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Healthcare Reform and Lean Leadership



Slides from a keynote by Dr. John Toussaint, former CEO of ThedaCare, on U.S. healthcare reform and lean leadership.

Slides from a keynote by Dr. John Toussaint, former CEO of ThedaCare, on U.S. healthcare reform and lean leadership.



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Healthcare Reform and Lean Leadership Healthcare Reform and Lean Leadership Presentation Transcript

  • 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 with at least one chronic condition:  81% of hospital admissions; 91% of all prescriptions; and 76% of all physician visits  Accounts for more than 75% of the nation’s $2 trillion medical care costs.  Diabetes : $174 billion/yr  Smoking: $193 billion/yr  Heart disease and stroke: $448 billion/yr  Obesity: $117 billion/yr  Cancer: $89 billion/yr
  • Enacted Legislation Patient Protection and Affordable Health Care and Education Care Act (“PPACA”) Affordability Reconciliation Act  Became law March 23, 2010, Pub.  Became law March 30, 2010, Pub. L. No. 111-148 L. No. 111-152  Contains “bulk” of health  Modifies/adds to PPACA reform law Health Reform 3
  • Impact of Coverage Expansion (excluding Medicare- eligible population)+ Current coverage Employer-Sponsored Coverage Medicaid/CHIP Exchanges Uninsured 150 million covered through their 40 million covered by Currently 50 million are employer Medicaid & CHIP uninsured By 2020 Employer-Sponsored Coverage Medicaid/CHIP Exchanges Uninsured 159 million will have coverage 51 million will be enrolled in 24 million will purchase 22 million nonelderly through their employer Medicaid & CHIP coverage through residents will remain Exchanges uninsured (about 1/3 of whom are unauthorized immigrants)
  • 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 Revenue provisions  Market basket adjustments (including  Industry fees (pharmaceutical industry fee, productivity adjustments) for certain medical device fee, insurance industry hospitals and other providers - $196 billion fee) - $107 billion  Restructuring of payments to Medicare  Higher Medicare tax on high-income Advantage (MA) plans - $136 billion taxpayers - $210 billion  Reducing Medicare and Medicaid  “Cadillac tax” - $32 billion Disproportionate Share Hospital (DSH) payments to hospitals - $36 billion  Other cuts (e.g., home health payment  Penalty payments by employers and rates) - $87 billion uninsured individuals - $65 billion Total = $455 billion  Other revenue (e.g., indoor tanning tax) - $111 billion Total = $525 billion 5
  • Key Delivery Reform Provisions • Center for Medicare and Medicaid Innovation • Independent Payment Advisory Board (IPAB) • Accountable Care Organizations (ACOs) • Medical Homes • Hospital Value-Based Purchasing Program • Value-Based Payment Methods • Pilot Program on Payment Bundling • Reforms for Hospital Acquired Conditions and Hospital Readmissions 6
  • Implementation Timeline for Delivery Reforms • Prohibition on federal • Hospital value-based purchasing Medicaid payments for program begins (FY 2013) hospital-acquired conditions (FY 2011) • Financial penalties imposed for hospital readmissions (FY 2013) •Deadline for Center for Medicare and Medicaid • Deadline for establishing pilot Innovation (January 1, program on payment bundling 2011) (January 1, 2013) 2010 2011 2012 2013 2014 2015 2017 2020 • Deadline for • Independent • Reductions in Medicare hospital establishing ACOs Payment Advisory payments for hospital-acquired (January 1, 2012) Board to submit first conditions (FY 2015) recommendations to • Deadline for reform Medicare • Physician value-based payment establishing Medicare payments (January 15, modifier applied to specific medical homes (January 2014) physicians (January 1, 2015) 1, 2012)
  • • “You can count on Americans to do the right thing … after they have tried everything else” (Winston Churchill)
