Carolyn Clancy M.D. the director of the Agency for Healthcare Research and Quality is making a presentation to the Wisconsin Collaborative for Healthcare Quality in Madison, Wisconsin on Tuesday May 11th. Following that she will be traveling to Appleton for a gemba visit at ThedaCare.
ThedaCare will be host to the director of the agency charged with studying and improving the quality of the nation’s healthcare. AHRQ rates states on a variety of measures and last year named Wisconsin No.1 in the nation on a series of quality measures. She is coming to Wisconsin presumably to try and understand what we are doing that is leading to this ranking.
It’s a great honor that she would choose ThedaCare as the one place in the No.1 state for quality to spend a second day. Dr. Clancy will be going to the gemba (where value is created for the patient) on Wednesday May 12th at ThedaCare. We will be taking her to the Collaborative Care Unit at Appleton Medical Center which represents ThedaCare’s revolutionary redesign of inpatient care using lean. In addition we will observe ThedaCare’s new lean leadership model which is leading to remarkable safety and quality improvements. We will also get to see Ortho Plus which is ThedaCare’s multidisciplinary one piece flow for patients with musculoskeletal problems. Finally we will go to the Kimberly Clinic to observe how the lean process works in the outpatient setting of the patient’s medical home.
On Wednesday I will post another blog regarding what Dr. Clancy felt were the highlights of her visit to Wisconsin.
After gemba at many health systems in the last few months, there is one common theme that is recurring: Lean is considered as the add-on to improvement, not the improvement system itself.
From academic medical centers to community hospitals I am finding that the lean method is being isolated as just another project to lower cost. This in contrast to the organizations successfully implementing lean which view it as THE improvement system. Our experience at ThedaCare was to create one improvement system designated the ThedaCare Improvement System which was the only improvement system. Sure, we had clinical improvement in one corner, and 60 day workouts in another, and 6 sigma techniques in a third corner but when we started the lean journey we decided to transform the organization we decided that as part of the implementation process we required a single improvement system which was clear and communicated as the only set of tools for improving care. This was hard but frankly, our staff and physicians were sick of the lack of consistency the organization used to solve problems. In fact, we couldn’t solve problems because none of us knew how; let alone how to sustain improvement.
The value of creating a common improvement system is that it removes confusion at the front line. If everyone is trained in PDSA (plan-do-study-act) and every time a defect is encountered a PDSA is done to understand the problem, the root cause, and identification of countermeasures it creates a sense of confidence that no matter the problem there is a process that people understand and know will help them solve it. A teacher once told me “the essence of education is repetition”. One PDSA won’t embed problem solving in a culture but a dozen might work to get our front line workers solving problems every day. This won’t happen if we ask them to learn dozens of different techniques and each improvement facilitator uses a different tool box.
The argument from clinicians sometimes is “that lean stuff is fine for cost control but it doesn’t work on patients”. How about Bolton, U.K., a 23% reduction in stroke mortality after a year of value stream mapping and kaizen events. How about 0 medication reconciliation errors for 3 years running at ThedaCare’s Collaborative Care unit after redesigning the inpatient care process using lean. There are many other examples.
Why is the lean methodology not being used as the improvement methodology? I think as Mark Graban has commented on his blog recently part of the problem is poor implementation which then leads to wrong conclusions about the methodology. The fact is if quality, cost, and staff satisfaction don’t improve all at the same time the implementation process is flawed. Unfortunately there are many lean implementations that are flawed and doctors and nurses begin to believe that the initiative is just about cost reduction. This is another reason it’s important to integrate all quality improvement processes into the lean transformation. Since this is such a big problem in healthcare today we need to figure out away to address it. I invite you to send me some ideas on what you have seen work. Is it simply a top down decision to change this or is it something else? How do we get the doctors to understand that lean is the improvement system not just a cost lowering initiative? The Center is very interested in supporting an educational event addressing this, so thoughts any of you have regarding what we should create would be welcomed.
The Healthcare Value Leaders Network members gathered in Winnipeg yesterday and today to review the great work going on there
St. Boniface has been at the lean transformation since 2007.The Healthcare Value Leaders Network visited the site on the 22nd and 23rd and found some powerful lean ideas.
I visited St. Boniface 8 months ago and the difference between now and eight months ago is remarkable.First, a few stats. They have taken the time nurses look for equipment from 45min. to 15 seconds by applying 6 S and supply chain work. They are ranked number 2 of all Canada’s academic medical centers for hospital efficiency. This is measured by the Canadian Institute for Heath Information and is compared across all hospitals. The inpatient measure is cost/weighted case which takes into a number of factors including nursing wages,geographic wage disparity,hours worked per patient day,case mix, etc. and scores every service in the hospital which then roles into an all hospital score.
