Transcript Beyond Heroes: A Lean Management System - My Site

Beyond Heroes: A Lean
Management System for
Healthcare
Kim Barnas, Former Senior Vice President ThedaCare
President of Appleton Medical Center and Theda Clark
Medical Center
2014
Beyond Heroes…
ThedaCare as a Healthcare
Delivery System
In 9th year of Lean Journey
6300 Employees
3500 employees affected by BPS so far
•5 Hospitals, including a Cancer Center, Heart
Institute, Level II Trauma Center, Stroke Center,
Acute Rehab Unit
•6 Behavioral Health Locations
•3 Home Care Locations
•2 Employer Health Locations
•1 Skilled Nursing Facility
•1 Senior Living Facility
Appleton Medical Center
ThedaClark Medical Center
True North Metrics
Measuring the health of the organization
Safety
• System Patient Safety
Bundle
• D.A.R.T
&
Quality
• Preventable Mortality
• 30 Day Readmission
Customer
“Lori”
• Customer Loyalty Score
People
Financial Stewardship
• Engagement Index
• Health Assessment Score
• Operating Margin
• Productivity
© 2011 ThedaCare
11/1/12 Rev: 10
How we got started: Our Lean Journey
We began in 2004
Value Stream
Analysis
Rapid
Improvement
Events
Action Plans
The next step in the Journey:
A Lean Management System…this is how we
Deliver on Strategy Deployment and Daily
Continuous Improvement
Deepening the roots of the lean
journey through daily improvement
Our goal Today is to begin a dialogue
1. How do we fundamentally change the way
our leaders lead in a lean healthcare
environment?
2. Begin to explore components of a lean
management system
3. Consider the role of standard work for
leaders
Performance
Culture of
continuous
Improvement
Human Development
Value Stream:
Respect for People
ThedaCare Improvement System: Lean
Thinking&Tools
Time
Reason for Action-2008
We are on a continuous improvement cultural
transformation, and current systems for managing the
business are not in alignment with new expectations.
• No one way to manage
• No way to measure performance
• No consistent way to problem solve
Our Goal:
To develop our people to
solve problems and improve
performance.
Elements of a Lean Management System
Monthly
Scorecard
Daily Huddle
Daily Stat Sheet
Leadership Team
Monthly
A3 thinking and
Performance Countermeasures
Review
Meeting
Leader
Standard
Work
Unit Flow Waste Removal
Visual
Management
Sustaining
Improvement
Thru
Training
and Managing to SW
The No Meeting Zone
Status of the business today
Daily Stat Sheet VP to Manager
VP Daily/Weekly Stat Sheet Kim B.
Department: Inpt Oncology
Monday
Tuesday
Dates
Manager 3S Inpatient Oncology
Daily Measures
Safety
How many patients or staff are at risk?
Daily Measures
infections
Safety
interpreter concerns
How many Patients/Families or staff are at Risk?
Quality
employee injuries
Any Quality Opportunities or concerns?
Falls, bundles, med rec/errors
Quality
Any quality opportunities or concerns?
falls, bundles, med. Rec/errors
Any patient complaints/Follow ups?
Patient complaints/Follow Ups
People :
Any Staff with Problems/Barriers?
Any equipment or room concerns?
People
Who needs the most support today (weakest link)
