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Leading a Lean Transformation in Healthcare

John S. Toussaint M.D.

CEO Thedacare Center for Healthcare Value

IHC 08/30/12

Remarkable Results

• At St Jude Medical Center in Fullerton California a visual board exists outside of each ventilated patient’s room. On this board are Red/Green magnets that are flipped every two hours as the preventable measures are executed. This allows for the team to quickly see and avoid missing any preventable measure anytime. As a result of this focused effort on the true north metric, Critical Care has had zero preventable VAPs in over three years.

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Remarkable Results

• Inova in integrated delivery system in Virginia with 9 ERs and 400000 visits per year reduced time to doctor in all the ERs from 55 minutes to 22 minutes at the same time reducing ambulance on diversion hours from 1371 in 2008 to 17 in 2010, improving operating margin by 10 million dollars and improving customer satisfaction.

• The Christie Clinic decreased patient wait times 28% increased capacity by 10% and improved patient satisfaction to 4.5 out of 5 in the ENT outpatient clinic over nine months.

Remarkable Results

• New York Health and Hospital Corporation across eight hospitals improved on time surgical starts by 40% and reduced the percentage of O.R. cases that had to be rescheduled due to late starts from an average of 21% to an average of 4.4% of total cases.

• At Seattle Children’s Bellevue Center surgeries start on time 99% of the time. Patient/family satisfaction with the Surgery Center ranks second among the entire organization, with 92% of families giving the Bellevue Surgery Center a “9” or “10” rating for overall care. And these outcomes are within a facility that is only 79,000 square feet, built at $30 million less than initially estimated.

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Definition of Lean in healthcare

• An organization’s cultural commitment to applying the scientific method to designing, performing, and continuously improving the work delivered by teams of people leading to measurably better value for patients and other stakeholders.

Lean Healthcare is an operating system composed

of six principles

1. Value creation for patients2. Unity of purpose3. Continuous improvement (pursuing

perfection)4. Visual management to see and understand

patient flow5. Standard work for administrative and clinical

care processes 6. Respect for the people

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5 Principles of Lean Thinking

VALUE - what customers are willing to pay for

VALUE STREAM - the steps that deliver value

FLOW - organizing the Value Stream to be continuous

PULL – triggering flow from customer needs

PERFECTION - continuous improvement forever (culture)

(from Lean Thinking, Womack and Jones, 1996)

Value Creation for the patient

• Value=Q/C

• Value Stream: The steps in a process that deliver value to the customer

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Vertical Orientation of Healthcare

Horizontal Focus for Healthcare

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ThedaCare All Rights Reserved

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“First Pass”

13

Baseline Improvement by segment…

‐ OSHA Recordable Injuries‐ HAT Scores‐ Employee Engagement Index

‐ Operating Margin‐ Productivity 

Financial StewardshipPeople

Safety/Quality 50%‐ Preventable Mortality ‐Medication Errors

- Access- Turnaround Time- Quality of Time

12/15/09 Draft. 6

CustomerSatisfaction

Unity of purpose: True North Metrics

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A3: What Are You Talking About?

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Unity of purpose:Deploying

Level 1 Prioritiesto Level 2ThedaCare’s

StrategicPlan

Safety(level 2)

People(level 2)Peoplelevel 2 A3

Safety(level 2)Safety(level 2)Safety(level 2)Safety(level 2)Safety(level 2)

Safetylevel 2 A3

Shared Growth(level 2)

Shared Growth(level 2)

Shared Growth(level 2)

Shared Growth(level 2)

Shared Growth(level 2)

Shared Growthlevel 2 A3

Productivity(level 2)Productivitylevel 2 A3

Safety A3(level 1)

People A3(level 1)

SharedGrowth A3(level 1)

Productivity A3(level 1)

Plan Plan Plan Plan

ThedaCare’s Breakthrough Objectives

“Measurably Better Value”

Cross Function Team

Cross Functional 

Team

Cross Function Team

Cross Function Team

Cross Function Team

Cross Function Team

Cross Function Team

Cross Function Team

Cross Functional 

Team

Cross Function Team

Cross Function Team

Cross Function Team

Cross Function Team

Cross Function Team

Cross Functional 

Team

Cross Function Team

Cross Functional 

Team

Problem statement, background and targets deployed

Continuous Improvement:Thedacare

Improvement System

• 6s• Visual Management• PDSA• A3• Value Stream mapping• Kaizen• Standard work• 3P

• 2P

• Vertical Value Streams

• Hoshin Kanri

• Senior Management Visual Control

• Gemba

• Transparency

• Kanban

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O:SLT/Pub Pres/HEVLN June 1, 2009

Mission“Improve The Health of Our Communities”

Vision

Shared Values

Strategy“Measurably Better Value”

True North Metrics

SD Work (20%) Safety People Shared Growth Productivity

Continuous Daily Improvement Work (80%)

“Running The Business”

Lean Management System

SD ‐ CDIOverlap

“Catchball”VSM’s, RIE’s, 

PDSA

Strategy Deployment:Breakthrough objectives developed through the use of PDSAs and cross-functional teams

Scientific Method: PDCA

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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

Understanding Flow using visual management

What is the current state?

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Visual Management:Color Coding on Tracking Tools

Same colors used – light red/light green for tracking information.

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Visual management: Flow of the “lanes”

Tracking sheet

Pareto sheet

A3s/Actions related to lane.

Standard Work

• “A paradox of standard work is that the standards established release creativity. With standard clinical approaches, patients who deviate from the standard are more easily appreciated, freeing up the clinicians to expend their mental energy on issues and patients that demand it. An example at Seattle Children’s is the asthma care unit, in which standardization of albuterol therapy has allowed doctors to better identify patients that are not following the typical course. The fact that the standard approach to treatment doesn’t work calls into question the diagnosis of asthma and forces the doctors to search for other etiologies”. Howard Jeffries M.D. – Seattle Childrens

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Respect for People:Whitecoat leadership vs.

Improvement leadership

• All knowing

• “In charge”

• Autocratic

• “Buck stops here”

• Impatient

• Blaming

• Controlling

• Humility

• Curiosity

• Facilitator

• Teacher

• Student

• Communicator

• Perseverance

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• 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?

Can you say yes to these three questions every day?

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Respect for people: Developing a Community of Problem

Solvers

5 10 15 ??

K

Lean “Grad”School

.We are Here

100% of employees are problem solvers 

improving something every 

day!!!

Time (years)

Educatio

n/Skill Level

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Management by objectives: It nourishes short term performance, annihilates long term planning, builds

fear, and demolishes teamwork

It leaves people bitter, crushed, bruised, battered, desolate, and despondent

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The lean management system or management by process

A way to do it right the first time