The 3rd entry in this series on organizational transformation using lean comes again,under the rubric of Process:Transparency is one of the keys to improvement but there are critical core characteristics of implementation that can make or break success.
Admitting mistakes is not easy. Look at the problems Toyota is dealing with because of their lack of transparency. Healthcare is no better. 5 years ago I met with a colleague at a very prestigious U.S. healthcare organization. I was invited by the Chief Medical Officer to give a talk on transparency and to share the results of the Wisconsin Collaborative for Healthcare Quality which was one of the first public reporting initiatives in the country (www.wchq.org). Following the talk I met with a small number of senior executives from the organization and asked them what they thought about reporting their data like we had in Wisconsin. They told me they thought what we were doing was great but they could never participate in such a process because they wouldn’t look very good on some of the performance indicators and this would damage their image. The CEO and marketing department wouldn’t let them do it in other words.
Actual real time performance data reported in a public way drives improvement faster than any other action. We know because it’s happened at ThedaCare and all across Wisconsin.As performance has been publicly reported resources have focused on fixing problems. The first step though is the hardest. Commitment to sharing results with the world starts at the top and cannot be manipulated by marketing and communications departments. When workers see their true performance they strive to improve. Most never know how they are doing and so they believe they are doing a good job. In my internal medicine practice years ago I thought I was a great internist managing heart disease and treating high cholesterol patients. Then when I actually did a chart review and found only 25% of my heart patients were meeting the cholesterol targets I was humbled. That humbling is what drove improvement and standard work for managing heart patients in my clinic. The root causes were identified and a standard protocol was implemented for treatment that brought our results to 75% of patients meeting goal within 6 months.
Visual control of performance can get the front line staff involved. That cholesterol control is now posted at every clinic at ThedaCare by doctor team on a visual tracking center(see slide 27 posted in blog no.1 PowerPoint) which all staff (and patients) can see. In fact these results are reviewed daily at huddles by the team and posting is done by the staff themselves.
Visual tracking centers must be meaningful to front line workers. For example,posting ventilator associated pneumonia rates in an outpatient clinic is useless. The staff and physicians have no impact on this. But posting the number of heart patients who have met their cholesterol goal is engaging because it is a big part of the work the staff and physicians do in a clinic.
It’s more than just posting results. There needs to be action. When problems are identified they need to be solved immediately, so part of the tracking process involves identifying and solving problems in cholesterol management using a standard work problem solving tool. This tool called a pdsa (plan-do-study-act) template will be described in greater depth in subsequent blogs but sufficed to say it involves a front line staff or physician identifying a problem and using the scientific method which we all learned in high school to solve it.First,identify what the problem is, in other words write a problem a statement. Then, decide why the problem exists the back round concerning the problem. Decide what the goal for improvement is, then do a root cause analysis on the problem and then run some experiments to see if a different process improves the results. Check the new results and start the whole pdsa over if improvement is not achieved. This level of scrutiny should be taught to all staff and physicians(not a small task). However, until the front line workers know how to identify and solve a problem nothing will improve and transparency will be useless.
In summary, there are two key components to transparency related to whole system transformation; public reporting of results and reporting of performance(and defects) at the level where the work is being done. This has to start from a commitment at the top of the organization and must be focused at the level where front line doctors and staff are actually doing the work.
This is the first in a series of blogs I am writing over the next few weeks that will help define the high level framework for a whole system transformation using the lean methodology.
I am not going to focus on the specific tools required to achieve each of the framework components because there are many ways to implement this framework and you must find the right way for your organization. Usually that means working with external sensei or teachers and each has their own process on how to achieve results.
Today we are focused on the first core structural principle Toyota uses for any initiative;Purpose.Every organization exists for a reason. It’s important to be able to clearly state that reason so that employees,customers and the world understands why the organization does what it does.In many cases this starts with an organizational mission statement. A mission statement should help employees understand what they are supposed to do when they come to work each day.