Any Physician or Leadership issues?
Any staff with special concerns or barriers?
Any thing, staff or provider to recognize or celebrate
today?
Who needs the most support how can we help them?
Delivery
Any physician or leadership concerns?
Any areas that Demand exceeeds Capacity
Any thing, staff or provider to recognize or celebrate today?
For Oncology- Any non- oncology pts on the floor ?
How many filled beds ?
How is care management helping to progress care today
How many discharges planned today?
Copyright 2011 all rights reserved
How are you planning on covering lunches and breaks?
16 beds
16 beds
Any care management concerns?
Delivery (Service and Timeliness)
Huddle
Sponsor: Greg Devine
Title: Radiation Oncology Business Strategy
1.
•
4.
Gap Analysis:
Problem
Statement
Lack of MD and
ThedaCare
Alignment
$15
15%goal
$10
18%goal
Delivery of Services
across continuum
disjointed
Jan
B
M ar
A pr
M ay
Jun
Jul
A ug
Se p
Oct
N ov
1,901,927
2,187,246
( 2007 EOY goal)
( 2008 EOY goal)
89,837
98,821
Gross Revenue / FTE
( 2007 EOY goal)
Gross Revenue / FTE
( 2008 EOY goal)
16 Business Days
10 Business Days
Total Flow time from
Q Decrease
referral to treatment by 37%
Increase amt of employees who have
seen and used the problem solving
A4
Target
(Monthly Avg Jan 07 - April 07)
14%
100%
3/21 Total Employees
22/22 Total Employees
Don't understand referral channels
PCP is removed from process
A3 to next level -How to
transision to Continuous
Daily work and tracking?
Who
Kim
By When Complete
10/1
Status
Processing A3 for Oncology
Program Karen / Kim working
on VS phase
Disjointed & ordinary 1994 strategy
No multidisiplinary team
8. Confirmed State:
No standard proces for entry
Lack of optimal navigation
Lack of w ellness planning
1,554,750
83,107
Gross Revenue / FTE
16 Business Days
(Monthly Avg Jan 07 - April 07)
14%
Our cost/quality
outcomes are not
transparent
3/21 Total Employees
We have state of the art services and expertise that
public and MD population is unaw are of
No current w ay to measure outcomes real time
Payor channels not understood
Lack of payor relationships
No understandable measure for the patient make choices
w ith
5. Solution Approach:
Problem Statement
Lack of MD and Leadership
Alignment
Countermeasure
Root Cause
No shared cancer services vision
Don't understand referral channels
PCP is removed from process
Space for Services is inadequate/
ordinary
Dec
Increase gross revenue by 15% from
2007
Increase productivity by 10% from
2007
E
Feb
Initial 2007
No shared cancer services vision
Completion Plans:
What
Unfullfilled retail needs
Initial 01/01/07
$-
Measure
7.
Root Cause (based on CEDAC)
Revision 18, Date: 01/28/09
Lack of PCP champion
Act ual Cumulat ive
$5
Sensei:
Space for Services is Not sure if one location or satellites should be strategy
inadequate/ordinary Cancer center is land locked
No enough presence at TC
Millions
Reason for Action
2.
Initial
ThedaCare’s Radiation Oncology
State:
program is a critical element of our
comprehensive Cancer Center.
•
Our market leading program
requires:

