ThedaCare’s Collaborative Care Units
Missing from most healthcare organizations is a well defined methodology that the entire organization can utilize to solve problems, continuously improve processes and sustain results. In 2003 ThedaCare embarked on the journey to deeply understanding the principles and practices of the Toyota Production system otherwise known as lean. After several years of building the understanding of lean principles a core group of inpatient providers including nurses, pharmacists and physicians were pulled off patient care duties and allowed to lead a complete redesign of inpatient care using the principles and tools of the Toyota production system. After 18 months of facilitating front line workers in improvement events and designing future sate flow with value stream mapping Collaborative Care was created.
Collaborative Care is a completely redesigned inpatient care process which involves a fundamental redesign of the roles and responsibilities of all care givers. The redesign is focused on what the patient considers as value to their experience. It was designed with patients and caregivers working together to identify the steps in the inpatient care process that are important to care while eliminating the steps that are wasteful.
The basic unit of collaborative care is the interdisciplinary team with the patient at the center. On admission, a physician, nurse, discharge planner and pharmacist jointly meet the patient and with the patient’s input develop a single plan of care. This unified plan replaces the multiple, sometimes contradictory, plans of care previously maintained separately by physicians, nurses, and ancillarypractitioners. The nurse monitors the progression of care using evidenced based guidelines available in the single care plan which exists in the electronic health record. When he or she detects a barrier to the progression, it is the nurse who contacts the team’s physician with recommendations, not the other way around. To support the nurse’s new role as care coordinator, wasteful and interruptive tasks such as searching for missing supplies or equipment have been eliminated by designing nurse servers that allow more than 90% of supplies and medications to be at the bedside and tasks not requiring RN skill such as bathing are reallocated to others.
The cost per case has decreased 15-28 percent, and average length-of-stay has dropped 10-15 percent depending on the year measured. At the end of 2010 the direct and indirect cost of inpatient care in the Collaborative Care units at ThedaCare was $5781. This compared to the units in which Collaborative Care had not been implemented yet $7775. In addition, the Collaborative Care units have achieved zero medication reconciliation errors upon admission for four years in a row and 100 percent compliance with a specified bundle of procedures for caring for pneumonia patients. Patient satisfaction scores have risen sharply in Collaborative Care units: 95 percent of patients rated their satisfaction level as "excellent" in 2010, compared with 68 percent in 2006, before the rollout of Collaborative Care.
The reimbursement for this higher quality lower cot care has actually been reduced by Medicare. In some cases the patient is discharged before the length of stay minimal stay threshold Medicare has established. This is due to waste that is removed from inpatient stays. Unfortunately, ThedaCare is penalized for this. The non penalty payment (related to length of stay threshold) for the medical Medicare DRGs averages $6,919 but the penalty payment drops to $5,038. This example confirms it is critically important to redesign inpatient care and payment systems if we expect sustainable innovations to occur.
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