Mike Radtke Director, Diagnostic Imaging ThedaCare michael.radtke@thedacare.org

Mike Radtke Director, Diagnostic Imaging ThedaCare michael.radtke@thedacare.org

Is a comprehensive, community-owned healthcare system focused on achieving measurable, better value for our customers. Our mission is to improve the health of our communities. Appleton Medical Center 160-Bed Acute Care Medical Center Theda Clark Medical Center 260-Bed Acute Care Medical Center New London Family Medical Center 25-Bed Acute Care Medical Center Riverside Medical Center 25-Bed Acute Care Medical Center ThedaCare Physicians Employing Over 125 Physicians At 22 Locations Orthopedics Plus The New Standard for Quick, High Quality Orthopedic Services In The Fox Cities ThedaCare at Home Home Health, Hospice, DME, Respiratory Therapy, Infusion, Pharmacy Services Shawano Medical Center 25-Bed Acute Care Medical Center Ingenuity First Offers Innovative Solutions to Employers For Health Care Costs Fox Cities Community Clinic A Free Clinic Jointly Owned With St. Elizabeth Hospital The Heritage/ Peabody Manor Continuing Care Campus for Older Adults ThedaCare Behavioral Health Inpt and Outpt Mental Health, Substance Abuse Services Gold Cross Ambulance Service Jointly Owned With Affinity Health Systems ThedaCare at Work Occupational and Employee Health Services, Employee Assistance Program 6,600 employees - located in Eastern Wisconsin 2

A Community of Problem Solvers Delivering MBV Lean Grad School Education/Skill Level K. We are Here 100% of employees are problem solvers improving something every day!!! 5 10 15?? Time (years) 3

How is your hospital or health system performing today? 4

What does the future look like? 2015? 2020? 5

Family of Four Total PPO Cost Versus Median Family Income % of Income 15% 18% 26% 45% 42% 38% Sources: PPO cost 2002-2011, Milliman; median family income 2002-2011, Census Bureau Notes: 2011 family income is an estimate for Federal FY12; total PPO cost = employer contribution, employee payroll deduction, and employee out-of-pocket co-pays/deductibles. Numbers rounded to nearest hundred. 6

The Word of the Moment in Healthcare Is Unsustainable The size of the federal budget deficit is unsustainable The annual increase in the Medicare budget is unsustainable The percentage of healthcare spending to GDP is unsustainable State Medicaid programs are unsustainable The continued transfer of costs to employers and consumers is unsustainable 7

Do you feel a sense of urgency? 8

What actions will be necessary to preserve your margin? What impact will those actions have on your overall performance? 9

What are you willing to do to not let that happen? How are YOU willing to change? Lead differently? 10

What is Lean About? Providing Value to Our Customers Continuous Improvement Engaging People in Problem Solving Respect for People Identify and Eliminate Waste 12

Elements of Lean Processes 14

Respect for People No Layoff Philosophy Reassignment Process Candor with Respect Learning Environment Communicate! Engage staff and physicians in problem solving 16

Problems are Opportunities Failures are okay!! 17

Lean Tools PDSA (Plan, Do, Study, Act) A3 Rapid Improvement Event (Kaizen Event) Value Stream Mapping 2P/3P (Process, Preparation, Production) 5S (Sort, Scrub, Straighten, Safety, Standardize, Sustain) Strategy Deployment 18

A3/PDSA thinking Background Why are you talking about it? Tell the story 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? - What is the root cause(s) of the problem? - What requirements, constraints and alternatives need to be considered? Recommendations/Experiments What is your proposed countermeasure(s)? How will you know it is working? Plan What activities will be required for implementation and who will be responsible for what and when? Follow-up/Study/Adjust How we will know if the actions have the impact needed? What remaining issues can be anticipated?

What is a Rapid Improvement Event? A two to five day focused improvement activity It has aggressive, measurable objectives Emphasis on the elimination of unnecessary non value-adding activities Rapid Implementation (during the event) Anticipate the work to really begin after the event followup and sustainment

Value Stream Mapping 2-4 day process to create a future state picture and action plan to create breakthrough and fundamentally change how we perform a process Starts with the customer and their requirements Includes understanding the flow of the product being transformed as well as the flow of information Identifies key problems to be worked 21

2P (Process, Preparation) 2P in Healthcare: Utilizes the current known methods and constructs/organizes them in the least waste way to create performance in defined objectives New Facility Process change or re-location New product or service development or introduction Major capacity rate change Chronic problems/process not meeting targets New Equipment: Process & Layout 22

