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Peter Mariahazy: Thank you for tuning in to The Lens! I am your host, Peter Mariahazy. Today I am joined by Dr. Eric Dickson, CEO at UMass Memorial Health Care, and Dr. John Toussaint, Executive Chairman of the Board at Catalysis. We have invited them to join us to discuss the difference between continuous improvement and new care model development. Both methodologies are important for healthcare systems to utilize in order to remain competitive and relevant in the future. Thank you both for joining me today. Eric Dickson: Thank you, Peter, happy to be here. John Toussaint: Happy new year. Peter Mariahazy: Happy new year. Eric, will you please start out by telling us a little bit about yourself and what value stream improvement means to you? Eric Dickson: My name is Eric Dickson. I am an emergency physician at UMass Memorial Healthcare. We are 8 hospital campuses, about 14,000 employees, and 1,100 employed doctors. I also for the past 8 years have served as CEO for the healthcare system and have done my best to bring in a lean management system to improve performance over time. I must say that I think 8 year in we continue to head in the right direction. We get a little bit better each year, sometimes a lot bit better, but it’s made a big difference in terms of our overall success. Peter Mariahazy: That’s great to hear, it sounds like a great journey. John, can you tell our listeners what new care model development means? And can you give us an example or two? John Toussaint: Yeah, so new care model development really is designing care models that are obsoleting existing ones. And that is different than improving existing care models, which needs to be done too. What are talking about with new care model development is identifying core elements of customer needs through a research process. Then developing concepts around those needs, prototyping something different that is adding new value, building and testing that, and then spreading it. It’s really creating something new and thinking about creating new value for the customer versus the breakthrough value stream improvement which is taking what we have and making it more efficient. Peter Mariahazy: Eric, what are the differences between these two approaches from a clinical and health system standpoint? Eric Dickson: If you think about it from a value stream most people will be familiar with… think about a woman who ends up with breast cancer and requires treatment. Typically, it starts with a mammography, the mammography is abnormal and then there’s an advanced imaging associated with a biopsy if the advanced imaging doesn’t go well. The pathology gets read as it goes to typically to a surgeon next and somebody is going to inform the woman. There is usually a chemotherapeutic approach, a surgical approach, and a radiation/oncology approach. In our healthcare system with multiple hospitals and 29 different companies and 19 different academic departments, that poor woman is bounced from the imaging center to the hospital to the advanced pathologist, each with their own waste built into the process. When we think about the value stream we are talking about that particular patient journey and saying that we need to improve every process along the way. Instead of individual, vertical silos, thinking about just their piece of the process. Taking out the waste and shortening the time from the mammography to the cancer cure, hopefully. That has to be done because there is a lot of waste in those processes and almost an endless amount of waste that can be taken out. That is a values stream that we are working on here at UMass Memorial. And then there’s the big innovations. What can we do to eliminate the need for that whole value stream, or a big chunk of that value stream. Is there home diagnostic testing for breast cancer that would eliminate the need for mammography screening such that a woman could have a positive test and move directly to advanced imaging. We’ve seen this with colorectal cancer screening that always used to be an endoscopy to what is now a home kit. So there are examples of really creating something new and having it displace the old. And that process for me always has to start with empathy for the customers and what they are suffering. So going every five years or more frequently for an endoscopy and giving up the day and how you feel the night before and waiting for the results. That’s not something that we want to do to patients, but it was necessary under the old model. With the home screening kits that are now available you can eliminate that. So we start our process of radical redesign with understanding the needs of the patient and having empathy for the needs of our customer such that we can get it right. Peter Mariahazy: Thank you, Eric. John is there an example you would like to share? John Toussaint: I think that as Eric has identified… What’s happening is we constantly have new technology that is coming available. The question is can we do something with that new technology, whether is it colorectal screening or something else. An example that we have written about in Harvard Business Review is some work that Atrius did on something called “Care in Place,” which is where they actually worked with the VNA to build a completely different care model where frail elderly patients would call the office, instead of sending them to the emergency room a nurse practitioner would go out the home and examine the patient. That reduced the amount of emergency room visits by half and it helped keep those patients at home. That is a different system than what existed before, it’s a different care model. Same thing with “Medically Home” another thing that Atrius has worked on where now 30% of patients that were admitted to the hospital are treated at home. The technology is there now to support some of these new processes, but the thing is we still have to design the new process. The technology itself is not the innovation, it’s the thinking behind what that new process is. I totally agree with Eric in terms of empathizing with the patient. If we really listen from an empathetic perspective we will understand what they are telling us about