For the last four and a half years, I have been blogging on this site about important events in healthcare. The ThedaCare Center for Healthcare Value has grown rapidly in that time. In fact, we have created a team of highly talented individuals that have a world of expertise in a range of subjects. The Center has made the strategic decision to use my blog as a place to showcase this talent. Mike Stoecklein, for example, recently shared thoughts some time he spent with W. Edwards Deming, and the importance of understanding how to understand and react to variation. Mike is contributing again (read below) regarding his work as Network Director for the Healthcare Value Network. We will continue to showcase the ideas and work of the great team members at the Center going forward. I will continue to contribute as I have in the past when I believe there is something very important that our audience should be aware of. As always, we invite you to comment on our blog and send us suggestions.
– John Toussaint, MD
CEO, ThedaCare Center for Healthcare Value
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Some Attributes of The One Percent, Part 1
When I reconnected with John Toussaint in 2009 and heard he was up to something new (the ThedaCare Center for Healthcare Value), I told him I was interested to learn more and perhaps play a helpful role. We met briefly at the IHI Annual Forum. He was on his way to attend a short breakout session featuring ThedaCare and something they called their “collaborative care model” (something that turned out to be a pretty big deal). John told me, “I’m interested in working with the “top one percent” in healthcare. We both agreed that most healthcare managers and clinicians may not fully understand, nor are they interested in, the kind of management transformation that healthcare needs. We don’t know what percent DOES understand and IS interested, but we think it a small percent – very small. Thus, we call them the “one percent.”
Outcome metrics regarding the use of the lean methodology are few and far between in healthcare. In this extensive study of many cardiac centers around the country, we now have evidence that practicing lean management leads to better outcomes for patients. Up to now we have relied on individual case studies http://www.createvalue.org/blog/post/?bid=304 which although powerful, leave the question open as to whether this knowledge is transferable across the industry. At the Center, we are training many healthcare managers and executives in the lean management system. We have seen remarkable results in hospitals across North America in terms of patient and staff outcomes.
More research of this type is needed to answer even deeper questions and the Healthcare Value Network members will be at the center of this important research.
Cost and quality transparency is critical to driving health care reform. It is one of the three fundamental principles I have been blogging and writing books about for more than a decade. Some progress has been made but there is much left to do.
This report gives side by side comparisons of the laws in each state that promote transparency of cost. For example the report describes which states require actual paid amounts to be publicly disclosed. Moving toward a metric of Total Cost of Care, states will need to publish actual amounts paid to providers. For years this has been proprietary information. But times are changing rapidly. The Center supports any and all initiatives that help get accurate, timely information in the hands of consumers. This report may help move the agenda along.
One of the core elements missing in most healthcare organizations’ lean transformation is the management system required to support continuous improvement. The core elements of that system include:
A3 thinking
Daily status sheet
Daily performance-and-defect review huddle
Unit-based leadership teams
Standard work for leaders and supervisors
Standard work audits
Visual progress tracking
Andons
John Toussaint describes each of these components in the article.
In addition, senior executives’ behavior must change. This article outlines the key changes leaders must commit to:
Improvement leadership actions vs. White Coat Authority
Going to the gemba
Humility
Perserverance
Curiosity
Finally there is a section on how to get boards prepared to support the improvement journey.
This article is more evidence that public reporting of physician reporting improves performance. The study design compared other upper midwest healthcare providers with Wisconsin providers that reported data to the Wisconsin Collaborative for Healthcare Quality (WCHQ). The results indicate that the WCHQ members improved performance faster and farther than the organizations that are not publicly reporting.
As I point out in Potent Medicine, the combination of public reporting combined with paying for value will encourage healthcare providers to redesign care. When all three of these components are in place, the industry will begin to change. I would encourage healthcare researchers to address all three of these components in the next research design.
Network Director Mike Stoecklein in guest posting today over at The Deming Institute’s blog. He shares about his own experiences with Dr. Deming and discusses how Deming’s approach and teachings can be applied by managers today.
Relying on the help of Group Health of Puget Sound, Seattle Children’s and other lean companies like Starbucks, the Governor of Washington has been delivering better value to state residents for their tax dollar.
“Washington’s pioneering approach of adapting Lean to all of state government enhances the state’s national reputation as a leader in performance improvement and commitment to provide efficient, effective services to its citizens. The statewide transformation began with Governor Gregoire directing agencies to adopt this improvement system and philosophy used with great success in the private sector.
In essence, Lean provides proven principles, methods and tools to develop a culture that encourages employee creativity and problem-solving skills. The Lean Transformation Executive Order 11-04 was issued in December 2011, and state agencies answered the call to action by successfully implementing Lean thinking, tools and techniques. In less than a year, state agencies used Lean to improve processes and provide better value to the people of Washington.”