The focus of our visit was “sustaining the gains of lean improvement”.St. Boniface is attempting to achieve sustainability by experimenting with a process of front line peer to peer coaching which is unique. After each kaizen event a team of front line workers are designated as coaches for the rest of the staff.These coaches are actually coached on how to be effective coaches by their managers and lean facilitators. Standard work has been developed for coaches. The newly minted coaches then work with the other staff on the unit to teach the the new standard work in the department and to get their feedback. The results are better staff satisfaction on the units.The staff have said they would much rather be coached by their peers than their manager on the new standard work. The coaches are full time front line workers who are given this additional front line responsibility to work with their peers.We asked three of the coaches if they felt burdened by this new role and additional work. They said that the work can be accomplished easily during their usual day. For the most part they have good relationships with their peers and usually coaching on the work changes doesn’t take much of their time. The other learning is that when the new standard work is actually not working the front line staff will bring that to the attention of their peer coach naturally and freely. That’s different than if they had to tell their manager about problems.In this way defects are being identified and corrected much more effectively than ever before. These managers now have a goal of training all of their staff to be coaches for each other.
There are many other good experiments going on at this hospital. I think part of the reason is the commitment of both their CEO and their board. For example we were impressed that most of their board members spent the whole day with us at gemba. They interacted with the staff and patients and found out what was really going on the hospital floors.This level of commitment at the top is bound to help keep St. Boniface on the path of total lean transformation.
Congratulations to the staff,doctors,administration and board of St. Boniface!
It’s official, president Obama has nominated Don Berwick M.D. to head CMS.This is good news for healthcare in the U.S.
Don Berwick has devoted his career to improving the quality of American healthcare.I can think of no one better to be at the helm of CMS now than Don Berwick. Our collective role now is to support his nomination. Sending support letters to your senators is a great way to start. Let’s make sure Don gets nominated.
For updates to this process follow the IHI website at http://www.ihi.org/ihi and congratulate Dr. Berwick!
The June 9th and 10th summit in Orlando is shaping up to be a terrific look at how some healthcare organizations are successfully changing their culture to continuous improvement using lean
At the summit you will hear presentations from Group Health Cooperative of Puget Sound on their daily management work which has led to remarkable improvements in cost and quality. You will hear from ThedaCare on the redesign of inpatient care called Collaborative Care which has led to zero medication reconciliation errors for 3 years in a row,as well as their work on the the redesign of primary care, their attempt at “medical home” using lean. The University of Michigan Medical Center will describe their senior executive use of A3 thinking and Park Nicollet will reveal how they used 3P to radically change the way they build facilities. You will also hear from the Iowa Health System on their unique way to introduce lean thinking to all their front line staff. Mercy hospital in Cedar Rapids Ia. will relay information on how to create continuous flow in emergency rooms and Hotel-Dieu Grace hospital in Windsor Canada will explain end to end patient flow through a whole hospital.
These presentations are only one part of the summit which include great networking opportunities as well as a CEO panel that includes the CEOs of McLeod in South Carolina, St.Boniface Hospital in Winnipeg and Harvard Vanguard Medical Group in Boston.
Paul Akers in Seattle interviewed John Toussaint regarding using lean to improve clinical and financial performance.
John Toussaint was interviewed on this radio show in Seattle two weeks ago. Paul Akers, the show’s host, has implemented lean in his own company and now is running for the U.S. Senate on the platform of creating lean government. Talk about an uphill battle! Good luck Paul!
Dr. Leape was quoted in a recent Modern Healthcare article implying lean methods don’t work.The following is what he said.
“…while hospital executives have dithered around with concepts like Lean process improvement, which have “industrialized” the system without regard to care.”
“Healthcare has become a production system,” he said. “We think more about nursing ratios than we do about nursing. … I don’t think most of us think this is progress.”
I have great regard for Dr. Leape but on this one he’s got it wrong. We have evidence from many hospitals across the world now that care dramatically improves when processes are standardized and improvement cultures are developed. Lean methodology does both and leads to dramatically better patient and staff satisfaction at the same time.We have shown this at ThedaCare as have others such as Group Health of Puget Sound,St. Boniface hospital in Winnipeg and St. Jorans in Sweden I could list many others.
The basic outcomes of lean include improved quality, lowered cost and improved staff and patient satisfaction. Frankly, if you are not getting all three you are doing something wrong in implementation. I have seen Lean poorly implemented in many institutions and it wouldn’t surprise me if Dr. Leape’s experience is in a failed implementation hospital.
The good news is the framework for successful implementation is emerging.Certainly Mark Graban’s book “Lean Hospitals” has helped. Our upcoming book published by the Lean Enterprise Institute “On the Mend” documents the journey of a successful Lean implementation and my recent series of blogs on this site frames the core components for organizational transformation using Lean.
The anecdotal evidence, however, is not enough that is why the Center along with 5 research institution including Clemson University has submitted a grant to AHRQ which is designed to prove that the lean methodology is superior to other methods in achieving the best patient outcomes.This is a 3 year study that will include matched pair hospitals,those doing lean and those not doing lean, to prove that the methodology works as many of us have described in our articles,books and blogs.We need to prove once and for all, to the scientific community, that the question shouldn’t be whether we implement the lean method but how do we do it faster.
Tuesday April 6th, a gathering of more 150 healthcare leaders from across the state took place to begin to craft the future of paying for value in healthcare. See one of the documents that was presented at the summit attached at the end of the blog.
