creating a lean culture at thedacare, usa
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by John Toussaint of Thedacare shown at the 1st Global Healthcare Summit of 25th June 2007TRANSCRIPT
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