Leading edge technology

Exceptional human talent
incorporated into effective
teams.

Defect free processes

Increased productivity

Customer focused culture

Requires exceptional
service
•
The market has become more
competitive putting TC at risk.
Measure
•
There are well organized, highly
B Increase gross revenue by 15% from
visible, and motivated competitors
2007
Increase productivity by 10% from 2007
seeking our market share.
•
Our customers are more
sophisticated in seeking the highest Q Decrease Total Flow time from referral
to treatment by 37%
quality at the lowest cost regardless
E Increase amt of employees who have
of geography
seen and used the problem solving A4
•
The number of cancer patients will
increase in the future and we have
questionable capacity to handle
increased volume.
3.
Target State: Recognized in
market as destination of choice for:2008 Radiation Oncology Gross Revenue Trend
quality outcomes, cost,
$30
technology, and
$25
patient experience
$20
Leader: Kim Barnas
Delivery of Services across
continuum disjointed
Our cost/quality outcomes are not
transparent
6.
Lack of PCP champion
Not sure if one location or satellites
should be strategy Cancer center is
land locked
No enough presence at TC
Disjointed & ordinary 1994 strategy
No multidisiplinary team
No standard process for entry
Relationship building with FVHO
Test commitment around a
multidisiplinary pilot with brain
cancer in Neenah
Identify PCP champion as
communicator with PCP's
Above
Develop Master Growth strategy
including space
Pilot Radiation Oncologist seeing
patients at TC
Test commitment around a
multidisiplinary pilot with brain
cancer
in Neenah.
- Develop
Begin plan
for possible Value
Stream of Cancer Services
Unfullfilled retail needs
Develop new Cancer Stratgey
Lack of optimal navigation
Lack of wellness planning
We have state of the art services and Develop Comprehensive Marketing
expertise that public and MD
Plan
population is unaware of
No current way to measure
Align with system initiative working
outcomes real time
on this for other disease processes.
Rapid Experiments:
Experiment
Edie K & Nathan M visiting TCP Drs to
heighten awareness of Rad Onc
Who
Expected Outcome
Increase referrals to Rad Onc from TCP & others -Reviewed
call list - Edie to indicate whom they met with / their
response.
Cyberknife mailer to all MD's in primary and Rose F/Karen
9/15/2008 Increase CK ref-90 days - lung specific mailer sent 4/22 sec markets
/Julie I
Started July Tracking Outcome Marketing to advise enough data? 6 surverys
submitted.
Billboard Hwy 43 outside Aurora
Kim/Julie l
9/15
Tracking impact of signage Reviewed new case data - plan
to compare YTD.
Develop concept and scope for
Kim/Christal/Jill Team by Improved model of care for our patients -2 Test Pilot of 4 patients multidisciplinary clinic pilot focus on brain CA CW/Wascher
7/17
FVHO not present - total of 6 sessions. David B has results
will share with Karen. 9/18 start next pilot - Kim looking for
written summary of results of pilot.
Breast Program - multidisciplinary team
Kim
10/15
VS effective model, inc.growth, "right treatment" - pull together
approach -Focus on breast cancer patients
the team To present to SMT
Sara
By When
9/15
Prostate - team approach Focus on prostrate Kim
patients
Early 2009 VS effective model, inc.growth, "right treatment" (Market Plan
Cyberknife/mtg with Urologists/plan pilot)
VSM Onc strategy A3 - continued
Kim
Summer '08 Focus on Navigators & other opps -prep for SMT
Thank You - before / after tumor image to
referring Dr.
Edie - TCP Shawano referrals to Green Bay;
Promote - Rad Onc visit Shawano
Wait work board - SMT
Karen / Julie
9/29
In process of draft creation; ready to implement.
Kim / Greg
9/15
Explore referring patterns ; DR reports to understand volumes
Kim / Greg
August
A3 boxes 1,2,3 are complete
9.
Insights:
Technology is only as good as the person operating the machine.
Manitowoc Holy Family has join St V group – we will continue to look at new
opportunities.
© 2007
1,974,251.00
(per month)
Page
A
Video of Monthly
Performance
Review
2010
Monthly Scorecard of Metrics
VP and Manager level
120.00%
100.00%
80.00%
60.00%
Drivers - Respond
40.00%
Watch Indicators - Observe
20.00%
0.00%
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
2009 VP Scorecard
Measure of: Safety
Owner: Barnas / Adair
Reduce number of falls in acute areas by 20%
Nov
Dec
2009 TARGET:
Yr End % Improvement:
2.3
20%
2008 Baseline:
2009 YTD:
YTD % Improvement:
2.83
1.38
51%
Reduce Patient Falls (in Acute care areas) (HD (AMC+TC)
Goal: 2.3
3.00
2.50
# of falls per 1000 days
2.00
MTD
YTD
1.50
Target
Baseline
1.00
0.50
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