what their needs are. In the case of the Care at Home model there were several patients that said, “I would rather die than go to the hospital.” Well, if we are carefully listening that means we better figure out a way to not have them go to the hospital. And that is why they were able to build a new system, a new care model, that allowed a number of those patients to be treated at home. Peter Mariahazy: John, you set up a nice segway to, what are some similarities between these approaches? John Toussaint: The first thing we have to really deeply think about is are we improving the right thing? In other words, is our existing process so fundamentally broken that we shouldn’t even spend one minute trying to improve it. Let me give you an example. When I was CEO our inpatient care process was fundamentally broken. We tried to improve it over a three year period and we could not achieve our goals. So a core team of entrepreneurial spirited people, a doctor, a nurse , a pharmacist, and some other folks, worked with a number of patients and providers to create something called “Collaborative Care,” which was one of the first team-based care models that emerged in 2006. This dramatically changed the way we do inpatient care and it improved quality, dramatically reduced cost, and the patient experience was much better. But we had to do that in a pilot unit because we couldn’t work with the original process because it was just fundamentally broken, we had to start over and do that pilot. So, I think the thinking behind improvement is the same in both of these models. In other words, we are constantly using PDCA thinking to try experiments and rapidly learning and rapidly changing things. The difference is this idea that we are going to create a team that is really focused on really blowing up the existing model for whatever reason… maybe it’s not the right business model, or like in our case we tried for three years to make it better and we couldn’t. So we had to decide that we were not going to improve that process anymore, we are going to obsolete it and change it. Peter Mariahazy: Eric, I’ve hear the phrase skunk works. That is what John is kind of describing. Do you have an example that you would like to share with the listeners? Eric Dickson: You often have to design these things in parallel tracks, or work them in parallel tracks. You can’t get rid of one thing, but you want to do something different. So I call them skunk works, or parallel tracks, or model cell (there are lots of different terms out there). But you get to start fresh and often we will do that in a separate company because you get to start the culture piece all over. And you bring your value stream thinking to that new work, but you get to do it fresh from design and focus on what does the patient really want in terms of this and let’s design around that requirement first. We did some work around high utilizers of the emergency department – we have people that have 200 visits per year to the emergency department if you can imagine that. So trying to reduce those visits that a lot of them we felt were unnecessary. We had to learn from the patients about what is it that they need to keep them from ending up in the emergency department. When we finally understood this we knew we could not do that within the emergency department, we had to build something outside the emergency department to work with those patients before they came to the emergency department. It was something called a modeling program. Often the folks needed substance abuse treatment, or a ride to the psychiatrist (there was often a behavioral health component there) and then thinking about us getting a 30% no show rate for psychiatry appointments, but a 5% no show rate if you do them virtually. So we ended us with a program that was totally outside the emergency department. All we got from the emergency department was an alert that the patient is somebody that might benefit from the new program. It really allowed us to start fresh without worrying about the emergency department and how that functions. Because in the emergency department something really busy was going to come up and you were going to drop the ball with that patient because there was a critical need. That didn’t happen when you were designing outside and there was a different pool of people that you were tapping into. Peter Mariahazy: So, Eric, you gave us a great examples specifically at UMass, how do you use continuous improvement thinking and new care model development and spread it through out the culture? Eric Dickson: When we talk about the culture here at UMass Memorial the foundation of our culture is innovation. Everyone looking for new, better ways to do the work today; take care of patients, to park their cars, to get a bill out the door (whatever it is) and supporting that innovative spirit with continuous experimentation, teach people how to do a well designed experiment and do so in a way that shows respect for people. Through that we drive towards a better place for our patients and our people. There are four things that we talk about when we talk about our culture and that’s it. We have tried to support the big bang kind of approach with a grants program that we call the innovation fund where a person can say “I want to try something totally different outside my work” and they can get up to $25,000 to do a pilot and we have had some great pilots come out of that. So the continuous daily improvement, we love the term innovation because we are an academic health science system, kind of occurs at the Innovation Station, that’s the name for our idea system, our local visual management systems. But if you want to go do something well outside that we have a grants program to support that. We have had all kinds of things come through that program that just weren’t going to happen from the innovation stations. Our biggest payoff to our patients and from a financial perspective was one from a nutritionist who said, “we have all sorts of people with protein malnutrition and nobody’s screening for it and nobody is treating it and it has a profound impact on the outcome of their disease.” She wanted to start a screening program for that so we gave her