prompts to remind Safety externally focused-"compliance"

Fear of challenging and punishment Dedicated safety rounds not done

Injury/errors are accepted RCA doesn't focus prompts/.behaviors Lack of Near misses accepted Not enough safety training Unwavering

Disruptive behavior Safetynot alw ays addressed Focus

Don't consider safety w hen

making purchasing decisions Safety not considered in purchasing decisions

Lack of incentive to improve Current unit layout does not support safe practice

Old policy not reflecting new practice We allow defects in w ork environments/practices to save $$

New policy deployment time consuming process Hazards not completely removed from w ork-place; risk for staff/pts

Bylaw s & TC policies don't reflect Not investing $$ in safe w ork place

behavioral expectations Not all w ork areas injury-proof

Policy Plant

Target = 0

EXPECTED

ACTUAL

PREVENTABLE MORTALITY

3%

2%

1%

2007 - 2008

MEDICATION ERRORS

Per

1,000

Doses

2008 2009 2010 2011 2012

video..\Video\Deb Wisnet.wmv

The 7-Week Cycle of an R.I. Event 3 weeks before – Value Stream review, Event

Selection, Select Team Leader/Co-Leader and team members estimated financial, quality and staff impact

1-2 weeks before – RI Checklist, preparation .. Cell Communication, aim statement, measures

day 1 - current conditions day 2 – create the future day 3 - run the new process day 4 - standard work day 5 - presentation

1st week after - Capture the savings 2nd week after – Update Standard

Work 3rd week after – CFO validation

•Step 1 “Identify” waste

•Step 2 “Eliminate” waste

Process

Process:Continuous Daily Improvement Front line workers and supervisors able to

solve problems, and sustain improvements. PDSA Process Actionable Item log Number of Staff ideas implemented

Visual Tracking CenterProcess:

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People (the hardest part)

Can you say yes to these three questions every day?

Are my staff and doctors treated with dignity and respect by everyone in our organization?

Do my staff and doctors have the training and encouragement to do work that gives their life meaning?

Have I recognized my staff and doctors for what they do?

White coat leadership vs. Improvement leadership

All knowing “In charge” Autocratic “Buck stops here” Impatient Blaming Controlling

Patient Knowledgeable Facilitator Teacher Student Helper Communicator Guide

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New Habits of Improvement Leaders

Help define the problem to be solved instead of jumping to solutions

Ask questions instead of providing answers Think of problems as golden nuggets

instead opportunities to blame Teach subordinates how to solve problems Mentor subordinates to replace you Be Humble

Employee Opinion Score results(6 point scale)

2009 Overall Mean = 5.027 2008 Overall Mean = 5.014 2006 Overall Mean = 4.496

KEY ATTRIBUTE TRADITIONAL MODEL COLLABORATIVE MODEL

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. Nursing maintaining thru heroics

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

Physician Role Hierarchical. Partner in care team. Exposes thinking to professionals team.

Nursing Role Task oriented. Too much time spent running for supplies and equipment.

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

Pharmacist Role Back end. Bedside presence. More involved in patient contact/education. Teacher to patient and team.

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

PAST vs. CURRENT

Copyright © 2009 ThedaCare. All Rights Reserved.

Tollgates

ThedaCare: Strategic Change Processes Clarity of roles and responsibilities Partnered approach to delivery of care and functioning

within one plan of care Respect for each other’s knowledge and skill Higher level of teamwork Engagement and influence in daily problem solving and

outcome measurement Continuous daily improvement of the new delivery system

Copyright © 2009 ThedaCare. All Rights Reserved.

Daily Bedside Care Conference Done daily (more than once if patient demand exists) Care Team (MD, Nurse, Pharmacist, Care Manager/Social

Worker) present Pre-huddle, in room patient assessment and discussion, post huddle Plan of Care evaluated and updated using Milliman Guidelines as

the framework for the team Production Control Board visual tracking

Copyright © 2009 ThedaCare. All Rights Reserved.

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

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:

Video Shana/AJ Problem solving at frontline

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Outcomes: ThedaCare (Wisconsin)Measure Pre-

Collaborative Care (2006)

End of

2007

End of

2008

2009 YTD

(thru Sept)

Compares to non-Collaborative Care units 2009 thru Sept

Defect-Free Admission Medication Reconciliation

1.05 defects per chart

0.01 defects per chart

(-99% vs.2006)

0 defects 0 defects 1.25 defects per chart without RPh

Quality Bundle Compliance

38% Pneumonia

(2005 baseline)

No baseline for CHF

100% Pneumonia

92.5 %

CHF

95% Pneumonia

85%

CHF

91% Pneumonia

100 % CHF

89% Pneumonia (All or none bundle score )

89 % CHF (all or none bundle score)

Patient Satisfaction

68% rated as top box

87%

(+30% vs. 2006)

90% 4.95 on scale of 5 (revised tool Sept ‘08)

Not captured for other units.

Length of Stay* 3.71 2.96

(-20% vs. 2006)

3.16 3.19 3.48 days (through June)

Case Mix Index* Used top 16 DRG’s that match across cc and non-cc

1.08 1.12 1.11 1.12 1.27 (through June)

Average Cost Per Case* (using Medicare RCC)

$5669 - fully loaded

$4467 - fully loaded (-21% vs. 2006)

$5849 $4970—fully loaded (thru August—lagging metric)

$6093—Fully loaded (thru June)

•Financial Indicators represent a subset of the patients to demonstrate impact of the delivery model. Excluded from both baseline and pilot are: observation patients, ICU patients, and LOS >15 days. Pilot numbers includes: Admits from ED to Unit, or direct admits to unit. 2006 is updated baseline.

•From: "Writing the new playbook for health care: lessons from Wisconsin," 2009, Health Affairs, 28, p.1348

•Copyright © 2009 ThedaCare. All Rights Reserved.

video..\Video\Bob Ferante honesty.WMV

What’s in it for the physician to participate in improvement?

Don’t “throw the waste over the wall” Fix what’s broken and get early wins Use individual physician performance data! Develop the champion’s for improvement

Physician engagement: Lessons Learned(the hard way!)

Medication Reporting-Inpatient

Network Purpose

Accelerate the transformation journey for each organization

Multiple small learning communities Spread of current best practices Drive change in the larger healthcare

system www.healthcarevalueleaders.org