How To Manage In A Lean Environment And Link Organizational …fall2012.medaxiom.com/images/SOBAL_Integrated_BPS.pptx.pdf · 2012-10-03 · need to stay balanced and keep our ...

Larry Sobal – ThedaCare System Vice President of Cancer and Cardiovascular Services

How To Manage In A Lean Environment And Link

Organizational Strategy To Continuous Daily

Improvement

October 4, 2012

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Focus Of Today’s Presentation •  Who is ThedaCare? •  Context – Strategy Deployment and

True North Metrics •  Who is “Lori”? •  Background – What triggered the creation

of BPS? •  Mechanics – How does BPS work? •  Deliverables – Examples of BPS in action

in various CV settings •  Where to go if you want

more information?

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Is a comprehensive, community-owned healthcare system focused on achieving measurable, better value for our customers. Our mission is to

improve the health of our communities.

Appleton Medical Center

160-Bed Acute Care Medical Center

ThedaCare Physicians

Employing Over 125 Physicians At 22 Locations

Ingenuity First Offers Innovative

Solutions to Employers For Health Care Costs

Gold Cross Ambulance Service Jointly Owned With

Affinity Health Systems

Theda Clark Medical Center


New London Family Medical Center


Riverside Medical Center


ThedaCare at Home Home Health, Hospice,

DME, Respiratory Therapy, Infusion, Pharmacy Services

Shawano Medical Center


Orthopedics Plus The New Standard for Quick, High Quality Orthopedic Services In The Fox Cities

The Heritage/ Peabody Manor Continuing Care Campus for Older

Adults

ThedaCare Behavioral Health

Inpt and Outpt Mental Health, Substance

Abuse Services

Fox Cities Community Clinic A Free Clinic Jointly

Owned With St. Elizabeth Hospital

CV Division

ThedaCare at Work Occupational and Employee Health

Services, Employee Assistance Program

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Continual Improvement

In Community

Health

Leadership in

Healthcare Value

Prudent Financial Oversight

Access to Coordinated

Care

ThedaCare’s Owner Expecta2ons

Better Health at Lower

Cost Than Other

Communities

5

What Are True North Metrics? •  True North Metrics: Establishes measures

of our organizational health and provides our focus for improvement

•  Five Areas of Focus: Safety, Quality, Customer Loyalty, People, and Financial Stewardship

•  Triangle: Our True North Metrics are built around a triangle to visually emphasize the need to stay balanced and keep our customers in the center of what we do

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ThedaCare True North Metrics Safety • System Patient Safety

Bundle • D.A.R.T

Quality • Preventable Mortality •  30 Day Readmission

People • Engagement Index • Health Assessment

Score

Financial Stewardship • Operating Margin • Productivity

Customer “Lori”

• Net Promoter Score

&

7

What Lori Wants - Key Drivers Key Drivers: First tier attributes are most actionable across the ThedaCare system. These attributes are consistently rated by customers (Lori) as most important and have strong impact on customer loyalty. They are also core to our system strategy.

Attributes Description

Listening: My care team/providers listened carefully to me

Care planning with my input:

My care team/providers delivered a care plan designed with my input

Appointments on my terms: I was able to see my provider at a time that worked well for me and it was when I wanted to be seen

Understanding provider roles:

I understood the role played by each of the care team/providers involved in my care

Working to lower costs: My care team/providers worked hard to reduce out-of-pocket costs

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We Want To Create Connection and Engagement

9

Creating Alignment at ThedaCare 1.  Strategy: Our True North Metrics 2.  Deployment of Strategy: through A3’s and

Value Streams 3.  Continuous Improvement through the

Business Performance System

10

History - ThedaCare’s Lean Journey Began In 2004

Value Stream Analysis

Rapid Improvement

Events Action Plans

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“While There Were Clear Successes ThedaCare Was Hitting A Wall In Lean Implementation"

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It become apparent there was a gap between Value Stream-based Improvement Event work and how we were managing in a Lean Culture •  “Like pouring new wine into

old skins” •  “The ultimate arrogance is to

change the way people work but not to change the way we manage.”

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Call for Action We were on a continuous improvement cultural transformation, but current systems for managing the business were not in alignment with new expectations. •  No one way to manage •  Uncertainty on how to measure performance •  The right information was not being escalated

for leadership to help •  Leadership intervention was “clunky”

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Hypothesis Problem Root

Cause Countermeasure

We were not consistently performing in all aspects of necessary organizational improvement

Lack of standard manage-ment systems and processes

IF: We create a business management system THEN: Managers will understand performance, know the problems affecting it, and respond to problems in a timely manner IF: We create tiers of progression THEN: We can developmentally coach through the management system and managers will have clear performance expectations IF: We create standard work to support each piece of the system THEN: We will have consistent management expectations across divisions and for each level of leadership IF: Our management system employs the performance criteria from the Human Development Value Stream THEN: We will have a balanced approach to leadership development

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What Emerged Was BPS The Business Performance System- how to connect Strategy to daily Continuous Improvement

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The Foundations of the Business Performance System 1.  Leader Standard Work at all levels 2.  Visual Tracking Of Key Drivers 3.  Consistent Processes for Problem Solving ,

