Monthly Reflections from John Toussaint

During this anxious time, it’s hard to make time for new learning. But necessity is the mother of invention. Many of you have been forced to get creative in this time of crisis and it’s that creativity I’m so excited to share. We have a great tradition of shared learning at Catalysis because so many of you give of your time to help. The purpose of this letter is for me to share highlights from the world of lean thinking. I plan to write this column once a month to provide you with some of the best takeaways as I see them.
Let us begin with vaccination. I have been on four different websites for hours trying to get registered to receive one. The process where I live for people over 65 is failing fast. That is why I was thrilled to listen to the presentation by Salem Health sharing the elegant process they designed using lean principles. Salem decided they were not going to wait for the public health department, so the lean improvement team worked with managers to immediately stand up a vaccination center. Originally this was designed for their own employees but leaders at Salem Health reached out to the public health department and offered the approach to the community. On the 31st of December they became a distributor of vaccines working with the Oregon Health Authority. By January 7th they opened the community vaccination center at the local fairgrounds. In the first four days they vaccinated 8000 patients and now are on track for 3000 vaccinations per day. Using a modified 3P process they redesigned the fairgrounds building and built two flows. One for patients with MyChart which is registration through Epic and the other flow a paper process for patients not on MyChart. The best way to describe this is for you to watch this 6-minute video.
The work at Salem reinforces core principles of lean thinking. From the time the patient drives onto the fairgrounds to the time they are back in the car you see the principle of one-piece flow. One person at a time is efficiently registered into one of two flows and then simply flows to the vaccination station after waiting literally only seconds. This has led to 400 people being vaccinated per hour. If every county in the U.S. utilized a similar process, we would be done with vaccinations for the 65 and older in a month and on to the rest of the people. President Biden please call Salem Health for advice!
On a different front, Eric Dickson and I recently talked about the difference between breakthrough value stream improvement and an innovation system we are naming “New Care Model Development,” on our podcast, The Lens. We agreed health care delivery organizations need both. Eric is an E.R. doctor and CEO of UMass Memorial a large academic medical center in Worcester, Massachusetts.
The age-old model of healthcare delivery has relied on three value streams. Demand, delivery, and support. The demand value stream includes the marketing communications, patient acquisition, and other processes required to attract patients to your health system. The delivery value stream includes the core elements of delivering the service; doctors, nurses, technicians, etc. and the processes such as outpatient and inpatient surgery, clinic care etc. The support value stream includes all the system resources such as IT, HR, etc. that are required to assure high functioning services. But most of our organizations are missing the fourth value stream; development.
Breakthrough value stream improvement has focused on the existing care delivery processes. An example would be improving the throughput of colonoscopy to improve cancer screening rates. That is really important, and I am sure you have specific problems in existing care processes that need significant improvement using breakthrough value stream improvement. But what if we decided to obsolete an existing process? Say, for example, hospitalization for pneumonia.
Through deep customer research Atrius, a multi-specialty group in Boston heard a scathing comment from frail elderly “I’d rather die than go to the hospital." This mantra guided the innovation team to create the breakthrough known as Medically Home, which allowed for certain patients that would have traditionally been admitted to the hospital to be cared for at home. Cost of care dropped 30% and patient satisfaction soared. The new care model obsoleted hospitalization and filled an unmet need for patients that absolutely did not want to go to the hospital.
Medically Home was developed through a different system. You can read about that in our white paper Designing the Future of Healthcare. This system is based on a manufacturing R and D model and has five phases. First is research, trying to understand customer needs. That takes several months to complete and requires careful empathetic listening to patients with careful documentation. Concepts emerge from the research which then leads to a prototype. Rapid experimentation follows with multiple PDSA cycles until a model cell is developed. Finally, the model cell must be spread and scaled throughout the entire organization. New care model development is revolutionary change versus the incremental change of value stream improvement. You must decide which you need to achieve your goals. Read more in HBR.
These are my reflections over the last month. What are yours? Is there something you can share? Let me know at [email protected].

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