6S 1: SORT GET RID OF WHAT'S NOT NEEDED 6: SUSTAIN SELF-DISCIPLINE AND CARE 6-S APPLIES TO ALL AREAS AUDIT AND IMPROVE 2: STRAIGHTEN ORGANIZE WHAT IS NEEDED (VISUAL MANAGEMENT) 5: STANDARDIZE ESTABLISH WHO / WHAT / WHEN FOR UPKEEP 3: SCRUB CLEAN UP (SEE AND SOLVE) 4: SAFETY ADDRESS UNSAFE ACTS, CONDITIONS, MOTIONS 23

Measurably Better Value ThedaCare s Strategic Plan People A3 (level 1) People People (level 2) level 2 A3 Strategy Deployment ThedaCare s Breakthrough Objectives Safety A3 (level 1) Shared Growth A3 (level 1) Productivity A3 (level 1) Plan Plan Plan Plan Safety Shared Growth Productivity Safety Shared Growth Productivity (level Safety 2) Shared (level 2) Growth (level 2) (level Safety 2) Shared (level 2) Growth level 2 A3 (level Safety 2) Shared (level 2) Growth (level Safety 2) Shared (level 2) Growth (level Safety 2) (level 2) (level 2) level 2 A3 level 2 A3 Cross Cross Function Functional Team Team Cross Cross Function Cross Function Team Cross Function Team Cross Function Team Cross Function Team Cross Function Team Functional Team Team Cross Cross Function Cross Function Team Cross Function Team Cross Function Team Cross Function Team Functional Team Team Cross Cross Function Functional Team Team

Leadership The Key to Lean 25

We have been trying to add Toyota Production System practices and principles on top of our existing management thinking and practice without adjusting that thinking and practice. Mike Rother from Toyota Kata 26

Culture is an idea arising from experience. That is, our idea of the culture of a place or organization is a result of what we experience there. In this way, a company s culture is a result of its management system culture is critical, and to change it, you have to change your management system. Creating a Lean Culture by David Mann 27

Jim Womack Lean Enterprise Institute: ThedaCare visit 5/9/08 All processes have a desperate desire to head toward chaos, to get worse fast, and the only thing standing in the way is management. Who is responsible for this process with their team?

Leadership In Lean Lean is much more about transforming the way we lead than any tool. Paradigm shift: leader as a teacher of problem solving instead of solving problems 29

Customers Staff Where the work happens that provides value to the customer Leads/Supervisors Customers Manager Executives

My Story 31

Lean Management System No Meeting Zone Daily Stat Sheets Leader Standard Work Daily Performance Huddles with Team Monthly Scorecard Reviews PDSA thinking Process Observation Calendaring Visual Management 32

NO MEETING ZONE Won t we just have to stay later in the day? How do you possibly make that stick? People don t actually follow it do they? When will we really get things done? I nice idea but..? 33

Daily Stat Sheet Manager to VP Manager 3S Inpatient Oncology Daily Measures Safety Quality People How many patients or staff are at risk? infections interpreter concerns employee injuries Any quality opportunities or concerns? falls, bundles, med. Rec/errors Any patient complaints/follow ups? Any equipment or room concerns? Any staff with special concerns or barriers? Who needs the most support how can we help them? Any physician or leadership concerns? Any thing, staff or provider to recognize or celebrate today? How are you planning on covering lunches and breaks? Delivery (Service and Timeliness) Any care management concerns? VP Daily/Weekly Stat Sheet Kim B. Safety Quality People : Daily Measures Dates How many Patients/Families or staff are at Risk? Any Quality Opportunities or concerns? Falls, bundles, med rec/errors Patient complaints/follow Ups Any Staff with Problems/Barriers? Who needs the most support today (weakest link) Any Physician or Leadership issues? Any thing, staff or provider to recognize or celebrate today? Delivery Any areas that Demand exceeeds Capacity For Oncology- Any non- oncology pts on the floor? How is care management helping to progress care today Monday Tuesday How many filled beds? 16 beds 16 beds How many discharges planned today? Department: Inpt Oncology

Leader Standard Work 35

Daily Performance Huddle New Improvement Opportunities S Q C P F Work In Progress Just Do Its Improvement Ideas Implemented Monthly Tracking PICK Chart Daily Tracking PDSAs 36

Monthly Performance Communication Diagram Leadership Teams, Monthly Scorecards and Monthly Performance Reviews Hospital Leadership Team Monthly Performance Review Hospital Leadership Team The VP s meet together to discuss their scorecard as it relates to strategic deployment and True North True North Metrics Vice President Leadership Team Monthly Performance Review Vice President Leadership Mgr 2 Mgr 1 Team VP meets with managers around their scorecards. Countermeasures summaries are presented, and additional resources are allocated if needed. VP Drivers Mgr 3 Mgr 4 COO Ops VP 3 rd Monday of the month 6 th or 8 th Business Day Lessons Learned Shared Stratification of Red Metrics Repeat for each VP Manager Leadership Team Monthly Performance Review Manager Leadership Team The manger meets with leadership team following defined Standard Work around scorecard. When areas are not meeting goalcountermeasures are developed. Business Unit Drivers Lessons Learned Shared Stratification of Red Metrics Mgr 4 th or 5 th Business Day Repeat for each Manager