  • Lessons from the Massachusetts Health Plan  Cost is twice the original estimate and growing faster than the US …Looming $5.4 billion State deficit – 1/3 of the State budget is dedicated to Medicaid  35% of the FPs are not taking new patients, average wait for IM appointment is 50 days …..Overuse of ED by newly insured  61% of physicians rate their income level as “uncompetitive;”  Hospital operating margins have trended down since 2006! …. The Boston Med. Center forecasts first loss in five years … median operating margin for community hospitals in 2008 was .04%  “The current fee-for-service system is a primary contributor the problem of escalating costs and pervasive problems of uneven quality”.  Special Commission formed to recommend fundamental reform of the payment system. Source: Massachusetts Commission Report, July 16, 2009
  • Core components of the public policy problem? • Payment systems that do not reward healthcare providers to deliver better value • Lack of transparency of performance • Providers lack of a consistent methodology to improve care
  • Current Payment Systems Reward Bad Outcomes, Not Better Health Healthy Continued Consumer Health Preventable No Condition Hospitalization Efficient Successful Acute Care $ Outcome Episode High-Cost Successful Outcome Complications, Infections, Readmissions
  • Comprehensive Care Payments To Avoid Episodes Healthy Continued Consumer Health Preventable No Condition Hospitalization Acute Care Efficient Successful Episode Outcome High-Cost $ Comprehensive Care Successful Payment Outcome or Complications, “Global” Infections, A Single Readmissions Payment Payment For All Care Needed For A Condition
  • Transparency of Healthcare Performance
  • WCHQ is a 501-C3 voluntary reporting entity The purpose Develop performance measures for assessing the healthcare quality outcomes Guide the collection, validation, and analysis of measurement data Publicly report measurement results for healthcare providers,purchasers and consumers Share best practices with the WCHQ community
  • Wisconsin Health Information Organization • The WHIO Health Analytics Exchange At-a- Glance -- The Exchange contains claims data that spans multiple care systems and services provided statewide -- The Exchange holds a rolling 27 months of claims data on the majority of people in Wisconsin -- The Exchange contains 7.3 million “episodes of care” which capture the patient quality and cost experience over time with conditions such as pneumonia, diabetes, congestive heart failure and 750 others.
  • Provider Detail – Diabetes Cost Index List
  • Provider Overview – Cost Ranking
  • WHIO Cost vs WCHQ Clinical Quality
  • We must revolutionize healthcare delivery but how?
  • Results using Lean • Group Health of Puget Sound reduced E.R. visits by 29% using their medical home redesign resulting in a $10/pm premium reduction to customers • 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 3 years running and the cost of inpatient care dropped by 30% www.createhealthcarevalue.com • 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 Source: Health Affairs 2009, Volume28, No: 5:1343-1350 , America Journal of Managed Care, September 2009
  • The Methodology of Lean
  • TRUE NORTH METRICS 12/15/09 Draft. 6 Safety/Quality - Preventable Mortality - Medication Errors Customer Satisfaction - Access - Turnaround Time - Quality of Time People Financial Stewardship - OSHA Recordable Injuries - Operating Margin - HAT Scores - Productivity - Employee Engagement Index
  • 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
  • A3 or PDSA: What Are Talking About? Background Why are you talking about it ? Recommendations What is your proposed countermeasure(s)? Current Situation Where do we stand ? What’s the problem? Plan What activities will be required for Goal Where we need to be? implementation and who will be responsible for what and when? What is the specific change you want to accomplish now? Follow-up Analysis How we will know if the actions have the impact needed? What remaining issues can - What is the root cause(s) of the problem? be anticipated ? - What requirements, constraints and alternatives need to be considered?