What if the other Washington got serious about removing waste? Could we have an impact on our $16 trillion and mounting debt? There is no question. I congratulate Governor Gregoire and the leaders of all the great companies in Washington for their perseverance and tenacity at fighting government waste.
“Dow Jones is asking District Judge Marcia Morales Howard to lift a 1979 court order that exempted from the Freedom of Information Act all provider-specific data on Medicare payments. Arguments ended in August, and a ruling could come at any time”.
This is an important issue for American healthcare. As I have pointed out many times on this blog, transparency of physician performance data is key to improving healthcare. Once physicians see each other’s results things will change. Not only are we interested in how much was paid, we also want to see utilization rates and quality performance such as readmission rates and complications. Physicians are very competitive and if we find someone who is outperforming us we quickly try to go there and improve our own score.
The other side of the argument is represented by the AMA: “The doctors warn of “deleterious effects on the physician-patient relationship.” One physician affidavit avers that “it would undermine my ability to care for my patients if they think that I might be prescribing” a particular therapy “for the money rather than for their well-being.” Public disclosure of Medicare billing would increase such purported misconceptions, because non-experts can’t interpret the data accurately, the doctors claim”.
Oh come on! Times have changed. People, even doctors, need and want this information. The paternalistic view of the AMA on this is something out of the dark ages. For example, physicians in Wisconsin are clamoring for this data to be added to our existing all payer claims data base (Wisconsin Health Information Organization) so as to shine an even more accurate view on their performance.
Hopefully we will move to modern times and leverage the Medicare data set for real health reform.
Dr. Leonard Berry at Texas A & M University “embedded” himself within ThedaCare one year ago. He wanted to deeply understand the inner workings of a lean healthcare organization. After this experience, he asked me if I would help him to document what lean in healthcare is.
The result was this article, “The Promise of Lean in Health Care,” in the latest issue of Mayo Clinic Proceedings.
We started with the following definition: Lean is an organization’s cultural commitment to applying the scientific method to designing, performing, and continuously improving the work delivered by teams of people leading to measurably better value for patients and other stakeholders.
We then go on to define six core principles of the lean transformation:
Attitude of continuous improvement
Value creation
Unity of purpose
Respect for front-line workers
Visual tracking
Flexible regimentation or standard work.
These principles are quite similar to what Womack and Jones described in Lean Thinking and are the basis of the Shingo Model.
Our intent with this paper is to bring lean thinking into the mainstream of physician activity. We use powerful examples from Healthcare Value Network. These include Christie Clinic, Inova, St. Jude’s Hospital, New York Hospital and Health System, Martin Memorial, Seattle Children’s and ThedaCare. All have been implementing the lean operating system. The question I am asked by most from CEOs and senior executives of healthcare organizations is, “What is lean in healthcare?” Our hope is this article contributes to answering that question.
It’s been a long time coming but we finally have a report with simple to understand performance metrics rating many of Wisconsin’s medical groups. Much like we compare automobiles and appliances we can now compare medical providers. This report compares several important healthcare measures across the main medical groups in Wisconsin.
Not surprisingly ThedaCare tops the list with a total Consumer Reports score of 87 and Marshfield Clinic is next at 83. There is a wide variation in quality scores ranging from a low of 51 and the top score of 87. The national average is 50.
The report is based on data from the Wisconsin Collaborative for Healthcare Quality (WCHQ). In existence for ten years, it is a respected source of performance data on physicians which Consumer Reports physician executive, John Santa, vetted rigorously before being willing to attach Consumer Reports trusted name to the results. As the founding chair of WCHQ, this report is a dream come true. The healthcare leaders in Wisconsin envisioned a decade ago that one day patients would have simple, understandable information by which to make decisions on their care. The next step is to move in this direction across the nation. At the Center, we continue to work with leaders in other states to do just that. For more information contact Julie Bartels at jbartels@createvalue.org.
This report raises a number of interesting questions. Why are there are a number of medical groups in the state not reporting? Purchasers should be asking this question. If 60% of medical groups in the state report voluntarily what is the mechanism required to get everyone to report? The absence of certain groups should give pause to patients as well. I would be skeptical of the data if the medical group is releasing it on their own as suggested by Consumer Reports. Is it accurate? Is it audited? How does the patient know the numbers aren’t being fudged? A public reporting process that everyone must comply with is the only way to assure accuracy.
Congratulations to all the medical groups that have had the courage to report. WCHQ and Consumer Reports continue groundbreaking work in transparency of healthcare performance.
