organization that delivers better patient value

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1 Building a Healthcare organization that delivers better patient value John S. Toussaint M.D. CEO Thedacare Center for Healthcare Value CEO Emeritus Thedacare MMS 04/06/11 Financing Reform through Program Cuts, Higher Taxes/Fees Over 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 Market basket adjustments (including productivity adjustments) for certain hospitals and other providers - $196 billion Restructuring of payments to Medicare Advantage (MA) plans - $136 billion Revenue provisions Industry fees (pharmaceutical industry fee, medical device fee, insurance industry fee) - $107 billion Higher Medicare tax on high-income taxpayers - $210 billion Reducing Medicare and Medicaid Disproportionate Share Hospital (DSH) payments to hospitals - $36 billion Other cuts (e.g., home health payment rates) - $87 billion Cadillac tax -$32 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 2 1

2 Core components of the quality and cost problem? Payment systems that do not reward healthcare providers to deliver better value Lack of transparency of performance Providers do not have a consistent methodology to improve care Current Payment Systems Reward Bad Outcomes, Not Better Health Healthy Consumer Continued Health $ Preventable Condition No Hospitalization Acute Care Episode Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 2

3 Healthy Consumer $ A Single Payment For All Care Needed For A Condition Comprehensive Care Payments To Avoid Episodes Continued Health Preventable Condition $ Comprehensive Care Payment or Global Payment No Hospitalization Acute Care Episode Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions Member Organizations Wisconsin health systems, physician groups, hospitals and health plans Approx. 40% of all WI physicians (5,200) & 50% of WI primary care physicians (2,000) Aurora Advanced Healthcare Mercy Health System Aurora Healthcare Meriter Hospital Aurora UW Medical Group Monroe Clinic Bellin Health Prevea Health Columbia St. Mary s ProHealth Care Medical Associates Dean Health System QuadMed Fort HealthCare Sacred Heart Hospital Franciscan Skemp Healthcare - Mayo Saint Joseph s Hospital Health System St. Mary's Hospital (Madison) Froedtert & Community Health ThedaCare Gundersen Lutheran West Bend Clinic Luther Midelfort - Mayo Health System UW Hospital and Clinics Marshfield Clinic UW Medical Foundation Medical College of Wisconsin Wheaton Franciscan Healthcare Wisconsin Collaborative for Healthcare Quality 6 3

4 WCHQ Data Flow Wisconsin Collaborative for Healthcare Quality 7 4

5 WCHQ Chronic Care Ranking (Based on the 10 Measures Top 15 out of 20 businesses) Business Sum of Total Ranking 1) ThedaCare 14 2) 39 3) 45 4) 66 5) 73 6) 73 7) 78 8) 85 9) 92 10) ) ) ) ) ) 142 Source: wchg.org Wisconsin Health Information Organization The WHIO Health Analytics Exchange Ata-Glance -- The Exchange contains a volume of data that spans multiple care systems and services provided statewide -- The Exchange holds a rolling 27 months of claims data that captures the experiences of more than 1.6 million people and 72 million treatment services -- The Exchange contains 7.3 million episodes of care and will continue to expand as new members contribute to the cooperative effort. An episode of care is defined as the series of treatments and follow-up required for a single medical event or the year-long treatment of a chronic condition -- The current version of The Exchange contains more than $9.3 billion of health care expenditures and allows comparisons by region, county, ZIP code or medical system 5

Wisconsin Health Information Organization Our members include: The Alliance Anthem Blue Cross and Blue Shield of Wisconsin Dean Health Plan Greater Milwaukee

6 Wisconsin Health Information Organization Our members include: The Alliance Anthem Blue Cross and Blue Shield of Wisconsin Dean Health Plan Greater Milwaukee Business Foundation on Health Group Health Cooperative of South Central Wisconsin Gundersen Lutheran Health Plan Health Tradition Health Plan Humana MercyCare Insurance Co. Security Health Plan United Healthcare of Wisconsin WEA Insurance Trust WPS Health Insurance Wisconsin Collaborative for Healthcare Quality Wisconsin Department of Employee Trust Funds Wisconsin Department of Health Services Wisconsin i Hospital lassociation i Wisconsin Medical Society Provider Detail Diabetes Cost Index List 6

7 How do we define value in healthcare? 7

Providers, policy makers, and academics are seeking value Leading perspectives on value have various nuances to consider, but all stress a more coordinated, patient-centered, and informed approach is

Nuances Definition Value is considered from the lens of the consumer Outcomes are defined as both health status and experience, with an implied interrelationship between the two Measurement

