The ThedaCare Improvement
John S. Toussaint, MD
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.
160-Bed Acute Care
260-Bed Acute Care
New London Family
25-Bed Acute Care
25-Bed Acute Care
The New Standard for
Quick, High Quality
In The Fox Cities
At 20 Locations
ThedaCare at Home
Home Health, Hospice,
ThedaCare at Work
Solutions to Employers
For Health Care Costs
A Free Clinic Jointly
St. Elizabeth Hospital
Campus for Older
Inpt and Outpt Mental
Jointly Owned With
the reason we are together
“ThedaCare’s mission is to improve the
health of our communities”
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.”
the internal compasses that guide our day-to-day
decisions; the glue that holds the organization together
Decrease Defects and Waiting
Time by 50% each year
Increase Productivity 10%
All staff and physicians
participate in 2 or more RIE’s
Defects per Million Opportunities
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
Himalayan mountaineering Death 388,537
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
Provided in environment designed specifically for
the model, to reduce waste, to ensure safety and to
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
One plan, developed by team in room
Patient Experience Disjointed. May be confusing, even
Single plan of care developed with
patient – is visible, continuously
updated with patient driven schedule
Clinical Quality Admirable, but not 100% reliable.
Manage errors. Dependent on heroic
Reliable, standard work, using
evidence-based quality and real time
problem solving to prevent errors.
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
Collaborative Care is the Model Which Will Transform Us
From Current to Future State
~ Collaborative Care ~
Measure Pre Desired Collaborative Care Unit
Defect Free Medication 1.5/pt .1/pt
Quality Bundle Pneumonia 38%
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
Collaborative Care Patient Progression
Collaborative Care Value Stream Metrics
ThedaCare Orthopedics Plus
MSC Care – January 2006
PCPs -Growth (increased providers, locations)
Tier 2 “Mayo-like”
Sports Med PT Occ Med
Rheum LAT Behavioral Med
1 surg case/10 patients,
More focused referrals
from larger referral base
•1/27 – Injured (R) knee pivoting on it getting into the shower.
Musculoskeletal Care Journey
•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,
•2/1 – 0630 MRI knee completed.
•2/1 – 0847 Radiologist report transcribed, report available
Musculoskeletal Care Journey
•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.
Door to Balloon
Cardiologists benchmarked in a
collaborative in Wisconsin
2 week long RIEs involving ER and Cath
Physician champion emerging to drive
Mean Time to PCI – AMC
(Door to Balloon)
Jan 05-Jun 06 Goal
2-6-06 Door to Balloon RIE
2-15-06 Standing orders AMI
2-27-06 Code STEMI initiated
Arrival Time: 1613 Via walk-in/EMS
EKG Time: 1618
Beta Blocker: 1627
Time to CVL: 1634
1st Balloon Time: 34 Minutes
DOOR TO BALLOON TIME: 34 MINUTES
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
3rd week after – CFO validation
•Step 1 “Identify” waste
•Step 2 “Eliminate” waste
GET RID OF WHAT'S
R.I. EVENT GOALS: IMPROVE AUDIT SCORE BY 20 POINTS
1: SORT OUT
TO ALL AREAS
AUDIT AND IMPROVE
ORGANIZE WHAT IS NEEDED
(SEE AND SOLVE)
ACTS, CONDITIONS, MOTIONS
WHO / WHAT / WHEN
6S is a Productivity tool not a workplace clean up campaign
Created the TIS Internship
1% of workforce have full-time jobs in
We can effectively manage 3 week-long
events each weeks
Standard work for executive GEMBA done
6S in all units
TIS Leadership Internship
Prepare participants for role transition to leading in a
continuous improvement environment, integrating TIS
tools, processes, and thinking
Logistics & Design
8 weeks, 50% of work time (160 hrs)
Coaching with Manager
• Application to department work
Linking with PDP
Operational managers of participants involved in the learning process
Evaluation-show and tell
O: ThedaCare Improvement System/TIS Internship for Leaders
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.
Manager Assessment of Participant2.0
Pre- Post- Pre- Post- Pre- Post- Pre- Post- Pre- Post-
Lead Improvement Leading Effective Teams PDSA Leader in TIS Culture People, Processes &
Establish a sense of
urgency for Change
Form a powerful
Create the new
the VisionEmpower others to
act on the Vision
Plan for and create
ThedaCare Change Model – Draft 2
•Development of Core Processes
•Capacity for Intervention
We are getting exactly
the results we are
designed to achieve! To
get something different,
we must change our
Sources: “Leading Change” – John Kotter
“Managing Transitions” – William Bridges
“Making Sense of Change Management” Cameron & Green
RIE Participant Survey
I would recommend this organization to a friend as a good place
Overall, I think this is a great place to work
My manager or someone at work seems to care about me as a
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
I am satisfied with my job security
People are encouraged to balance their work and personal life
Management has kept promises made to us
Statistically significant differences in satisfaction for
those involved in 2 or more RIEs
• 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
• 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?
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
• 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
• Is the staff member designing business models to meet our customer/patient
We capture learning
• Does the staff member celebrate successes and failures in big ways and in
• 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
We are candid and respectful
• Is the staff member open to new information?
• Does the staff member have regular, open, honest communication with
• 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
Create Pull for Physicians
Radiology transcription data
Outpatient surgery center/under arrangement
partnership (partnership with physicians)
TIS Leadership Education (Learning to See)
Cell lead & training visit to Ariens
3% of work force full-time on improvement
Issues With Suggestion
Managing change related to professional
• 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
Change the people or change the people
- Dan Ariens