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Source: Business-improvement.eu
Lean: Value adding organization
Thedacare's staff improves a layout (1) The Lean Journey of ThedaCare
By Dr Jaap van Ede, editor-in-chief & owner business-improvement.eu

During the last eight years, ThedaCare was transformed to a lean and patient-focused health organization, with respect for the work of the nurses and doctors, but with measurable and therefore sustainable results. This journey is decribed in the book On the mend – revolutionizing healthcare to save lives and transform the industry.

Not only the processes changed, but also the managers. The introduction of lean principles radically changed their role, which became increasingly humble and facilitating. What can we learn from the lean journey of ThedaCare?

Did you ever accompany someone who was admitted with haste to a hospital, with indistinct symptoms? I did. What I saw was nurses and doctors from various disciplines arriving at the bed, and disappearing again. Although they all were very kind, we wondered why they were asking the same questions, over and over again: what happened, were you unconscious, etcetera.

Cover On the MendSimilar experiences convinced Doctor John Toussaint, practicing internal medicine for seventeen years within ThedaCare, that it was possible to reform healthcare, with the aim to reduce costs and to provide better care.  When Toussaint became CEO of ThedaCare, he got the chance to execute this plan.

On the Mend
ThedaCare in Wisconsin is a mid-sized, not for profit healthcare provider with hospitals, clinics and nursing homes. ThedaCare has 20.000 hospital admissions each year. Toussaint describes its lean journey (2002-2009) in the book On the mend – revolutionizing healthcare to save lives and transform the industry. In 2008, he stepped down as CEO, and founded the ThedaCare Center for Healthcare Value (TCCHV). This is an education/consultancy/network-organization, which aims to spread knowledge of lean health care. Recently, TCCHV launched two ‘health care value leader networks’ in the US, in cooperation with the Lean Enterprise Institute (LEI).

Lean transformation
The above-mentioned book On the Mend has two authors, the one not mentioned yet is Dr Roger Gerard. As ThedaCare’s chief learning officer, a position he still holds today, he was involved in many change management trajectories.

On the Mend resembles the novel The Lean manager of Michael and Freddy Ballé, because that book is also about a lean transformation, be it of an automotive supplier. On the mend is much shorter and is therefore more an introduction to lean healthcare than a book suited for Lean specialists who want to deepen their knowledge. What pleads for it: this is a story about a real hospital, not a fictitious organization.

On the Mend describes how ThedaCare doubled its revenue, and how this organization became the lowest-price health care provider in Wisconsin. One typical example: the mortality rate for coronary bypass surgery dropped from 4% a year (12 deaths) to almost zero (one death in 2009). In addition, the time that the patients stayed in hospital fell from 6,3 to 4,9 days. These kind of results are attributed to the application of the principles of the Toyota Production System (TPS).  

Toyota brandThe Toyota Production System and the recent recalls

The Toyota Production System (TPS) seeks to reduce waste and costs, while improving the outcomes at the same time.

TPS is often equated with Lean manufacturing, but this is not entirely correct. It is system which was developed by trail-and-error within Toyota, so it should be regarded as a solution tailored to the needs of this car manufacturer. Included in the TPS are principles of different improvement methods, not only Lean manufacturing but among others also Total Productive Maintenance.

Nowadays, the TPS is being criticized as potential cause for the large recalls by Toyota, but this is incorrect. If there is any relation, then this is the fact that applying the principles weakened somewhat during the last years within Toyota. So, what actually is needed is a revival of the TPS1

Structured approach
Toussaint knew, based upon personal experiences, that he needed a structured improvement approach. In 1987, he had tried to reduce the number of life-threatening situations in the Intensive Care Unit, with patients receiving solutions with vitamins and highly concentrated glucose.  His idea: a standard protocol for the recipes would prevent patients getting to high blood sugar levels.

Although the doctors didn’t like that idea - they said it was cookbook medicine – Toussaint convinced them to use the protocol. Soon after that, the number of high blood sugar level incidents in the ICU dropped to virtually zero. Unfortunately, this improvement didn’t last very long: soon the doctors forgot about the protocol!
So, Toussaint knew that he needed an improvement program like the Toyota Production System, which prevents relapsing into old habits.  In the beginning of this century, a team of nurses, doctors and managers from ThedaCare studied the TPS at Ariens, a manufacturer of snow blowers. Their surprising experience: These blowers were sometimes better threated then patients!