8 Providers, policy makers, and academics are seeking value Leading perspectives on value have various nuances to consider, but all stress a more coordinated, patient-centered, and informed approach is necessary Porter Berwick Makadon Value Definition Vl Outcome f (Population Health, Quality x Experience Value = Experience of Care, Per Value = Cost Value = Capita Cost) Cost Overarching Themes Nuances Definition Value is considered from the lens of the consumer Outcomes are defined as both health status and experience, with an implied interrelationship between the two Measurement Measurement of value inherently requires a longitudinal / population based perspective Accuracy requires better accounting for and attribution of cost Outcomes include a three tiered Theory stresses alignment; to Value Curve defines the frontier of hierarchy: maximize value, there must be performance based on Quality, 1. Health status achievement aligned incentives for the individual Service, and Cost 2. Process of recovery actors in the system 3. Sustainability of health Cost includes the total costs of the full cycle of care for the patient s medical condition, not just the cost of individual services An integrator is needed to accept responsibility for the three aims for a specific population (e.g. Kaiser Permanente) Cost is measured per capita and requires measurement of actual costs, currently obscured by pricing and discounting methods Theory implies tradeoff between cost and quality, unless a provider can push the frontier Cost is measured on a per patient basis and could extend across many sites of care WHIO Cost vs WCHQ Clinical Quality 8

9 Results using Lean in Healthcare Group Health of Puget Sound reduced E.R. visits by 29% and hospital readmissions by 11% using their lean medical home redesign Bolton U.K., reduced Stroke mortality by 23% over 18 months 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% St. Boniface Winnipeg, Canada has the best cost/weighted case(canadian measure for inpatient cost efficiency) for an academic medical center in Manitoba, and is second in all of Canada Mercy Hospital North Iowa has had zero blood tube specimen errors for a year running Source: Health Affairs 2009, Volume28, No: 5: , America Journal of Managed Care, September 2009 The Methodology of Healthcare Lean 9

10 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 A3 As a standard process, it becomes easier for you To describe key ideas to others, and to understand others It fosters dialogue within the whole organization It develops problem-solvers It encourages front-line initiative Teaches scientific method 10

11 A3 or PDSA: What Are Talking About? Background Why are you talking about it? Current Situation Where do we stand? Goal What s the problem? Where we need to be? What is the specific change you want to accomplish now? Analysis - What is the root cause(s) of the problem? - What requirements, constraints and alternatives need to be considered? Recommendations What is your proposed countermeasure(s)? 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? Measurably Better Value ThedaCare s Strategic Plan People A3 (level 1) Problem statement, background and targets deployed People People (level 2) level 2 A3 Deploying Level 1 Priorities to Level 2 ThedaCare s Breakthrough Objectives Shared Sft Safety A3 Productivity it A3 Growth A3 (level 1) (level 1) (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 11

