11/16/2011
1
M22: Leading a Lean
Transformation
John S. Toussaint, M.D.
CEO ThedaCare Center for Healthcare Value
Kim BarnasSystem Vice President, ThedaCare
IHI
12/05/11
These presenters have nothing to disclose.
Objectives
� Discuss the core components of the Toyota
principles: “Purpose, Process, People” for whole-
system change
� List the behaviors required of staff, physicians,
managers, and executives to support whole system
continuous improvement
� Develop a whole-system change plan for your
organization by using A3 thinking, a specific Lean
tool used to create organizational change
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2
Lean works in Healthcare
� Group Health of Puget Sound reduced E.R. visits by 29% using their medical home redesign at the same time reducing hospital readmissions by 11%
� Akron children’s Hospital reduced cost by $8 M while reducing appointment access wait times by 74,600 days using lean
� ThedaCare’s redesigned inpatient Collaborative Care unit has achieved 0 medication reconciliation errors for 4 years running and the cost of inpatient care dropped by 25% www.createhealthcarevalue.com
� Henry Ford reduced infections rates, falls, and medication errors in 2010 resulting in a $4.4 M improvement
� Mercy North Iowa has achieved zero blood specimen tube labeling errors for over a year
� Seattle Children's avoided 200M in capital expense by freeing capacity with continuous process improvement
Source: Health Affairs 2009, Volume28, No: 5:1343-1350 , America Journal of Managed Care, September 2009
4
Financing Reform through Program Cuts, Higher
Taxes/FeesOver 10 years, despite $938 billion in additional spending, Health Reform actually reduces the deficit by cutting other programs and increasing revenues
Cuts to Medicare/Medicaid Revenue provisions
� Market basket adjustments (including productivity adjustments) for certain hospitals and other providers - $196 billion
� Industry fees (pharmaceutical industry fee, medical device fee, insurance industry fee) - $107 billion
� Restructuring of payments to Medicare Advantage (MA) plans - $136 billion
� Higher Medicare tax on high-income taxpayers - $210 billion
� Reducing Medicare and Medicaid Disproportionate Share Hospital (DSH) payments to hospitals - $36 billion
� “Cadillac tax” - $32 billion
� Other cuts (e.g., home health payment rates) - $87 billion
� Penalty payments by employers and uninsured individuals - $65 billion
Total = $455 billion � Other revenue (e.g., indoor tanning tax) -$111 billion
Total = $525 billion
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3
The Methodology of Lean is
about creating value for the
customer
Value =Q/C
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RESULTSCreate Value for the
Customer
True North
MetricsLeadership
Behaviors
Focus on the
Problems
CLEAR PURPOSEEnterprise Alignment
Align Strategy Align Systems Align Performance
SCIENTIFIC METHOD TO
SEEK PERFECTIONContinuous Improvement
Stabilize Process
Standard Process
Visual Management
Identify & Eliminate Waste
Front Line Data
Integrate Improvement with Work
RESPECT FOR PEOPLECultural Enablers
Involve Everyone
Develop People
Ensure a Safe Environment
Build Teamwork
Strategy Deployment
A management system that aligns – both vertically
and horizontally – a organization’s functions and
activities with it’s strategic objectives.
A specific plan is developed with precise goals,
actions, timelines, responsibilities and measures.
Strategy Deployment is a PDSA process.
Lean Lexicon, Lean Enterprise Institute
11/16/2011
5
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 : What Are Talking About?
Deploying Level 1 Priorities
to Level 2ThedaCare’s
Strategic
Plan
Safety
(level 2)
People
(level 2)People
level 2 A3Safety
(level 2)Safety
(level 2)Safety
(level 2)Safety
(level 2)Safety
(level 2)Safety
level 2 A3
Shared Growth
(level 2)Shared Growth
(level 2)Shared Growth
(level 2)Shared Growth
(level 2)Shared Growth
(level 2)Shared Growth
level 2 A3
Productivity
(level 2)Productivity
level 2 A3
Safety A3
(level 1)
People A3
(level 1)
Shared
Growth 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
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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•
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:
Thanks! This environment
is not judgmental so I feel safe in
reporting!
Great job recognizing that safety
problem and telling
someone!
- 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
Customer
Satisfaction
TRUE NORTH METRICS
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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
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ThedaCare: Strategic Change Processes
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.