The staff of ThedaCare participates in event weeks
The staff of ThedaCare participates in event weeks, to engage them in process improvement. Here, a metrics board is prepared for real-time trials.

Patient-focused and evidence-based

Next it was decided to implement the TPS – of course adjusted to the needs of a healthcare environment - within ThedaCare. The most important changes and principles which are the result are summarized below. The list is based on (1) a webinar given by John Toussaint and Roger Gerard on September 6th 2010, mediated by LEI,  (2) the book On the Mend, and (3) several interviews with Toussaint I read.

  • A shift to a patient-focused approach. Physicians, nurses and administrators no longer concentrate on what works best for them. Instead, care is designed around the patients. (you can easily imagine how this was copied from the way snow blowers are assembled - with high throughput -  in U-shaped work cells at Ariens) 

  • Identify value streams when treating patients, and redesign those treatments by deviding them into ‘product families’.  Next, focus on minimizing time and reducing waste.

  • Show respect and be humble as a manager, and empower your staff (nurses and doctors)  

  • Standardize to sustain the improvements. This means science comes before art, or, in other words, evidence-based medicine. An already mentioned example is the protocol for the recipes of the glucose solutions. However, within ThedaCare not only the work of doctors and nurses is standardized, but also – and that is something special - the work of the managers!. The way they go to their Gemba (working place, in this case the ward) and investigate problems there, is more or less laid down in a protocol.

  • Make results measurable, but dismantle at the same time the shame and blame culture. Introduce visual management so that problems can be identified quickly.  Focus should be on the quality delivered (how much value is added for patients) and not on quantity (number of interventions), as many insurance companies do today.

  • Do not simply improve everything, but introduce focused improvement by applying Hoshin Kanri and A3 Management.

Introducing Lean means transforming processes ánd people. The last part is often the hardest, therefore a well-known Lean-slogan is make people before products. Because of the importance of the human factor, it is interesting that John Toussaint and Roger Gerard concentrated on this aspect during the webinar I already mentioned.

Respect for people
‘The prevailing health management system is based on an autocratic mindset’, says Toussaint. ‘It does not engage front line staff in identifying waste and improving processes. White coat leadership - all knowing, controlling, autocratic, impatient and blaming - should therefore be replaced by improvement leadership: knowledgeable, being patient, facilitating, guiding and helping.

The two pillars of the Toyota Way are continuous improvement and respect for people, stresses Toussaint. Regarding the last pillar, he suggests that healthcare managers should test their approach by asking themselves the following three questions every day:

  1. Are my staff, the doctors en nurses, treated with dignity and respect by everyone in our organization?
  2. Do they receive training and encouragement to do work that gives their life meaning?
  3. Have I recognized them for what they do?

What's in it for me?
‘One of our biggest mistakes was, that we didn’t answer the question: What’s in it for me, I mean for our doctors and nurses’, Toussaint continuous. ‘As a result, the goal to reduce waste was sometimes thrown over the wall, and ended on their plate. Instead, you should concentrate on fixing their biggest problems, improve their daily work experience. Removing waste can also mean that for example less telephone calls are needed.’

When ThedaCare started to fulfill the needs of the patients and their staff during their improvement efforts, employee satisfaction rose from 4,5 in 2006 to 5,0 in 2009 on a 6 points scale.

Standardizing work
Every Lean manager knows that standardizing work is crucial for continuous improvement. Whenever a better process is identified this becomes the new standard, and then a new improvement cycle can start.   

Toussaint however adds something new to this: standardized work in some degree for everyone, including management!  ‘This is critical and must be in place for improvement to occur’, he says.

Are they not overdoing it within ThedaCare, regarding standardization?, I ask myself. I mean, is it for example possible to have a protocol for Going to the Gemba? It is an intriguing question. For Lean management it is necessary that managers visit their working place or Gemba very often, to check for abnormalities by picking up visual management signals, and to investigate if the people have difficulties doing their work. Workers are therefore encouraged to report problems, for example by placing notes on a wall. Next, managers should help to find solutions, by mapping the problems and possible solutions visually on a large piece of paper and checking what the reaction is on the Gemba. This process is called A3 Management.

