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 2007

by John Toussaint of Thedacare shown at the 1st Global Healthcare Summit of 25th June 2007

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  • 1. The ThedaCare Improvement System (TIS) John S. Toussaint, MD President/CEO ThedaCare, Inc.
  • 2. 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 Orthopedics Plus The New Standard for Quick, High Quality Orthopedic Services In The Fox Cities ThedaCare Physicians Employing Over 118 Physicians At 20 Locations ThedaCare at Home Home Health, Hospice, DME, Respiratory Therapy, Infusion, Pharmacy Services ThedaCare at Work Occupational and Employee Health Services, Employee Assistance Program 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 July 2006
  • 3. Mission the reason we are together “ThedaCare’s mission is to improve the health of our communities”
  • 4. Vision a 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.”
  • 5. Shared Values the internal compasses that guide our day-to-day decisions; the glue that holds the organization together Compassion Courage Honesty Innovation Integrity Respect Teamwork
  • 6. ThedaCare Goals 6/30/06 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
  • 7. Defects per Million Opportunities (DPMO) Performance Industry/Process Defect DPMO Commercial 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
  • 8. RESULTS: Collaborative Care A vision of hospital care with nursing at its center A 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.
  • 9. 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
  • 10. 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
  • 11. 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.
  • 12. Collaborative Care Patient Progression Tollgate 2 Tollgate 4 Tollgate 5 Tollgate 1 Tollgate 3 PatientDischarge Are we progressing care? Problem Solve NO PT Care Are we progressing care? Problem Solve NO PatientAdmission PT Care Are we progressing care? Problem Solve NO PT Care Are we progressing care? Problem Solve NO PT Care Are we progressing care? Problem Solve NO PT Care PT Care Collaborative Care Value Stream Metrics
  • 13. ThedaCare Orthopedics Plus MSC 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 Med Rheum LAT Behavioral Med Physiatry Imaging Tier 3 Orthopedic Surgery 1 surg case/10 patients, More focused referrals from larger referral base Hand Delays minimized Delays minimized EMR doc -------- Service & Clinical Quality
  • 14. •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.
  • 15. Musculoskeletal Care Journey RESULTS: •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.
  • 16. RESULTS: Door to Balloon Cardiologists benchmarked in a collaborative in Wisconsin 2 week long RIEs involving ER and Cath lab Physician champion emerging to drive competition Kim/PPT/John/HealthForumSF0706
  • 17. Mean Time to PCI – AMC (Door to Balloon) 0 20 40 60 80 100 120 140 Jan M ar M ay Jul Sept Nov Jan M ar M ay 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:
  • 18. “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:
  • 19. RESULTS:
  • 20. RESULTS:
  • 21. 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 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 •Step 1 “Identify” waste •Step 2 “Eliminate” waste Accomplishments:
  • 22. “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-DISCIPLINE AND CARE Accomplishments: 6S is a Productivity tool not a workplace clean up campaign
  • 23. Kim/PPT/John/NewEmployeeOrientation0307
  • 24. Accomplishments: Created the TIS Internship 1% of workforce have full-time jobs in improvement We can effectively manage 3 week-long events each weeks Standard work for executive GEMBA done weekly 6S in all units
  • 25. Accomplishments: TIS Leadership Internship Purpose Prepare participants for role transition to leading in a continuous improvement environment, integrating TIS tools, processes, and thinking
  • 26. Logistics & Design Accomplishments: 8 weeks, 50% of work time (160 hrs) Weekly schedule/focus Reading/pre-work Coaching with Manager Learning methodologies • Fieldwork • Application to department work Linking with PDP Operational managers of participants involved in the learning process Evaluation-show and tell PDSA Framework O: ThedaCare Improvement System/TIS Internship for Leaders
  • 27. Accomplishments: Outcomes 1. 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.
  • 28. TIS Leadership Internship Outcomes Accomplishments: 74 participants to date Retention rate-94.5% Participant Mix • 5 Managers • 34 Supervisors • 19 Facilitators • 16 (Lead, Educator, Coordinator, Analyst)
  • 29. 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
  • 30. 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 New Beginnings Collective/Group Cycle (Intellectual Change) Individual Cycle (Emotional Change) Fundamental Supporting 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:
  • 31. RIE Participant Survey Lessons Learned: I would recommend this organization to a friend as a good place to work Overall, I think this is a great place to work My manager or someone at work seems to care about me as a person My manager shows appreciation for the work I do At work, my opinion seems to count People here are willing to give extra to get the job done My manager provides me with sufficient opportunities to improve myself I am satisfied with my job security People are encouraged to balance their work and personal life Management has kept promises made to us
  • 32. Lessons Learned: Summary Statistically significant differences in satisfaction for those involved in 2 or more RIEs
  • 33. Lessons Learned:
  • 34. Habits Safety • 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?
  • 35. 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
  • 36. 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?
  • 37. Lessons Learned: Create Pull for Physicians Radiology transcription data Outpatient surgery center/under arrangement partnership (partnership with physicians)
  • 38. 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:
  • 39. Future Plans TIS Leadership Education (Learning to See) Cell lead & training visit to Ariens 3% of work force full-time on improvement through re-deployment
  • 40. 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
  • 41. Change the people or change the people - Dan Ariens