  • Sponsor: Leader: Greg Long, MD, CMO Revision #4, Date: Title: System Safety A3 (Hospitals, TCP, Senior Svs. Support Areas) Facilitator: Sensei: 03/30/09 1. Background 2. Current Conditions 5. Proposed Countermeasures • Our paradigm tolerates risk & errors. Cause Countermeasure Description Responsible Culture of Safety Report Card! Patient 1) Involve patient & family in creating safe environment 1) Create standard work that actively involves the patient & 1) • Healthcare nationally harms 5 million pts/yr and 1) Realize anyone can make a mistake! D OSHA RECORDABLES their family in creating a safe environment kills nearly 100,000 pts/yr-minimal change since 2) Create safe environment to report errors. C- People 1) Staff competency & training 1) Develop competency of staff related to risk assessment & 1) original IOM report (To Err is Human) released anticipation 3) Create collegiate interactive healthcare teams.C+ 2) Culture of Safety within ThedaCare 2) Educate & train, modify behavior toward culture of safety of 2) Roger G. in 1999. 10 4) Barrierless communications. C- all staff & physicians; anticipate safety/error issues JMichael G. • Our employees are at risk in the workplace. 5) Teams with mutual human caring & support. B- 9 3) Problem solving daily by all 3) Train all manager level and above employees in TIS problem 3) Roger G 8 solving (eg., A3 & A4 use) Katie B • Sub-optimal safety = avoidable cost ($$$) to UNSAFE INR 7 4) Embrace standard work 4) Performance to standard work is assured as it becomes a 4) ThedaCare and the national healthcare system. 6 way of life for all staff (purposeful variation is acceptable) • Our expectations r/t safety are unclear. 5 Process 1) Standard work creation & compliance 1) Develop, imbed, sustain standard work, including evidence- 1) Division 7% MEDICATION ERRORS based medicine pertaining to safety leaders 4 • We lack a true culture of safety limiting our 6% PREVENTABLE MORTALITY 3 2) Failure Mode Effect Analysis (FMEA) 2) Apply FMEA to key processes 2) awareness of the problem and effective 5% 3) Standard work for assessing safety issues 3) Align assessment results with appropriate intervention. 3) 2 interventions…..”not my problem”. 3% 4% 4) User-friendly reporting 4) Devise user-friendly reporting tool & process that insures 2% 1 maximum, non-judgemental reporting by all employees 3% Per • Safety resource needs unclear. 1% 2% 1,000 Policy 1) Safety assessments 1) Operational staff assess safety each shift with celebration of 1) AMC/TC TCP SR SV Doses 1% defect-free performance 2007 - 2008 • ThedaCare leadership’s behaviors and actions 2008 2) Amend bylaws & TC policies 2) Amend and enforce hospital bylaws & TC policies outlining 2) Humana EXPECTED do not always align with safety as a top priority. 2007 2008 Actual 2008 expected behaviors r/t safety Resources ACTUAL Robin Wilson 4 Known Deaths in 2008 Target 2009 Target = 0 2008 2009 2010 2011 2012 2009 Target = 3.8% 3) Align gainshare with safety 3) 3) 4) Add safety to target state in TIS events 3. Goals and Targets 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 2009 Safety A3 Initiatives Thanks! This 3) Safeguard our facilities 3) Assess & implement tools & techniques to eliminate pt/staff 3) Division Initiative Baseline 2009 Target (50% improvement) environment injuries…invest $ if needed. AMC/TC INR (% percentage of pts in safe range 64.60% 82.30% Great job is not OSHA recordables lifting/handling) AMC-2.45 AMC - 1.22 recognizing judgmental so TC-2.92 TC-1.56 that safety I feel safe in Medication Reconciliation TBD 50% improvement problem and reporting! Safe Patient Care NA Nat'l Patient Safety Goals Met telling Care Giver Communication 6. Plans: someone! Physician Services INR (% percentage of pts in suboptimal range 7.60% 3.80% OSHA recordables lifting/handling) 1.29 0.55 Sr Services Falls 180 90 OSHA recordables lifting/handling) 10.2 5.09 Medication incident reporting 168 252 New London INR (% of pts in safe range) 40% 70% Riverside INR (% of pts in safe range) 40% 70% 4. Analysis (Initial thoughts) Safety A3 Gap Analysis • People Process Patient No clear expectations for safety Don't involve patients & families in safety efforts Team: We don't know w hat an error-free environment looks like Physician data not shared Patients 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 Disruptive behavior Safety not alw ays addressed Focus 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 7. Follow-up• Old policy not reflecting new practice We allow defects in w ork environments/practices to save $$ 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 © 2007 Page A
