Beth Israel Deaconess has been working on lean for a number of years. They are redesigning care to focus on reducing hospital readmissions. Using lean tools such as value stream mapping and kaizen improvement teams they are identifying waste in the inpatient care delivery process and removing it. They have mapped each step in the process from when a patient enters the emergency room to when they are discharged. This understanding of the current state is a critical first step in improving care however, very few hospitals actually have done this.
Congratulations to the Beth Israel Deaconess team for the award. We look forward to learning from one of the true innovators.
In my new book Potent Medicine https://www.createvalue.org/delivery/books-media/new-potent-medicine I describe the fundamental factors contributing to this cost crisis and what is working to fix the problem. From an employer perspective, the continued purchasing of health insurance based on the size of discounts received from providers is one of the clear root causes.Why does this continue? Why not build benefit plans that encourage employees to seek care from high value providers?
The data in Wisconsin and other states is available now http://www.wchq.org/http://www.wicheckpoint.org/index.aspx to determine who the high value providers are. If insurance premiums are to ever come down it will take courage from employer and government payers to say enough is enough, stop buying on discounts!
Check out my interview with Mark Graban on his Lean Blog. Listen as we discuss my new book, Potent Medicine, which describes what’s working in Wisconsin and around the country.
I’m hoping many of you have already heard the news about my latest book, Potent Medicine: The Collaborative Cure for Healthcare. It launched earlier this month, and if you haven’t had a chance to check it out yet, jump over to our Books & Media page. The Kindle version will be available in May.
I’m particularly excited about this book for a couple reasons. One, it showcases the great leaders and colleagues I’ve known on the healthcare front here in Wisconsin, and two, it really goes beyond the page to offer a call to action for providers, patients, legislators and employers – all the key stakeholders in healthcare.
A piecemeal approach to solving this crisis is not the answer, and Potent Medicine offers a specific prescription for each of those stakeholder groups. You can learn from our mistakes and use them to inform a new roadmap for moving forward. Every example in the book is based on actual experience not theory.
Wisconsin is a place where innovation in payment and transparency is happening. Provider systems like ThedaCare and Gundersen Lutheran are achieving nation leading healthcare performance results thanks to the data and feedback from the Wisconsin Collaborative for Healthcare Quality and the Wisconsin Health Information Organization.
We encourage you to get involved in similar experiments regarding payment and data transparency. Keep us updated on your progress and connect with us to learn what others are doing as well.
There is no simple answer to achieving a sustainable, quality healthcare system in this country. The next steps will not be easy or natural, but they are the beginning of the cure.
ThedaCare along with several other Healthcare Value Network members have decided to participate in the Pioneer ACO program. Listen to Dean Gruner M.D. describe the reasons and challenges.
The following blog post by Mark Graban explores the ACO concept and how lean may fit into successful implementation of this payment reform strategy.
It’s getting confusing. What’s a Pioneer ACO vs. a CMS ACO? How is the savings shared or how are penalties determined? How many medicare patients does an organization need to be able to care for to participate? These questions and others are frequently asked in the circles I am in. I decided to define some of these questions and the answers at least as we know them right now.
First, the CMS website is a pretty good start to understand what an ACO is or at least what CMS thinks it is. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/ This also has links to the Medicare Innovation payment programs including bundled payment, comprehensive primary care payment, and community based transition programs.
Next I am enclosing a document that describes the difference, again as we know it today, between the Pioneer ACO model and CMS ACO model. This document helps to answer some of the questions above and others. ThedaCare – Pioneer and Shared Savings ACO Side-bySide_103083595(1)
It’s about time the medical societies in this country take aim at the waste that exists in patient care. One of those wastes is Overproduction. In healthcare it is manifested by unnecessary tests and procedures being done to patients. This results in excessive cost and at times, patient harm. In my recently released book Potent Medicine I describe what the responsibilities of all stakeholders are if we are to change the healthcare trajectory. The “five things physicians and patients should question” described below is headed in the right direction. Read the following press release from today.
“At the ABIM Foundation’s Choosing Wisely® press conference later this morning, leaders from nine specialty societies will identify specific tests or procedures that they say may be overused or unnecessary within their specialty, even though they may be commonly used.
The lists of “Five Things Physicians and Patients Should Question” provide specific, evidence-based recommendations physicians and patients should carefully consider, as part of making wise care decisions. This unprecedented campaign aims to spark discussion about the need – or lack thereof – for many frequently ordered tests or treatments.
The press conference begins at 10:00 a.m. and we invite you to follow the proceedings by:
Following @ABIMFoundation on Twitter and using the hashtag, “#choosingwisely.”
The organizations releasing lists as part of Choosing Wisely represent nearly 375,000 physicians:
American Academy of Allergy, Asthma & Immunology
American Academy of Family Physicians
American College of Cardiology
American College of Physicians
American College of Radiology
American Gastroenterological Association
American Society of Clinical Oncology
American Society of Nephrology
American Society of Nuclear Cardiology
Consumer Reports – the world’s largest independent product-testing organization – is also working with the ABIM Foundation and the specialty societies to lead the effort. At today’s press conference, Consumer Reports will announce eleven consumer-oriented organizations joining Choosing Wisely to help disseminate information and educate patients on making wise decisions.At the ABIM Foundation’s Choosing Wisely® press conference later this morning, leaders from nine specialty societies will identify specific tests or procedures that they say may be overused or unnecessary within their specialty, even though they may be commonly used.