2011 copyright all rights reserved
Managing Standard Work
Executive coaching
Video 2
Coaching with Standard Work
Some final Key Points
• Create a no meeting zone to do this work
• Coaching and developing your team is critical
• Executives must have dirty hands and be present
in gemba a prescribed % of time each day
(standard work in hand)
• Managers must be present and seen with their
standard work every day
• This is a disciplined approach and requires the
rigor to stay the course, improve
countermeasures and remain humble
A couple of examples of results
• Patient Safety Bundle has improved 48% over last three
years
• Employee Safety work began this year with a 13%
improvement in the DART rate
• Preventable Mortality focus is on Sepsis this year, and the
early results shows them beating the target of 62 with an
actual of 58
• The readmission rate has declined from an 8.2% rate in
2008 to a 7% rate in 2013
• The fall per thousand days rate has declined from 2.8 three
years ago to 1.2 in 2013
• The margin corridor of 4%-6% has been maintained or
exceeded for the last 5 years
Call to Action!
• Start somewhere – a steering committee/cross
functional team? A3?
• Take the first step and work through it diligently
while listening and developing your people!
• Remember, those closed to the work see the
problems and have the best opportunity to find
countermeasures…Experiment with them and
encourage them to influence the experiment and
develop the standards.
Questions?
Presentation Complete
The Physician Perspective
The Physician/Hospitalist
Journey
The Physician Journey Key Points
• Order from chaos – some physicians recognized this Lean stuff will
make me a better doctor and ..they became leaders
• Collaborative Care from the Hospitalist perspective (2008-2010)
–
–
–
–
•
Standard work – a new concept ( not well received at first)
Some loss of independence
Now have to solve problems with the rest of the clinical staff
Shift to a team concept (this is where humility and vulnerability come in)
The transition within the hospitalist group (2010)
– The team began using some tools in physician department meetings
– Leadership added a former Lean facilitator as the hospitalist department manager
– Began using A3’s in the larger group to problem solve…issues that were important to
them as individuals to get started…later clinical processes
• Scheduling process
• Weekend coverage
• Work load distribution
• Staffing to demand (Productivity)
– Individual members began using the A3 format for problem solving
• Extended A3 use to more of the group…this was slow and basic at first
The Physician Journey Key Points…From the
perspective of our hospitalist medical director
• 2004-2005 they heard about lean but no experience.
– “Patients aren’t widgets”
– Patient Centered care again (flavor of the month)
• Limited Exposure to Lean events and tools (2006- 2007)
–
–
–
–
Value Stream mapping
Kaizens/Rapid Improvement Events
Process flow mapping
Waste reduction
• Collaborative Care – first significant change (Value Stream) for
hospitalists (Pilot 2008-2010)
– Part of team- not “the boss”
– Exposed problems with other disciplines (recognizing some of which the
hospitalists caused)
– Humility and vulnerability
The Physician Journey Key Points
•
Intentionally Increasing Exposure. (2012)
–
–
–
–
–
•
Beginning to see a change in thinking and language (2013)
–
–
–
–
•
Medical Affairs Value Stream
Peer review redesign ( Kaizen events)
Professional behavior (Kaizen events)
Sepsis A3
Diabetes A3
More hospitalist huddles and bring forward specialist concerns.
More frequent attendance at unit huddles Value
Medical Affairs huddles
Most hospitalists are sponsoring improvement work using A3 methodology for both
administrative and clinical problem solving
Conclusions from our hospitalist team (2014)
–
–
–
–
–
–
A3 thinking mirrors clinical thinking
Be intentional about exposing providers to Lean compare to the scientific method
Limit Lean lingo
Provide the opportunities for those interested to gain experience
Share your successes
Utilize your informal leaders
Lean works in Healthcare
• Akron children’s Hospital reduced cost by $8 M while
reducing appointment access wait times by 74,600
days using lean
• 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 Hospital avoided 200M in capital
expense by freeing capacity with continuous process
improvement
Source: Health Affairs 2009, Volume28, No: 5:1343-1350 , America Journal of Managed Care, September 2009
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%
• 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
Success is not final, failure is
not fatal: it is the courage to
continue that counts.
― Winston Churchill