12 Sponsor: Title: System Safety A3 (Hospitals, TCP, Senior Svs. Support Areas) Facilitator: 1. Background 2. Current Conditions Our paradigm tolerates risk & errors. Culture of Safety Report Card! Healthcare nationally harms 5 million pts/yr and 1) Realize anyone can make a mistake! D OSHA RECORDABLES kills nearly 100,000 pts/yr-minimal change since 2) Create safe environment to report errors. C- original IOM report (To Err is Human) released 3) Create collegiate interactive healthcare teams C+ in ) Barrierless communications. C- 10 Our employees are at risk in the workplace. 5) Teams with mutual human caring & support. B- 9 8 Sub-optimal safety = avoidable cost ($$$) to UNSAFE INR 7 ThedaCare and the national healthcare system. 6 Our expectations r/t safety are unclear. 5 7% 4 We lack a true culture of safety limiting our PREVENTABLE MORTALITY 6% 3 awareness of the problem and effective 5% 2 interventions.. not my problem. 3% 4% 2% 1 3% Safety resource needs unclear. 1% 2% 1% AMC/TC TCP SR SV ThedaCare leadership s behaviors and actions 2008 EXPECTED do not always align with safety as a top priority. it Actual 2008 ACTUAL 4 Known Deaths in 2008 Target 2009 Target = Target = 3.8% 3. Goals and Targets 2009 Safety A3 Initiatives Division Initiative Baseline 2009 Target (50% improvement) Thanks! This AMC/TC INR (% percentage of pts in safe range 64.60% 82.30% environment Great job is not OSHA recordables lifting/handling) AMC-2.45 AMC recognizing judgmental so TC-2.92 TC-1.56 that safety I feel safe in Medication Reconciliation TBD 50% improvement problem and Safe Patient Care NA Nat'l Patient Safety Goals Met reporting! telling Care Giver Communication someone! 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% Per 1,000 Doses Revision #4, Date: Leader: Greg Long, MD, CMO Sensei: 03/30/09 5. Proposed Countermeasures Countermeasure Description Cause Responsible Patient 1) Involve patient & 1) Create standard 1) family in creating safe environment work that actively involves the patient & their family in creating a safe environment 1) Develop competency of staff related to People 1) Staff competency & training risk assessment & 1) anticipation 2) Educate 2) Culture of Safety within ThedaCare & train, modify behavior toward culture of safety of 2) Roger G. all staff & physicians; anticipate safety/error issues JMichael G. 3) Roger G 3) Problem solving daily by all 3) Train all manager level and above employees in TIS problem solving (eg., A3 & A4 use) Katie B 4) 4) Embrace standard work 4) Performance to standard work is assured as it becomes a way of life for all staff (purposeful variation is acceptable) Process 1) Standard work creation & compliance 1) Develop, imbed, sustain standard work, including evidencebased 1) Division medicine pertaining to safety leaders MEDICATION ERRORS 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 and enforce hospital 2) Amend bylaws & TC policies bylaws & TC policies outlining 2) Humana expected behaviors r/t safety Resources Robin Wilson 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, 2) Matt tools, techniques to eliminate injuries. Digman 3) Safeguard our facilities 3) Assess & implement tools & techniques to eliminate pt/staff 3) injuries invest $ if needed. 6. Plans: 4. Analysis (Initial thoughts) Safety A3 Gap Analysis Team m: 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 t 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 Safety Disruptive behavior Focus not alw ays addressed 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 allow defects in w ork environments/practices to save Old policy not reflecting new practice We $$ 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 2007 Page A TRUE NORTH METRICS Safety/Quality - Preventable Mortality - Medication Errors 12/15/09 Draft. 6 Customer Satisfaction - Access - Turnaround Time - Quality of Time People - OSHA Recordable Injuries - HAT Scores - Employee Engagement Index Financial Stewardship - Operating Margin - Productivity 12

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14 T.C.Medical Home Onstage and Offstage The Patient Experience Plan of Care Phone Call Arrival & Prep Provider Visit After Visit The Supporting Processes Provider Phone Pre-Regist Chart MA SW Visitit Plan of Cell Scrub Pre- Care Visit Document 5S d, visual, Epic-enabled Environment Cell Lead Lab In basket Collab Checkout 27 Target State Customer Delighters: Service Quality : Convenient Access on-demand User-friendly Operates on-time Leaving with and understanding a plan of care Quality of time spent with patients Lab results before end of visit Clinical Quality: Excellent/Far-exceeding industry trends Business Delighters: Differentiated from all market competition - locally & nationally Setting new standards for a healthcare organization in: - Service Quality -Clinical Quality -People Engagement Cost and productivity improvements of 5 to 10% year over year Critical Operational Success Factors Lab TAT/ Same Visit Ancillary Results Org Structure Flow Cells Running on-time: Managing Flow Escalation Visual Tracking Role of MA Leadership Model: Coaching Managing to Metrics Being in the Work Knowing the Business Encounter TAT Real-time Problem Solving Customer Service Plan of Care Standard Work: Content Seq Timing Outcome Scripting Alignment of Incentives, Policies, Expectations Phys Comp 14

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.

15 NEW DELIVERY MODEL RESULTS Safety/Quality from 80% to 93% within safe range from 20% to 96% Plan of Care first pass from 5% to 80% labs within 15 min. People employee & physician satisfaction Customer Satisfaction 100% option to be seen today Financial Stewardship visit encounters per HRS worked.05 AR days by 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 Step 1 Identify waste Step 2 Eliminate waste 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 15

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Patient Experience ThedaCare: Strategic Change Processes PAST vs. CURRENT KEY ATTRIBUTE TRADITIONAL MODEL COLLABORATIVE MODEL Disjointed. May be confusing, even contradictory.

Reliable, standard work, using Manage errors. Nursing maintaining evidence-based quality and real time thru heroics problem solving to prevent errors. Physician Role Hierarchical.

Expanded and empowered role in decision making and patient care progression. Bedside management of quality measures Pharmacist Role Back end. Bedside presence.