I have seen many healthcare mission statements and frankly, they are almost always about the same and not very revealing. I am not opposed to mission statements but taken by themselves they don’t provide the guidance people in organizations need to understand what they are supposed to do. Take this healthcare mission statement; “Our mission is to improve the health of our communities”. Now this is certainly a laudable goal but it begs a number of questions. Who is actually going to do this? What is meant by health? How much will health be improved? Which communities are impacted? The fact is we really don’t have a very good understanding of this organization’s purpose from the mission statement. Defining purpose is a lot like defining a problem. If we make it too general we are trying to solve for world hunger, if we make it too narrow we may miss what is really important. So, a mission statement without a statement of strategic purpose leaves staff unclear on what they need to do.When purpose is unclear staff do what they think is right which may be far from organizational priorities and goals. Management’s job is to bring focus by making purpose clear.
It’s important to understand the back round of information that is applicable to the organization before creating the the mission and then a strategic purpose statement. Is the geography important? Who is actually involved in delivering services? Is there contemplated growth? Is there focus on population health outcomes? What about and overall cost? Who are the customers?
As executives put more rigor to understanding the environment including focus on stakeholders,customers,and the marketplace, defining strategic purpose becomes easier. Here is the same healthcare organizations’ strategic purpose statement “Our strategy is to deliver measurably better value to our customers defined as 3.4 defects/million opportunities ,no interruptions in customer flow i.e. waiting and/or workarounds, and lowest cost”. With this statement the mission statement makes more sense and the staff have a clearer understanding of what they are focused on doing. But there are still a number of open questions. Who is going to do this and where are they going to do it? We do know who they are going to do it to which is the customer(the patient) and what they are going to do, deliver reliable quality at 3.4/million opportunities performance with no waiting.The process of continued dialog and discernment is critical to improve this strategic purpose statement however.
As this dialog process continues a second iteration of the strategic purpose statement brings us to another level of understanding. ” The physicians and staff in the 7 counties in eastern Wisconsin where we have health care facilities will deliver measurably value to our customers defined as 3.4 defects/million opportunities,waiting times for all services of less than 15 minutes, and lower prices than any of our competitors in the market”. With this statement it is clear what is going to be done where it will be done,who will do it and how success will be measured.If we now look at the mission statement and strategic purpose statement together it is much more meaningful.”Our mission is to improve the health of our communities”.” The physicians and staff in the 7 counties in eastern Wisconsin where we have health care facilities will deliver measurably value to our customers defined as 3.4 defects/million opportunities,waiting times for all services of less than 15 minutes, and lower prices than any of our competitors in the market”. Do you see how far we have come? Can we make it better?What are we missing? Is there more back round we need to make the purpose more clear? What would you do next?
This important job of defining purpose is the job of the board and senior management teams but involvement of all staff and physicians is critical to obtain the engagement in the ideas, it is the front line staff and physicians that actually will make this happen. My recommendation is take the time necessary to get this done well because without this compass the organization is lost.
Now that we have discussed our first topic, “Purpose”, we will move to “Process” next week.There are three topics under the process rubric: true north metrics,transparency of performance, and methodology for improvement. Next week we will tackle “True North Metrics”.
Congratulations to Eric Dickson M.D. and the work he did at The University of Iowa (my alma mater) and now the work he is doing at U. Mass. The results he reports in this paper from The Annals of Emergency Medicine clearly shows that successfully applying the lean methodology leads to remarkable results.The interesting point is that senior leadership engagement and front line staff involvement in kaizen are necessary for gains to be sustained.At “Hospital C” where neither occurred length of stay and patient satisfaction actually trended toward worsening.At the other three hospitals there were significant improvements that were sustainable.
This article documents some of the core principles in a successful lean implementation: Engagement of front line workers in kaizen and continuous improvement, Leadership involvement,and measurement of results.This work is more evidence that a lean transformation plan can cure many of our patient’s biggest frustrations.
I am continually asked for the prescription to whole system lean transformation. Being a physician I guess people expect me to write it out and hand it to them. I suppose they think they can then go to the pharmacy and get the pills and they will magically know what to do. Unfortunately,nothing important in life works like that. The journey of continuous improvement using lean is very personal. Each person as well as each organization needs to find their own way. There is no one “right way” to implement lean in healthcare or lean in any company. It is a series of trials and learnings, making many mistakes but applying PDSA to understand those mistakes and try new experiments.