The lists of “Five Things Physicians and Patients Should Question” provide specific, evidence-based recommendations physicians and patients should carefully consider, as part of making wise care decisions. This unprecedented campaign aims to spark discussion about the need – or lack thereof – for many frequently ordered tests or treatments.
Budgets are obsolete the day after they are created. Budgets are poor predictors and guides for performance. At ThedaCare budgets never perfectly predicted actual performance. Prediction accuracy varied from 2% to 169%. If this is such a flawed practice why does anyone still use a budget?
Read the following to understand what ThedaCare has learned.
Hospital Referral Regions or HRRs are 306 mutually exclusive regions, constructed by aggregating the residential zip codes from which Medicare beneficiaries traveled for major cardiovascular and neurological surgical procedures. Each local referral region has at least one hospital where these complex surgical procedures are performed. The HRR names reflect the location (city or town) where the referral hospital is physically located. The regions are meant to represent travel and referral patterns and thus do not align to political (county, state) boundaries and sometimes cross state borders.
The following are the top rated HRRs in the U.S. based on measures of Access, Prevention & Treatment, Potentially Avoidable Hospital Use & Cost, and Healthy Lives. Overall it is very interesting to see that many of the top HRRs are dominated by organizations focused deeply on continuous improvement and more specifically are using the lean methodology. In St. Paul, MN, by far the largest provider is Healtheast which has been working on a lean transformation. In Minneapolis, MN Park Nicolet, Minneapolis Childrens and others have been working for years on the lean transformation. In Appleton, WI and Neenah, WI Thedacare has led the charge of full lean transformation and Affinity has also been applying lean tools. In LaCrosse, WI Gunderson Lutheran has focused on continuous improvement using lean and in Cedar Rapids, IA. Mercy hospital and St.Lukes hospital who are part of the Healthcare Value Network are applying lean principles to improve performance.
1.St. Paul, MN
2.Dubuque, IA
3.Rochester, MN
4.Minneapolis, MN
5.Appleton, WI
6.Santa Rosa, CA
7.La Crosse, WI
8.St. Cloud, MN
9.Manchester, NH
10.San Mateo County, CA
11.Cedar Rapids, IA
12.Green Bay, WI
13. Lancaster, PA
14.Neenah, WI
15.Arlington, VA
It’s exciting that the work many of these health systems are doing with lean is leading to healthier lower cost communities.
This recent study from the Brookings Institution compares value performance in healthcare in three states: New York, Vermont, and Wisconsin. Data bases developed in each state in addition to Medicare and Medicaid data was used to make the comparisons. Although it is difficult to compare across all three states, in Wisconsin there are certain communities where cost and quality are measurably a lot better.
The two counties in Wisconsin delivering the best cost and quality are Lacrosse and Outagamie. These counties are areas where Gunderson Lutheran and ThedaCare have large portions of market share. ThedaCare has well over 50 percent market share and has been on the lean journey for years. Gunderson has also been applying lean healthcare and competitors in both markets have begun to apply lean to some processes.
This exhaustive study is another set of evidence that costs can be improved at the same time quality improves and in this case across an entire community. There have been studies which suggest Medicare spending is low in these two counties because cost shifting to commercial payers is occurring. This study debunks that idea showing that Outagamie County is a better value county among all payers, fee for service Medicare, Medicare Advantage, Medicaid, and commercial insurance.
The study also points out the need for the development of standard cost and quality metrics as well as data sets that are comparative. The center has been working nationally to develop an all payor claims data base similar to the Wisconsin health information organization model which is described in the study. With such a data base value metrics could be created and comparisons made across all provider organizations in the country.
This ideal state is what we all should be aiming for.
“Eighteen counties (Brown, Calumet, Dane, Door, Dunn, Jackson, Jefferson, La Crosse, Monroe, Outagamie, Portage, Price, Shawano, Sheboygan, Trempealeau, Waupaca, Waushara, and Winnebago) were identified as providing health care that was better quality and lower cost than the statewide payer average across two or more payers according to two different quality metrics.48 These counties tend to cluster in the mid-eastern region of the state, along with a small group of counties along the middle of the western border. Based on clinical care factors, five of these counties ranked in the top 10 (La Crosse, Outagamie, Dane, Winnebago, and Waupaca).49 Jefferson and Brown counties also qualified in the top 20. Outagamie County was recognized as a high-value county across all payers for both of the quality metrics used in this study. La Crosse County is also notable for performing as a high-value county across all payers in the ASC admissions measure and across three payers (all but Medicaid) in the diabetes composite measure. These are the counties that Wisconsin might seek to learn best practices from and share those methods with other counties, should further analysis across several other measures demonstrate a consistent pattern.”
