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

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

25. 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

26. Accomplishments:
TIS Leadership Internship
Purpose
Prepare participants for role transition to leading in a
continuous improvement environment, integrating TIS
tools, processes, and thinking

27. 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

28. 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.

29. 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)

30. 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

31. 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:

32. 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

33. Lessons Learned:
Summary
Statistically significant differences in satisfaction for
those involved in 2 or more RIEs

34. Lessons Learned:

35. 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?

36. 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

37. 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?

38. Lessons Learned:
Create Pull for Physicians
Radiology transcription data
Outpatient surgery center/under arrangement
partnership (partnership with physicians)

39. 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:

40. 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

41. 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

42. Change the people or change the people
- Dan Ariens