Corrective Action and Escalation of key information

4.  Leadership Development 5.  Leadership Discipline

-and-

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Emphasis on Teaching and Coaching as an EXECUTIVE Responsibility

Desired Leadership Behaviors: ü Dirty hands ü Know the tools ü Develop People

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Ideal State Information Flow Staff Staff Staff

Lead

CEO

VP

Sr VP

Super- visor

Level 1

Vision Goals Purpose ü Mentoring ü Teaching ü Barrier Removal ü Strategy ü True North

Status of the Business: ü Continuous Improvement Opportunities ü Metrics ü Escalation

Manager

Level 2

Level 3

Level 4

Level 5

Level 6

Level 7

Staff’s Role: ü Continuous Improvement ü Daily assessment ü 50-75% Standard Work

Leadership’s Role: ü Strategy ü Coaching ü Weekly/Monthly Assessment ü 10-25% Standard Work

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The Business Performance System

Daily Stat Sheet

Daily Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

Review Meeting

PDSA and

Countermeasures

Leader Standard

Work

Visual Management

Unit Flow Waste Removal

Sustaining Improvement

Thru Training

and Managing to SW

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Where do we begin ? Learning and

Understanding the Business

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“The No Meeting Zone” 8am – 10am

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Daily Stat Sheet

Daily Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

Review Meeting

PDSA and

Countermeasures

Leader Standard

Work

Visual Management



Thru Training

and Managing to SW

23

The Daily Stat Sheet Learning and

Understanding the Business

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Cultural Transformation Leaders need to rely on their daily stat sheet to understand what they need to know to run their business

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Ex: Cardiology Practice Daily Stats –  Tell me about any safety risks patients/staff/family

today? –  Tell me about medications – Any near misses with our

patients? –  Are there any incident reports to discuss? –  What is a potential quality problem for today? –  Tell me how me how we are doing on our key metrics? –  Do you have all the resources you need to do your job

today? –  Who is going to need the most support today? –  Are all the charts prepped for today’s

clinic visits?

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Ex: Cardiology Practice Daily Stats –  Who or what should we celebrate or recognize today?

How? –  What might be show stoppers for our

customers today? –  Who has openings for New or Return visits today? –  What is our planned number of office visits today? –  Who is absent or tardy? Who is over their FTE

for the week? –  How many people missed lunched yesterday?

What are are we doing to avoid that today? –  Are there any patients or procedures that

might be a good media opportunity?

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Daily Stat Sheet

Daily Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

Review Meeting

PDSA and

Countermeasures

Leader Standard

Work

Visual Management



Thru Training

and Managing to SW

28

Daily Huddles Use The Stat Sheet As The Basis For Daily

Review of Operational Performance And

Identification Of Improvement Opportunities

Daily Problem Solving in Gemba

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Cardiology Practice Daily Huddle

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Improvement Ideas Are Captured In A Standard Way

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Daily Stat Sheet

Daily Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

Review Meeting

PDSA and

Countermeasures

Leader Standard

Work

Visual Management



Thru Training

and Managing to SW

32

The Leadership Team The support to see

performance, understand problems

and implement responses

33

Cultural Transformation

The Entire Leadership Team Owns the performance of the

business, not just a single leader

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Ex: Leadership “Team” For Cardiology Practice Metric Review •  Practice Manager •  Lead RN •  Lead MA •  Supervisor: Scheduling/Call Center •  EPIC Optimizer •  Financial Analyst

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Daily Stat Sheet

Daily Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

Review Meeting

PDSA and

Countermeasures

Leader Standard

Work

Visual Management



Thru Training

and Managing to SW

36

The Monthly Scorecard

“Knowing our Numbers”

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Cultural Transformation The monthly scorecard reports the stability, trends and overall

performance of the business unit,

putting the FOCUS on the Driver Metrics !

38


Daily Stat Sheet

Daily Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

Review Meeting

PDSA and

Countermeasures

Leader Standard

Work

Visual Management



Thru Training

and Managing to SW

39

The Monthly Performance

Review Meetings

40

System Leadership Team

True North Metrics

System Leadership Team Monthly Performance Review

Monthly Performance Communication Diagram Leadership Teams, Monthly Scorecards and Monthly Performance

Reviews

Vice President Leadership Team

Vice President Leadership Team Monthly Performance Review

… Repeat for each VP

VP Drivers

Manager Leadership Team

Manager Leadership Team Monthly Performance Review

Mgr

… Repeat for each Manager

Business Unit Drivers

4th or 5th Business

Day

6th or 8th Business

Day

3rd Week of the month

Lessons Learned Shared Stratification of Red Metrics

Lessons Learned Shared Stratification of Red Metrics

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Ex: My Leadership “Team” For CV Business Line Monthly Review •  CV Director* •  Practice Manager – Cardiology/CV Surgery* •  CV Invasive Services Manager •  CV Diagnostics Manager •  Supervisor Scheduling/Call Center •  Inpatient CV Manager •  CV Value Stream Manager* •  System Business Line Marketing Manager •  System Finance VP •  CV imbedded LEAN facilitator

