Leading a Lean Healthcare Transformation. John S. Toussaint M.D. CEO Thedacare Center for Healthcare Value Lund Sweden 03/16/10

Transcription

1 Leading a Lean Healthcare Transformation John S. Toussaint M.D. CEO Thedacare Center for Healthcare Value Lund Sweden 03/16/10

2 Purpose Process People

3 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: , America Journal of Managed Care, September 2009

4 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

5 Isolated CABG Mortality 6 % Operative Mortalities

6 2009 STPD Monthly Scorecard 2009 TARGET: $ % Improvement: 5.9% Roll-Up of Total Clinical Labor Costs/UOS (Excluding OB & Psych) 2008 Baseline: $ YTD: $ YTD % Improvement 4.2% YTD Cost Savings $ 1,022,000 $ Goal = $ / UOS $ $ Cost / UOS $ $ $ MTD YTD Target 2008 Baseline $ $ $ Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec d *MTD Target and YTD Target are the same

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8 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

9 Process: What s True North? Quality Decrease Defects and Waiting Time by 50% each year Customer Business Increase Productivity 10% each year Engagement No. of Suggestions Implemented

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

11 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

12 Process: Strategy Deployment CEO/Board VP Manager Supervisor Staff

13 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

14 A3 or PDSA: What Are Talking About? Background Why are you talking about it? Recommendations What is your proposed countermeasure(s)? Current Situation Where do we stand? Goal Analysis What s the problem? 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? Follow-up How we will know if the actions have the impact needed? What remaining issues can be anticipated? - What is the root cause(s) of the problem? - What requirements, constraints and alternatives need to be considered?

15 Title: System Safety A3 (Hospitals, TCP, Senior Svs. Support Areas) 1. 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 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. 2. Current Conditions 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- PREVENTABLE MORTALITY 3% 2% 1% EXPECTED ACTUAL Target = 0 3. Goals and Targets 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 TC-2.92 TC-1.56 Medication 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) Sr Services Falls OSHA recordables lifting/handling) Medication incident reporting 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% UNSAFE INR Known Deaths in Target = 3.8% Great job recognizing that safety problem and telling someone! Sponsor: Facilitator: OSHA RECORDABLES AMC/TC TCP SR SV 2008 Actual 2008 Target 2009 Thanks! This environment is not judgmental so I feel safe in reporting! Per 1,000 Doses Leader: Greg Long, MD, CMO Sensei: MEDICATION ERRORS Plans: 5. Proposed Countermeasures Revision #4, Date: 03/30/09 Cause Countermeasure Description Responsible Patient 1) Involve patient & family in creating safe environment 1) Create standard work that actively involves the patient & their family in creating a safe environment 1) People 1) Staff competency & training 1) Develop competency of staff related to risk assessment & anticipation 2) Culture of Safety within ThedaCare 2) Educate & train, modify behavior toward culture of safety of all staff & physicians; anticipate safety/error issues 1) 2) Roger G. JMichael G. 3) Problem solving daily by all 3) Train all manager level and above employees in TIS problem 3) Roger G solving (eg., A3 & A4 use) Katie B 4) Embrace standard work 4) Performance to standard work is assured as it becomes a 4) way of life for all staff (purposeful variation is acceptable) Process 1) Standard work creation & compliance 1) Develop, imbed, sustain standard work, including evidencebased medicine pertaining to safety 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 1) defect-free performance 2) Amend bylaws & TC policies 2) Amend and enforce hospital bylaws & TC policies outlining expected behaviors r/t safety 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. 3) Safeguard our facilities 3) Assess & implement tools & techniques to eliminate pt/staff 3) injuries invest $ if needed. 1) Division leaders 2) Humana Resources Robin Wilson 2) Matt Digman Team: Analysis (Initial thoughts) Safety A3 Gap Analysis People Process Patient No 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 Safety not 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 7. Follow-up Page A

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17 Process The 7-Week Cycle of an R.I. 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 Step 1 Identify waste Step 2 Eliminate waste 1st week after - Capture the savings 2nd week after Update Standard Work 3rd week after CFO validation

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20 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

21 Process: Visual Tracking Center

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23 People (the hardest part)

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25 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?

26 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

27 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

28 Employee Opinion Score results(6 point scale) 2009 Overall Mean = Overall Mean = Overall Mean = 4.496

29 KEY ATTRIBUTE TRADITIONAL MODEL COLLABORATIVE MODEL Patient Experience Clinical Quality Disjointed. May be confusing, even contradictory. Admirable, but not 100% reliable. Manage errors. Nursing maintaining thru heroics Single plan of care developed with patient - is visible, continuously updated with patient driven schedule and goals. 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 PAST vs. CURRENT 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. Copyright 2009 ThedaCare. All Rights Reserved.

30 Tollgates Collaborative Care Patient Progression To llgate 1 Tollgate 2 Tollgate 3 To llgate 4 Tollgate 5 Patient Admission PT Care Are we progressing care? PT Care Are we progressing care? PT Care Are we progressing care? PT Care Are we progressing care? PT Care Are we progressing care? PT Care Patient Discharge NO NO NO NO NO Problem Solve Problem Solve Problem Solve Problem Solve Problem Solve Collaborative Care Value Stream Metrics Copyright 2006, All Rights Reserved Patent Pending

31 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.

32 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.

33 Lessons Learned: ThedaCare Change Model Institutionalize new approaches Establish a sense of urgency for Change Form a powerful guiding coalition Consolidate Improvements Plan for and create short-term wins New Beginnings Endings Chaos Individual Cycle (Emotional Change) Create the new vision Fundamental Supporting Processes: Leadership Development Rigorous Assessment Development of Core Processes Capacity for Intervention Communication/Indoctrination Empower others to act on the Vision Collective/Group Cycle (Intellectual Change) Sources: Communicate the Vision We are getting exactly the results we are designed to achieve! To get something different, we must change our approach! Leading Change John Kotter Managing Transitions William Bridges Making Sense of Change Management Cameron & Green 1

34 Outcomes: ThedaCare (Wisconsin) Measure Pre- Collaborative Care (2006) End of 2007 End of 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* (-20% vs. 2006) days (through June) Case Mix Index* Used top 16 DRG s that match across cc and non-cc (through June) Average Cost Per Case* (using Medicare RCC) $ fully loaded $ 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 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.

35 Physician engagement: Lessons Learned(the hard way!) 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

36 Medication Reporting- Inpatient

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38 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