17 Patient Experience ThedaCare: Strategic Change Processes PAST vs. CURRENT KEY ATTRIBUTE TRADITIONAL MODEL COLLABORATIVE MODEL 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. Reliable, standard work, using Manage errors. Nursing maintaining evidence-based quality and real time thru heroics 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. Copyright 2009 ThedaCare. All Rights Reserved. TOLL GATES 1 st 90 minutes Within 4 hours of Full calendar day admission 1 may loop here dependent on condition and LOS. Activities to progress care and reach next Toll Within 24 hours of DC Toll 4 Within 2 hours of DC last Toll Poka-Yoke Criteria to assure defects do not pass forward Decision makers in Purple Patent Pending ThedaCare, Inc. All rights reserved. For More information, contact ThedaCare, Inc. 17

Collaborative Care Patient Progression Tollgate 1 Tollgate 2 Tollgate 3

PT Care Are we progressing care? PT Care Are we progressing care?

Solve Problem Solve Collaborative Care Value Stream Metrics Supportive

at the bedside All designs created by front line clinicians Copyright

18 Collaborative Care Patient Progression Tollgate 1 Tollgate 2 Tollgate 3 Tollgate 4 Tollgate 5 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 NO NO NO NO NO Problem Solve Problem Solve Problem Solve Problem Solve Problem Solve Collaborative Care Value Stream Metrics Supportive Physical Environment Patient Servers- contain 90% of the supplies needed at the bedside All designs created by front line clinicians Copyright 2009 ThedaCare. All Rights Reserved. 18

19 Collaborative Care Outcomes through 2010 Measure Pre-Collaborative Care (2006) End of 2007 End of 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. Length of Stay* (In days) day readmission rate No data No data 13.98% 13.7% 12.9% 15.2% 14.7% * (2009) (2010) Average Cost Per Case* (using Medicare RCC) and restated in current dollars $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 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. 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. Continuous Daily Improvement 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 19

20 Color Coding on Tracking Tools Same colors used light red/light green for tracking information. 20

Can you say yes to these three questions every day?

encouragement to do work that gives their life

21 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? 21

22 White coat leadership vs. Improvement leadership All knowing In charge Autocratic Buck stops here Impatient Blaming Controlling Patient Knowledgeable Facilitator Teacher Student Tenacious Communicator Humble 22

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24 A Community of Problem Solvers Delivering MBV Lean Grad School Education/Skill Le evel K. We are Here 100% of employees are problem solvers improving something every day!!! ?? Time (years) 47 Productivity-Clinical Labor Costs/UOS 24

25 80% 70% 60% 50% 40% 30% Safety/Quality Lean Management Pilot Managers Percent Safety/Quality Driver Improvement over 2008 Baseline Note: Each unit with between 3-6 drivers /All units have different drivers Falls Coumadin Education Pain Assessment 1st Call Bed Access Turnover 20% 10% 0% AMC Inpt Oncology AMC 2S TC 2nd Floor AMC 3SW Staff competency Delays in access Interactions within 4 days of DC Employee Engagement 2009 Employee Opinion Survey Percent Improvement Lean Management Pilot Units 2008 vs % 40% Cancer Services-BPS Radiation Oncology-BPS 30% 20% 10% 0% AMC 2S-BPS TC 2nd Floor-BPS AMC 3SW-BPS TC OB-BPS -10% Would recommend organization Organization Inspires Me Likely to be here in 3 yr. Will put forth effort to help org Understands how daily work succeed contributes to mission 25

26 Isolated CABG Mortality 6 % Op perative Mortalities

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28 diture in Dollars & B Medicare Expend Part A & * 2008 Medicare Data * $57 Billion/yr in savings if all are at Outagamie spending levels 28

29 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 29

30 First 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 Second Network Alberta Health Services Alberta Health Services Akron Children s Hospital Beth Israel Deaconess BJC Healthcare Christie Clinic Harvard Vanguard Medical Associates g Kaiser Permanente Provena Covenant Medical Center Seattle Children s Hospital St. Joseph Health System (Orange, CA) 30

31 Bronson Healthcare Group Exeter Health Resources Network #3 Henry Ford West Bloomfield Hospital Inova Health System INTEGRIS Health Lucile Packard Children's Hospital Martin Memorial Health Systems Mercy Medical Center - North Iowa Parkview Health St. Joseph Regional Health Center Sutter Gould Medical Foundation Winona Health 31

Lean Leadership and Health Reform. John S. Toussaint M.D. AME 11/16/10

Lean Leadership and Health Reform John S. Toussaint M.D. AME 11/16/10 The Rate of Spending on Healthcare is Fiscally Unsustainable** McKinsey-RE: Japan Almost half of all Americans, (133 million) live