  • “Measurably Better Value” Deploying Level 1 Priorities ThedaCare’s to Level 2 Strategic Plan ThedaCare’s Breakthrough Objectives Shared People A3 Safety A3 Productivity A3 Growth A3 Problem statement, 1) (level (level 1) (level 1) background and Plan Plan (level 1) Plan Plan targets deployed People Safety Shared Growth Productivity People Safety Shared Growth Productivity (level 2) Safety (level 2) Shared2) (level Growth (level 2) level 2 A3 (level 2) Safety Shared2) (level Growth level 2 A3 (level 2) Safety Shared2) (level Growth (level 2) Safety Shared2) (level Growth (level 2) Safety (level 2) (level 2) level 2 A3 level 2 A3 Cross Cross Cross Cross Cross Cross Cross Cross Function Function Cross Function Cross Function Functional Function Cross Function Cross Functional Team Team Cross Function Team Cross Function Team Team Team Cross Function Team Cross Function Team Team Cross Function Team Function Team Function Team Functional Team Functional Team Team Team Team
  • Community GP Home Home Hospital Bed Management Pharmacy Pathology P/A P/A Working Hrs Working Hrs Capacity Capacity Freq Freq Patient Data System DLN P/A Working Hrs Patient Capacity Notes Freq Handover Nurse Obs Dr Assm’t Imaging Dr Review Spec’ Rev Nurse Obs Dr Assm’t Imaging W/Round Nurse Obs Physio W/Round Discharge P/A P/A P/A P/A P/A P/A P/A P/A P/A P/A P/A P/A P/A P/A Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Working Hrs Capacity Capacity Capacity Capacity Capacity Capacity Capacity Capacity Capacity Capacity Capacity Capacity Capacity Capacity Freq Freq Freq Freq Freq Freq Freq Freq Freq Freq Freq Freq Freq Freq 20 20 22 20 43 35 15 120 480 1080 360 4320 1440 1440 10 13 10 10 6 7 9 12 15 8 1440 12 8 15 WT = 9415 PT = 1615 A&E MAU Medical Wards
  • The Patient/Process Matrix Care Delivery Process Steps Health Maintenance Prevention Example: Physical + preventive care Minor Episodic Illness/Injury Example: Sore Throat Episode Major Acute Distress Treatment Example: Heart Attack Groups Elective/Restorative Procedures Example: Hip Replacement Chronic Disease Management Example: Diabetes Collaborative Ambulatory Imaging Care Patient Experience Potential Value Streams 0:/center/2008/ppt/processmatrix
  • 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 •Step 1 “Identify” waste  2nd week after – Update Standard Work •Step 2 “Eliminate” waste  3rd week after – CFO validation
  • 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
  • Color Coding on Tracking Tools Same colors used – light red/light green for tracking information.
  • What is a lean management system?
  • 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?
  • White coat leadership vs. Improvement leadership • All knowing • Patient • “In charge” • Knowledgeable • Autocratic • Facilitator • “Buck stops here” • Teacher • Impatient • Student • Blaming • Helper • Controlling • Communicator • Guide
  • A Community of Problem Solvers Delivering MBV 100% of employees Lean “Grad” are problem School solvers improving something every day!!! Education/Skill Level K . We are Here 5 10 15 ?? Time (years) 47
  • Productivity-Clinical Labor Costs/UOS
  • 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 80% Coumadin 70% Education 60% Pain Assessment 50% 1st Call Bed Access 40% Turnover 30% Staff 20% competency 10% Delays in access 0% AMC Inpt Oncology AMC 2S TC 2nd Floor AMC 3SW Interactions within 4 days of DC
  • Employee Engagement 2009 Employee Opinion Survey Percent Improvement Lean Management Pilot Units 2008 vs 2009 50% Cancer Services-BPS 40% Radiation Oncology-BPS 30% AMC 2S-BPS 20% TC 2nd Floor-BPS 10% AMC 3SW-BPS 0% TC OB-BPS Would recommend Organization Inspires Me Likely to be here in 3 yr. Will put forth effort to help org Understands how daily work -10% organization succeed contributes to mission
  • 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. Customer Satisfaction • 100% option to People be seen today Financial Stewardship • employee & • visit encounters per physician HRS worked .05 satisfaction • AR days by 10 51 51
  • 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 • www.healthcarevalueleaders.org
  • 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 • 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)