What I will attempt to do is frame the journey over the next few weeks. Not telling you how to implement lean in your organization but explaining the framework leaders need to consider as they tackle this monumental task. I will try to point you to data along the way and examples that may help but you must remember this is all based on an N of one.I have been the CEO of only one healthcare organization that is implementing lean (ThedaCare).I have had the privilege to go to gemba at many great companies(52 in the last 18 months) including some in healthcare and I will try to incorporate examples from these organizations as well.The purpose of these posts is to start a dialog about what is working and what isn’t so we can accelerate our learning together.Feel free to disagree with me ,share your own experience or offer advice.
White House Press Secretary Robert Gibbs said President Barack Obama and congressional Democrats should “let the dust settle” before making any decisions. Senior Senate Democrats such as Jay Rockefeller (W.Va.) urged lawmakers to take “a couple days to cool off.” And House Democrats such as Robert Andrews (N.J.), who chairs a health care subcommittee, predicted his leaders would decide on a strategy by the end of next week even as he said any new movement on legislation would “take awhile.”
“We have to know what our possibilities are and that means in both houses and with the White House,” Speaker Nancy Pelosi (D-Calif.) said.
As noted in my last blog legislators should apply a standard problem solving process to actually determine what the nation needs in the way of health care reform. The fact is there is a trillion dollars of waste in the present health care delivery system. We know we could take out 30% of the cost of the existing system over the next 10 years if we can focus Medicare on getting the payment system right(see my Medicare payment flaws paper and if we can help hospital and health system CEOs focus on removing the waste in health care delivery.(see my paper in “Health Affairs” from September 2009 posted on our home page).
We also have created The Healthcare Value Leaders Network, the mission of which is to facilitate rapid and dramatic improvement in the performance of health systems. A number of these organizations will be gathering each summer to share and learn from each other, we invite you to attend.
We do have an historic opportunity to change American health care let’s make sure we get it right!
Washington legislators remind me a lot of GM; top down management focused on the wrong problems leading to poor results. At great lean companies management exists to serve the needs of their customers. For years GM produced cars that many Americans didn’t really want with quality that was average at best. Management not only didn’t listen to their customers they arrogantly defied them and eventually the customers revolted. The result was Toyota won. Toyota won by focusing on delivering better value to each and every customer.They deeply understood the problems customers uncovered and they used the Toyota Production System methodology to rapidly improve their products.
Compare and contrast that to Washington legislators. The customer(those of us whom legislators represent) have clearly stated that the health care solution the government’s top down managers are imposing is not what the customer wants. Despite this clearly stated concern the customer is going to receive something they don’t want at below average quality(sound familiar). The total cost, 900 billion dollars, most feel is outrageous with no plan to attenuate the 6-8%/yr rise it will grow much higher. The quality of the solution at best is unclear. Not all Americans will be covered but the good news is 31 million new people will be. Access may suffer due to under funding and lack of adequate primary care.
If legislators would have actually spent the time to clearly identify the problem they were solving for a completely different solution would have evolved one that would address most of the issues in our present broken system. What is the problem? The cost of our health care is out of control.Any comparison made to other countries confirms this. The background related to this cost crisis is that at least 30% of the present system is wasteful in the eyes of the customer. Waste occurs when we deliver a medication error, give a patient an infection or duplicate a test. By removing this waste we could save at least 30% of the cost or nearly a trillion dollars. This easily pays for insurance coverage whether public or private and also addresses the year over year cost increases presently ready to bankrupt Medicare.Sadly, our legislators haven’t taken the time to understand the information required to identify the right problem. If they had been using a standard approach to problem solving they might have gotten there.