a pool of money to work on it outside of her other things. So this was happening almost unknown to the medical teams until they identified it and easily said that they identified it and determined they wanted to treat it. This opened the door for the utilization of the new service. It has significantly improved those patient’s outcomes and if you identify and code it properly you get paid higher on a DRG. So it has paid for itself tens time over so this was beneficial to the organization and was done with a $25,000 grant but you have to have some mechanism that you are going to let people do some of these things and then we celebrate it through our innovators of the year program and some big public display of the innovation that occurs. Peter Mariahazy: John, Eric has kind of teed us up, there has been a lot of talk about innovation in healthcare. How does that fit in with these approaches? John Toussaint: Frankly, I think innovation is an overused word in healthcare. I don’t think it is well defined. We recently published a white paper on new care model development in which we try to stay away from the word innovation and say, let’s talk about new care models because a lot of people think of innovation as the newest gadget or app or some technology thing. Like, oh if I just had that all of my problems are going to go away. But like Eric is describing, these are processes that we are talking about. We are not talking about some app or technology. We are talking about designing another way to take care of patients. In other words designing a new patient experience. Whether it is his example with the high fliers in the emergency room or a simple idea from a nutritionist. One of the things we now know… When I was CEO for eight year we had two breakthrough innovations. What I have learned from that is there needs to be a lot more focus on the system that it takes to create these new ideas, these new models, these new patient experiences. That is what we are calling the development value stream. We need to create a development value stream for our organizations. Most healthcare delivery organization have a demand generating value stream and a delivery value stream, but not a development value stream. Most healthcare delivery organization don’t and if you look at the rest of industries, R&D at Google, at Toyota, at wherever, these companies are constantly creating new value. I think that one of the things we are missing is a system which is reproduceable. You know, its great to have a great idea and go do it, but can we continue to develop these new models in a consistent way… more that two in eight and a half years is my point… I believe if we don’t build a system, with the people that it takes to do that, that we are going to be missing the boat in terms of how do we create these new customer experiences. Peter Mariahazy: Eric, John has kinda put out there an idea of creating that system. What are you looking for a UMass down the road as far as that possibility of developing a system for developing new models? Eric Dickson: I think John is exactly right, the term innovation is overused and not well defined. We use it a lot here because it draws people in because it is been overused and isn’t well defined, almost. If you walked in our strategy room you would see our primary value streams laid out and we put up our improvement efforts. But there is nothing on our board, or within our management system, about what our standard work is to look for these breakthroughs in care. And often it is not something truly novel. It’s things were you just look and understand the needs of the customer and maybe simpler things that you can’t do within your existing infrastructure that we need a process for. If you look at our standard work, we are on version 13 now, hopefully by the time we get to version 14 or 15 we will have a standard process for looking for and implementing breakthrough innovations and new care models. Peter Mariahazy: Why are these two systems important for healthcare organizations to stay competitive? John Toussaint: Basically we are talking about breakthrough value stream improvement and new care model development and we need both of those things. Traditionally in lean thinking healthcare delivery we have focused all of our energy on breakthrough value stream improvement. That is not bad, I am not saying that is bad. I am just saying that is not enough. Even if we do build new care models or patient experiences we still need breakthrough value stream improvement to improve it. We have got to have both. I am just asking is there a process? Do you have a system to actually create new care models? If you don’t I am challenging people to say, “I think that is going to be a system that is really important as different technology and things come along that we can build new processes. Maybe breast cancer treatment will be completely revolutionized in a way that we can’t even imagine today. If we have a system to be able to look at that differently I think it is going to be better. So we need both things. We need our traditional breakthrough value stream improvement work (and we need to improve a lot of things like Eric said) but some things we shouldn’t improve, we should just obsolete them. But if we don’t have a system in place to obsolete them we are not going to be able to do that. Eric Dickson: We need both evolution and revolution. Right now we have great processes for evolution – continuous improvement of a value stream, which in some cases (as John mentioned) allows us to do the wrong thing more and more efficiently over time. So we get twice as good at doing the wrong thing. Sometimes that locks you into keeping it the same way. We need good processes to look for that revolution piece – that new breakthrough. It is something that I am looking forward to learning more about overtime. Peter Mariahazy: Eric, any final thoughts you would like to share with the listeners? Eric Dickson: Go Packers! Peter Mariahazy: That’s right, we are all looking forward to Saturday. John anything from you? John Toussaint: No it is the first year that the New England Patriots haven’t been in the playoffs, so Eric I guess you can come on vacation and not worry about it.