M22: Leading a Lean Transformation

Transcription

1 M22: Leading a Lean Transformation John S. Toussaint, M.D. CEO ThedaCare Center for Healthcare Value Kim Barnas System 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 wholesystem 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 1

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% 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: , America Journal of Managed Care, September 2009 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 4 2

3 The Methodology of Lean is about creating value for the customer Value =Q/C 3

4 True North Metrics RESULTS Create Value for the Customer Leadership Behaviors CLEAR PURPOSE Enterprise Alignment Focus on the Problems Align Strategy Align Systems Align Performance Stabilize Process Standard Process Visual Management SCIENTIFIC METHOD TO SEEK PERFECTION Continuous Improvement RESPECT FOR PEOPLE Cultural Enablers Identify & Eliminate Waste Front Line Data Integrate Improvement with Work Involve Everyone Develop People Ensure a Safe Environment Build work 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 4

5 A3 : What Are Talking About? Background Why are you talking about it? 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 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 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 People A3 Safety A3 Productivity A3 Growth A3 (level 1) (level 1) (level 1) Plan Plan (level 1) 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 Function Functional Function Function Function Function Function Function Functional Function Function Function Function Function Functional Function Functional 5

6 Title: System Safety A3 (Hospitals, TCP, Senior Svs. Support Areas) 1. Background 2. Current Conditions Sponsor: Facilitator: Leader: Greg Long, MD, CMO Sensei: 5. Proposed Countermeasures Revision #4, Date: 03/30/09 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. 3. Goals and Targets Great job recognizing that safety problem and telling someone! Thanks! This environment is not judgmental so I feel safe in reporting! 6. Plans: 4. Analysis (Initial thoughts) Safety A3 Gap Analysis : 7. Follow-up 2007 Page A TRUE NORTH METRICS Safety/Quality 50% - 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 6

7 The 7-Week Cycle of an R.I. Event 3 weeks before Value Stream review, Event Selection, Select 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 7

8 11/16/2011 8

9 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. 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. Copyright 2009 ThedaCare. All Rights Reserved. TOLL GATES 1 st 90 minutes Within 4 hours of admission Full calendar day 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. 9

10 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 Wilson video 10

11 Collaborative Care Outcomes through 2010 Measure Defect-Free Admission Medication Reconciliation Pre- Collaborative Care (2006) 1.05 defects per chart End of defects per chart End of Compares to non- Collaborative Care units thru 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 is updated baseline. Case mixwas not significantlydifferent between collaborativecare and non-collaborativecare Updated from: "Writingthe 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 Length of Stay* (In days) 30-day re-admission rate Average Cost Per Case* (using Medicare RCC) and restated in current dollars Pre- Collaborative Care (2006) End of 2007 End of Compares to non- Collaborative Care units thru 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 medicalsurgical unit re-admissionsfrom a comparablenon-collaborativecare unit in the samehospital 11

12 CODE STEMI 100 AMC Code Stemi Door to Balloon (Goal 60 min) Minutes Year 250 Remote STEMI ThedaCare Remote Stemi-6 sites (Goal 90 min) Minutes st of 6 remote sites initiated Year 12

13 Field STEMI Field Stemi (EMS contact to reperfusion) (Goal 90 min) 82 Minutes Year 2010 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 13

14 Number of Drivers BPS Scorecard Driver Improvement 88% improved 3 14 Safety/Quality 85 % improved 2 11 Customer Satisfaction 83% Improved 1 5 People True North Driver Category 48% improved Financial Stewardship No improvement Improved 80% 70% 60% 50% 40% 30% 20% 10% BPS Alpha Units-Percent Employees "Engaged 2009 vs % AMC CVS Inpatient AMC 8th Floor AMC Inpt Oncology TC Birth Center TC Neuro Surgical Radiation Oncology 14

15 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? 15

16 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. 16

17 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 17

18 Part A & B Medicare Expenditure in Dollars * 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 18

19 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 19

20 Physician Value Metrics Emerging Provider Detail Diabetes Cost Index List 20

21 KNEE REPLACEMENT EPISODES SINGLE KNEE, SINGLE ADMISSION, SEVERITY 1 WHIO DMV4 Analysis by WMS $60,000 $50,000 $55,061 y = x R² = $40,000 $30,000 $20,000 $36,594 $31,924 $27,254 $22,584 $17,914 $10,000 $ 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) 41 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 21

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23 References Health Affairs 28, No.5 (2009) : Health Affairs 30, No.3 (2011) : Joint Commission Journal on Quality and Patient Safety 37, No.9 (2011) : American Journal of Managed Care 17, No.3 (2011) :

24 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 Healthcare Value Network Network #1 Network #2 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) 24

25 Healthcare Value Network Network #3 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 #4 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 5 commitments Scottsdale Health Alexean Bros health Oregon Health and Sciences University Martinspoint Health Mayo Lae 25