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.
11/16/2011
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Collaborative Care Patient
Progression
Tollgate1
Tollgate3
Tollgate4
Tollgate5
Tollgate2
Are we progressing
care?
ProblemSolve
NO
PTCare
Are we progressing
care?
ProblemSolve
NO
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
Wilson video
11/16/2011
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Collaborative Care Outcomes through 2010
•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 updatedbaseline.•Case mix was not significantly different between collaborative care and non-collaborative care•Updated from: "Writing the new playbook for health care: lessons from Wisconsin," 2009, Health Affairs, 28, p.1348•Copyright © 2011 ThedaCare. All Rights Reserved.
Measure Pre-
Collaborative
Care (2006)
End of
2007
End of
2008
2009 2010 Compares to non-
Collaborative Care
units thru 2009
Defect-Free Admission Medication Reconciliation
1.05 defects per chart
0.01 defects per chart
0 defects 0 defects 0 defects 1.25 defects per chart without RPh
Patient Satisfaction(number of patients rating care 5 out of 5)
68% 87% 90% 86% 95% Not captured for other units.
Measure Pre-
Collaborative
Care (2006)
End of
2007
End of
2008
2009 2010 Compares to non-
Collaborative Care
units thru 2009
Length of Stay*(In days)
3.51 2.92 3.09 3.05 2.91 3.5
30-day re-admission rate
No data No data 13.98% 13.7% 12.9% 15.2% (2009) 14.7% * (2010)
Average Cost Per Case* (using Medicare RCC) and restated in current dollars
$6512 $5024 $6326 $5789 $5781 $7775
Collaborative Care Outcomes through 2010
(Continued )
* This is all medical surgical unit re-admissions from a comparable non-collaborative care unit in the same hospital
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91
65
52
37 37
45
0
10
20
30
40
50
60
70
80
90
100
2005 2006 2007 2008 2009 2010
Min
ute
s
Year
AMC Code Stemi Door to Balloon 2005-2010(Goal 60 min)
CODE STEMI
212
154140
93 93 89
0
50
100
150
200
250
2005 2006 2007 2008 2009 2010
Min
ute
s
Year
ThedaCare Remote Stemi-6 sites2005-2010
(Goal 90 min)
1st of 6 remote sites initiated
Remote STEMI
11/16/2011
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82
60
0
10
20
30
40
50
60
70
80
90
2009 2010
Min
ute
s
Year
Field Stemi 2009-2010(EMS contact to reperfusion)
(Goal 90 min)
Field STEMI
Sustainment of improvement
through the Lean management
system
� Front line workers and supervisors able to
solve problems, and sustain improvements.
� PDSA Process
� No. of defects identified(front line staff
defect huddles)
� Number of Staff ideas implemented
11/16/2011
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1411
5
11
3
2
1
12
0
5
10
15
20
25
30
Safety/Quality Customer
Satisfaction
People Financial
Stewardship
Nu
mb
er
of
Dri
ve
rs
True North Driver Category
2010 BPS Scorecard Driver Improvement
No
improvement
Improved
88%
improved 85 %
improved
83%
Improved
48%
improved
0%
10%
20%
30%
40%
50%
60%
70%
80%
AMC CVS
Inpatient
AMC 8th
Floor
AMC Inpt
Oncology
TC Birth
Center
TC Neuro
Surgical
Radiation
Oncology
BPS Alpha Units-Percent Employees
"Engaged“ 2009 vs 2010
2009
2010
11/16/2011
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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?
11/16/2011
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The key to culture change is
changing leader behaviors
But, one characteristic came up that really stood
out. It was clearly shared by all the individuals who
were demonstrating ability to be successful and it
was not necessarily a characteristic that would
usually appear on a standard list of leadership
characteristics (all the others can be found in one
form or another on pretty much any leadership
list). That characteristic that stood out was:
demonstration of a deep desire to learn. The
individuals we picked out simply wanted to learn
more and more.
11/16/2011
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1. Drive for continuous (and daily) improvement
2. Mentorship; a corporate demand for and almost an obsession with developing people
3. Challenge; setting what might seem as unreasonable goals or targets both as a corporation and for individuals
White coat leadership vs.