Problem Solving A3 Template

Nove Dece mber Janua ry Febru ary Marc h April May June July Augus t Septe mber Octo ber Nove mber Dece mber Process Observation Calendaring Processes Example Process White Board Process Observation Pareto Sun Mon Tue Wed Thu Fri Sat PCB Problem Solving Tool (tollgates/delays) I&O Pain Management Environmental Safety Safe Patient Handling Care Plan Notes Purposeful Rounding Fall Bundle

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Lessons Learned Adopting lean means adopting a new way of leading Involve customers wherever possible Communicate early and often to line staff Engage key stakeholders Teach people to fish don t just give them the fish (ask questions, don t give answers) Once you ve implemented a change, you ve only just begun (you re only at the D in PDSA) Don t underestimate the pull of process to go back to their original state, regardless of how great the new process seems 41

Minutes CODE STEMI 100 AMC Code Stemi Door to Balloon 2005-2010 (Goal 60 min) 90 80 91 70 60 50 40 30 65 52 37 37 45 20 10 0 2005 2006 2007 2008 2009 2010 Year

Minutes Remote STEMI 250 ThedaCare Remote Stemi-6 sites 2005-2010 (Goal 90 min) 200 212 150 154 140 100 93 93 89 50 0 2005 2006 2007 2008 2009 2010 1st of 6 remote sites initiated Year

Minutes Field STEMI 90 80 70 Field Stemi 2009-2010 (EMS contact to reperfusion) (Goal 90 min) 82 60 50 60 40 30 20 10 0 2009 Year 2010

% Operative Mortalities Isolated CABG Mortality

2011 Wellness Monthly Scorecard Current HAT Scores All ThedaCare Employees Employees 2011 TARGET: 80.0 % Improvement: 1.25% 2009 Baseline: 77.5 2011 YTD: 79.9 YTD % Improvement: 3.0% Baseline and Current HAT Scores Monthly Most Current Mean HAT Score All ThedaCare Employees Target EE Actual & YTD HAT Score 81.00 80.00 79.00 79.01 Feb-11 Removed Shawano Medical Center. 79.11 79.10 79.15 79.23 79.33 79.34 79.50 79.53 79.63 79.79 79.90 78.00 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

Number of days NET A/R Days 58 56 54 52 50 48 AMC/TC 46 NLFMC 44 42 40 Physician Services Target System AR 38 36 34 32 Apr- 08 May- 08 Jun- 08 Jul- 08 Aug- 08 Sep- 08 Oct- 08 Nov- 08 Dec- 08 Jan- 09 Feb- 09 Mar- 09 Apr- 09 Month 2008

Cost per Case Collaborative Care model implemented Average Cost per case inliers, fully loaded Avoidable Day Production control implemented $10,000 $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 Baseline 2006-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 49

Collaborative Care Outcomes through 2010 Measure Defect-Free Admission Medication Reconciliation Pre- Collaborative Care (2006) 1.05 defects per chart End of 2007 0.01 defects per chart End of 2008 2009 2010 Compares to non- Collaborative Care units thru 2009 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. 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. 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.

Collaborative Care Outcomes through 2010 (Continued ) 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) 30-day re-admission rate Average Cost Per Case* (using Medicare RCC) and restated in current dollars 3.51 2.92 3.09 3.05 2.91 3.5 No data No data 13.98% 13.7% 12.9% 15.2% (2009) 14.7% * (2010) $6512 $5024 $6326 $5789 $5781 $7775 * This is all medical surgical unit re-admissions from a comparable non-collaborative care unit in the same hospital

Part A & B Medicare Expenditure in Dollars * 2008 Medicare Data * $57 Billion/yr in savings if all are at Outagamie spending levels

Where can you get help? Learn from each other! Go and See! Get your hands dirty! 53

Caution when going to see Lean is not about other peoples solutions Focus on how they are leading through the process and on the methods used to create the solutions 54

1. Identify the crisis 2. Create a lean promotion office 3. Find change agents 4. Map your value streams 5. Engage senior leaders early in strategy deployment 6. Acquire and disperse knowledge broadly 7. Teach a man to fish 8. Involve suppliers in lead 9. Restructure your organization into product families 55

Lean Enterprise Institute: www.lean.org ThedaCare Center for Healthcare Value: www.createhealthcarevalue.com Healthcare Value Network: www.healthcarevalueleaders.com