Such a method could be standardized, and I agree that it should. However, in the book On the Mend there are even takt times coupled to visiting the Gemba.  In my opinion, this pushes the idea of standardization too far. It seems an impossible job, to find for example the root cause of a problem in a standard amount of time. Even only mapping problems cannot be done within a certain time frame I think, since a lot of communication is needed for that, which is intrinsically a chaotic process.

An event week group studies the layout of a work unit
An event week group studies the layout of a work unit, and plans to move things around to facilitate a more effective, waste-free process.

Dirty hands
The webinar continuous with a lecture by Roger Gerard, ThedaCare’s chief learning officer. ‘Lean can only be learnt by taking risks, and therefore by making many mistakes, one at a time’, he says. ‘So, training does not come first, but doing. Lean is dirty hands learning’.
What Gerard describes here reminds me of the book The Birth of Lean. That book is a bundle of interviews with the people who developed the Toyota Production System, like Taiichi Ohno. What you can learn from them, is that TPS was developed by trail-and-error.

Gerard continuous his presentation by describing a change management process in five steps:

  • Initiation/Awareness/Informing.

  • Reality Testing.  In this phase people are enthusiastic, but that is only pseudo-commitment as ThedaCare learnt the hard way!

  • Resistance: People ask you to slowdown, they often say this is not what they expected, or that the old way of doing things is better.

  • Dialogue phase / Seeking for a Compromise.

  • Integration: lock in and standardize.

‘The dialogue phase usually takes five times longer than you want’, warns Gerard. ‘This phase is all about emotions, and feelings you can’t cope with logic.’ 

According to Gerard, the percentage of employees that understands how their daily work at ThedaCare contributes to the mission rose from 77.9% in 2008 to 80,8% in 2010.

This makes me wonder how that is measured, and second: what do the rest of people (20%) think they are doing? Gerard pursues to some of my comments in the box below.

Roger A. Gerard, PhDRoger Gerard pursues to some of the comments in this article
Go to the Gemba to learn!

Gerard  [about standardizing Going to the Gemba]:
‘We have put quite a bit of standardization to the process of Going to the Gemba.  Early on, we noticed that, when managers went to their Gemba, they had a strong instinct to communicate what they saw in the moment, to ask targeted questions leading to problems that were inherent in the work, and to dispense advice and admonition.  However, all of this was intimidating to the medical staff.  We had to teach our managers that their role in going to gemba was to learn.  Teaching should only be done through Socratic questioning.  [This means for example: a manager helps the medical staff to solve their own problems by making clear where there is waste in a process, which helps them to think clearly, red. ]
'We had to put a bit of standardization to the process [of learning and asking Socratic questions], to ensure that this pattern held over time.’

Gerard  [about the way in which employee engagement is measured]:
‘We measure employee engagement annually, through a survey process designed and conducted by the Advisory Board, out of Washington DC.  This survey includes 60+ indicators, two of which we track very closely, due to their power to predict engagement based on our statistical analysis.  These two indicators focus on whether people really know what is expected of them, and whether they feel they make a difference in their work.' 

'These are the two indicators that I displayed in the Webinar.  But they are two among many, and overall, we are seeing the entire engagement index showing some substantial improvement in those areas where we have applied the ThedaCare Improvement System in a robust way.’

Intriguingly, although the number of people who understand how they contribute to ThedaCare’s mission increased, the percentage who thinks that their ideas are valued fell by 3,4% in the same period. The current percentage is 46,0%. ‘We think this unexpected result is because their expectations did increase in a lean environment’, says Gerard.

Employer of choice
To develop Lean leaders, ThedaCare evolved an ambitious human development value stream, with the goal of being an employer of choice and to create leaders with all the capabilities to drive continuous improvement.

Gerard shares a number of interesting one-liners with us, like One man’s silo is another man’s value stream, and the one that I like best: The fastest way to create pull for something is to tell them they can’t have it. That sounds as an idea that is worth to try out. Imagine that you visit a ward, telling them that the Lean achievements of another ward are impossible there…

Gerard concludes by stressing that patience is the key for a lean transformation. ‘Hatch the egg, don’t smash it!’

1) See also: Toyota returns to its roots after recalls

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