Improvement leadership
� All knowing
� “In charge”
� Autocratic
� “Buck stops here”
� Impatient
� Blaming
� Controlling
� Humility
� Tenacity
� Facilitator
� Teacher
� Student
� Mentor
� Communicator
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Pa
rt A
& B
Med
ica
re E
xp
end
itu
re i
n D
oll
ars
* 2008 Medicare Data
* $57 Billion/yr in savings if all are at Outagamie spending levels
Books
On the Mend:
Revolutionizing Healthcare
The story of ThedaCare’s seven year
lean journey to improve the delivery
of healthcare
Coming soon –
Lifeline: A Collaborative Cure
for Healthcare
The journey to create transparency and
a payment system based on value
11/16/2011
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The “Big Three” for better
healthcare value
� Pay for value not volume
� Provider performance on cost and quality is
transparent to the patient
� Redesigned care processes
Health Reform in “one piece
flow”
11/16/2011
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Physician Value Metrics Emerging
Provider Detail – Diabetes Cost Index List
11/16/2011
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41
$55,061
$27,254
$31,924
$36,594
$22,584
$17,914
y = -0.0004x + 3.8284R² = 0.0033
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,0001
44
87
13
017
321
625
930
234
538
843
147
451
756
060
364
668
973
277
581
886
190
494
799
010
33
10
76
11
19
11
62
12
05
12
48
12
91
KNEE REPLACEMENT EPISODESSINGLE KNEE, SINGLE ADMISSION, SEVERITY 1
WHIO DMV4 Analysis by WMS
Grand Total Average Total Std Cost Avg + 1 st dev
Avg + 2 st dev Avg - 1 st dev Avg - 2 st dev
Health risk, retrospective Linear (Health risk, retrospective)
PHPR Pilot Conditions
� Chosen at April 2010 payment reform
summit
• Attended by 170+ c-suite provider, insurer,
private employer and government leaders
• Voluntary workgroups formed
� Acute Care chose total knee replacement
� Chronic Care chose adult diabetes
11/16/2011
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11/16/2011
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References
� Health Affairs 28, No.5 (2009) : 1343-1350
� Health Affairs 30, No.3 (2011) : 422-425
� Joint Commission Journal on Quality and
Patient Safety 37, No.9 (2011) :387-399
� American Journal of Managed Care 17,
No.3 (2011) : 80-88
� www.createhealthcarevalue.com
11/16/2011
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Network Purpose
� Accelerate the lean transformation journey
for each organization
� Multiple small learning communities
� Spread of current best practices
� Drive change in the larger healthcare
system
� www.healthcarevalueleaders.org
Healthcare Value Network
� Gunderson Lutheran
� Group Health Cooperative
� Hotel-Dieu Grace
� Iowa Health System
� Johns Hopkins Medical
� Lawrence & Memorial Hospital
� Lehigh Valley Hospital and Health
Network
� McLeod Health
� Mercy Medical Center – Cedar Rapids
� Park Nicollet Health Services
� St. Boniface Hospital
� ThedaCare
� University of Michigan Health System
� UCLA
� Alberta Health Services
� Akron Children’s Hospital
� Beth Israel Deaconess
� BJC Healthcare
� Christie Clinic
� Harvard Vanguard Medical
Associates
� Kaiser Permanente
� Provena Covenant Medical
Center
� Seattle Children’s Hospital
� St. Joseph Health System
(Orange, CA)
Network #1 Network #2
11/16/2011
25
� Bronson Healthcare Group
� Exeter Health Resource
� Henry Ford West Bloomfield
Hospital
� Inova Health System
� Integris Health
� Lucile Packard Children’s Hospital
� Martin Memorial Health System
� Mercy Medical Center – North Iowa
� Parkview Health
� St. Joseph Regional Health Center
� Sutter Gould Medical Foundation
� Winona Health
Network #3
Healthcare Value Network
� Blood Center of Wisconsin
� Cleveland Clinic
� New York Health & Hospital
Corporation
� Palo Alto Medical Foundation
� Regina Qu’ Appelle Health Region
� St. Francis Hospital & Medical Center
� Saskatoon Health Region
� St. Mary’s General Hospital
� Stanford Hospital & Clinics
Network #4
Network 5 commitments
� Scottsdale Health
� Alexean Bros health
� Oregon Health and Sciences University
� Martinspoint Health
� Mayo LaCrosse