A3 thinking is just that,a standard process to solve problems,identify new problems,study the action put in place and act on the information gathered to improve the solution. This isn’t a 30 second sound bite method of gathering information which unfortunately is what legislators are used to but a thoughtful way to understand what problems the customer is facing and eliminate them. So…GM or Toyota I guess we know the answer what we don’t know is how long it will take for the customers to revolt.
Read the following synopsis and send it to your legislators asking for a do-over. A3 Summary2
Most of the energy in Washington has surrounded the insurance component of reform. Although it is a laudable goal to have all Americans covered with some form of health insurance it is only one step. without significant delivery reforms Medicare and Medicaid simply go bankrupt sooner.
The first step in delivery reform should be transparency of heath care performance. The reason is that providers who report performance that is poor or even average compared to peers have been shown to significantly improve that performance. Most of our experience in reporting quality measures like A1-c rates and LDL cholesterol levels is at the Wisconsin Collaborative for Healthcare Quality www.wchq.org .We have seen dramatic improvements in performance by many of the providers that have been publicly reporting since 2003.
In the present bills in the house and senate there is verbiage related to performance reporting. The way this is written it would be a CMS initiative rather than one at the state or regional level. Our experience in being a CMS BQI (better quality information) pilot site is that it much more likely that regional or state quality collaboratives have a better chance of achieving the reporting requirements than a federal program. Each state has different issues with physician reporting and physicians are less willing to work with the federal government than state public private partnerships when it comes to design and compliance of reporting initiatives.
It is our contention that if reporting is done appropriately we can dramatically reduce cost and improve quality. for example,if a reporting initiative required hospitals and physicians to report medication errors on inpatients and outpatients we would likely see huge reductions in errors. The caveat is what are the definitions. Are we going to report medication reconciliation errors, near misses, or actual errors that do harm. The definitions will take years to work out at the federal level but at WCHQ or The Wisconsin Hospital Association we could probably come to agreement relatively shortly as to what we can measure right now.Doing things this way would also create some competition between states on which state was coming up with the best ideas.This would spread much more quickly than a federal mandate to report.
Let’s leverage what many states already have rather than recreating an ineffective wheel of new federal government mandates for reporting.
Unfortunately, the language introduced by Senator Kohl regarding the Healthcare Value Leaders Network (HCVLN) did not survive the final senate bill. It’s unclear how the ballooning costs of healthcare are going to be managed if providers like those in the HCVLN aren’t studied and lessons learned not passed to the rest of the industry. At some point government officials are going to have to engage a few people who actually have experience at reducing costs and improving quality. In any event,the house and senate will begin reconciling the two radically different bills they passed in January. We will wait to see if anyone wakes up to the fact that trajectories of 6-8 % increases per year in medicare have not been factored into the CBO’s estimates of the price tag of this legislation.
The WHIO data base has been 4 years in it’s development.This non-profit organization is a collaboration of many of the state’s key health care organizations representing payors, employers,providers,and the state government (see the individual organizations involved at http://www.wisconsinhealthinfo.org/about_us.php )
Presently 1.6 million Wisconsin residents are in the data base but at the end of next year that will rise to 3 million and will increase each year thereafter. Using this data along with clinical data being reported by the Wisconsin Collaborative for Healthcare Quality (www.wchq.org ) we are building a value index that will be comparable across provider organizations.Thus we will be able to compare both cost and quality of medicine delivery.
This is simply continued evidence that Wisconsin is leading the way in innovative approaches to improving healthcare value for it’s residents.
I have had the privilege of being the founding chairman of two organizations in the state of Wisconsin which are now considered national models by many leaders. The Wisconsin Collaborative for Healthcare Quality (www.wchq.org) is a unique non-profit focused on reporting all payor all patient quality data on a range of indicators. It was one of the CMS pilot sites for better quality information and it is part of the value exchange established by former HHS Secretary Leavitt.
The Wisconsin Health Information Organization (www.whio.org) is a non-profit focused on reporting resource utilization on physician groups through an administrative claims data base which is built on data contributed by the health plans in the state.
These organizations would not exist if it weren’t for the collaborative leadership of many individuals representing insurance companies,providers,employers,and state government.
Read the following third party assessments of how we actually did it.