Previously, on this blog we have outlined what we think real health reform looks like. It boils down to three things: paying for value not volume, transparency of healthcare performance through public reporting, and redesigning the care delivery process to take out waste. We took a step closer to paying for value with the day long meeting in Pewaukee on Tuesday. Leaders from provider organizations, insurance companies, employer groups, state government and consumers all came together to address the difficult issue of paying for healthcare differently.
Harold Miller from the The Center for Healthcare Quality and Payment Reform facilitated our meeting. We have posted many of Harold’s articles on this blog in the last few months. We divided the audience into 6 groups and we focused on preventive care, chronic care, and major acute care. Within each of these categories we discussed the issues and options regarding payment reform. Each group developed recommendations and reported back to the whole group at the end of the day. The summary of the work of this group should be posted in the few days and we will link you to it.
This is only the first of many sessions that will be required to further define what is necessary to begin to reward value in healthcare. We will make sure you can follow the progress and get involved by following our site. Make sure you RSS my blog to receive the updates. For now, here is Harold Miller’s paper on national payment reform concepts.
Once I completed the transformational blog series I realized there is still much more to discuss.”Gemba” is an important place and it means “place where value is created”. I am going to discuss why going to the Gemba is so important.
In our upcoming book “On the Mend”, we describe going to Gemba as on of the core actions of lean leaders. I think Gemba is important for a number of reasons:
1. Leaders learn to see. This means they learn to recognize what steps in a core process are waste. Waste has eight ways of manifesting itself, these are:
The Eight Wastes of Lean Healthcare
1. Defect: making errors, correcting errors, inspecting work already done for error
2. Waiting: for test results to be delivered, for a bed, for an appointment, for release paperwork
3. Motion: searching for supplies, fetching drugs from another room, looking for proper forms
4. Transportation: taking patients through miles of corridors, from one test to the next unnecessarily, transferring patients to new rooms or units, carrying trays of tools between rooms
6. Over processing: a patient being asked the same question three times, unnecessary forms; nurses writing everything in a chart instead of noting exceptions
7. Inventory (too much or too little): overstocked drugs expiring on the shelf, under stocked surgical supplies delaying procedures while staff goes in search of needed items
8. Talent: failing to listen to employee ideas for improvement, failure to train emergency technicians and doctors in new diagnostic techniques
Once leaders learn to see these wastes they can then help staff to see the waste with the goal to have all staff continuously removing waste.
2. Leaders send a strong message that they really care about the front-line workers’ problems. A CEO working with nurses to solve a complex problem has a very positive impact on morale in the hospital or clinic.
3. Leaders understand the business better and know the troubles their staff and patients are experiencing. This knowledge is used to make better decisions on resource priorities.
4. Leaders learn about standard work for management. Gemba is a structured process to review work processes at the front-line. Leaders must come prepared to do that. They should know how to see waste in a patient care process and be able to help staff learn to see that waste. This is done by asking staff questions which helps staff to think about the problems themselves. The leader should never tell the staff what to do but instead need to be able to ask the right questions. This is hard work and requires focus and concentration. This means the leader has to know something about the work and that doesn’t happen unless the leader is at the place of work regularly. Good teachers motivate their students to learn more about the subject being studied. Good lean leaders motivate their staff to better understand their work so they can see and remove waste.
Going to Gemba is not an action to be taken lightly. It’s hard work and it takes time to learn how to do it effectively. It must be done often to be learned. I invite you to start going to Gemba once a week for four weeks. Each time you go write a log of what you have seen, then compare what you saw the first time to the fourth time. I think you will be surprised you have started to learn to see.
Now that we have a bill the next steps should be to identify the most important priorities for really changing the cost and quality of healthcare.See the link below and read a chapter in our new book “On the Mend”, then send it to your legislators!
The 2,500 page plus bill is daunting in and of itself, but the administration rules that are written as a consequence will dwarf the actual bill itself. Many of the details of this bill are left up to the HHS Secretary to define. So what should Secretary Sibelius be focusing on?
Last week a letter was sent to many of the legislators who were responsible for shepherding this bill through the congress and senate. The letter was sent by Paul O’Neill and Arnie Milstein, two respected leaders who have spent much of their working life trying to change healthcare to make it less costly and defect free. In the letter they suggest that the government must now support the experiments around the country that are showing promise to reduce cost and improve quality. One of the most important experiments is the Healthcare Value Leaders Network. These are the organizations in the U.S. committed to fundamentally changing healthcare delivery with lean. They are showing remarkable results that are being published in peer review journals (see Articles by John Toussaint).
In addition, the Lean Enterprise Institute will be releasing a book which describes the framework of lean healthcare. This book is the story of the ThedaCare journey to transform itself including the lessons learned along the way. We have excerpted the second chapter of this book and sent it to our legislators along with the the well crafted letter from Mr. O’Neill and Dr. Milstein. Our intent is to influence our government leaders to begin to understand that change in healthcare delivery is possible and in fact, required if we are to bend the cost curve and improve quality.
We invite you to send this link to your legislators and ask them to read the letter, the book chapter and then support the real change that needs to happen.