CV Division North Metrics Safety • CV Inpatient

Complication Rate

Quality • CHF and AMI 30 Day

Readmission rate • AMI Compliance Bundle • Pioneer ACO metrics

People • CV employees Health

Assessment Score • CV employees

Engagement Score

Financial Stewardship • CV Cost Per Unit Of Service • CV Productivity • CV Market Share

Customer “Lori”

• Net Promoter Score • CGCHAPS (practice)

• HCAPS (inpatient)

&

43

CV Division North Metrics Safety • CV Inpatient

Complication Rate

Quality • CHF and AMI 30 Day

Readmission rate • AMI Compliance Bundle • Pioneer ACO metrics

People • CV employees Health

Assessment Score • CV employees

Engagement Score

Financial Stewardship • CV Cost Per Unit Of Service • CV Productivity • CV Market Share

Customer “Lori”

• Net Promoter Score • CGCHAPS (practice)

• HCAPS (inpatient)

&

44

CV Division Monthly Watch Indicators Watch Indicators: The Performance we are watching and may only respond to if the metric is changed to a DRIVER. COLOR BOTH THE MONTH AND YEAR To Date RED OR GREEN

Category of Measure Source TN, SD,

HD, HI HW Watch Indicators Owner

Target or Trigger (only if there is

one) Previous Year or

Baseline Estimated

Completion Date Jan Feb Mar Jun Jul Aug Sept Oct Nov Dec YTD Avg YTD % Change vs.

Baseline)

Direction of Metric UP or

DOWN

Safety/Quality TN HF order set utilization (Admit) Dan 80.0% 0.0% 12/31/2012 Plan > 65.0% 65.0% 65.0% 70.0% 70.0% 75.0% 75.0% 80.0% up Actual > 22.2% 61.5% 24.0% 40.7% 34.2%

Safety/Quality TN HF order set utilization (Discharge) Dan 20.0% 0.0% 12/31/2012 Plan > 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% up Actual > 0.0% 0.0% 0.0% 0.0% 32.0% 44.4% 12.7%

Safety/Quality TN Diabetic BP <= 130/80 Dan 65.0% 5.0% 12/31/2012 Plan > 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% up Actual > 58.1% 57.7% 57.3% 59.1% 59.7% 60.3% 57.7%

Safety/Quality TN Hand-off Communication Pam 95% 65% 12/31/2012 Plan > 95 95 95 95 95 95 95 95 95 95 95 95.0% up Actual > 56 71 82 99 76.5%

Safety/Quality TN Chart prep 3 days Tom 93% 12/31/2012 Plan > 93.0% up Actual > 79.0% 80.0%

Safety/Quality TN Decrease 30 day readmits for HF Dan 11.7% 18.0% 12/31/2012 Plan > 11.70% 11.70% 11.70% 11.70% 11.70% 11.70% 11.70% 11.70% 11.70% 11.70% 11.70% down Actual > 15.63% 5.71% 25.71% 24.00% 17.90% 16.19%

People TN AMI bundle Dan 100.0% 18.0% 12/31/2012 Plan > 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% up Actual > 95.0% 97.0% 100.0% 100.0% 96.7% 95.8%

People TN Improve Emploiyee Engagement Tom 12/31/2012 Plan > up Actual >

People TN Improve Emploiyee Engagement Mike 12/31/2012 Plan > down Actual > 98.0%

People TN Improve Emploiyee Engagement Pam 83% 83.4% 12/31/2012 Plan > 83 83 83 83 83 83 83 83 83.0% up Actual >

People TN Increase provider engagement in HF events Dan 12/31/2012 Plan > up Actual >

People TN 12/31/2012 Plan > up Actual >

Customer Satisfaction TN CTO cases scheduled accurately to template Mike 80.0% 12/31/2012 Plan > 80.0% 80.0% 80.0% 80.0%

up

Actual > 100.0% 50.0% 75.0% 0.0%

Customer Satisfaction TN 1st available NP slot 3 days out Pam 3.0 12/31/2012 Plan > 3.0 3.0 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00

down

Actual > 7.60 10.10 13.90

Customer Satisfaction TN Press Ganey Dan 12/31/2012 Plan > 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

up

Actual > 90.0% 90.0%

Customer Satisfaction TN 12/31/2012 Plan >

up

Actual >

Customer Satisfaction TN 12/31/2012 Plan > up Actual >

Customer Satisfaction TN 12/31/2012 Plan >

down

Actual >

Financial Stewardship TN Decrease cost per case for HF (AMC) Dan

12/31/2012 Plan > $8,191.14 $8,191.14 $8,191.14 $8,191.14 $8,191.14 $8,191.14 $8,191.14 $8,191.14 $8,191.14 $8,191.14 $8,191.14 down Actual > $3,297.00 $7,263.00 $2,925.00 $4,172.20

Financial Stewardship TN Reduce the number of no Shows in cardiac rehab Hedy 10/mo 22/mo 12/31/2012 Plan > 10 10 10 10 10 10 10 10 10 10 down Actual > 25 8 12 20 25

Financial Stewardship TN Expense/UOS Mike 12/31/2012 Plan > $1,387.30 $1,387.30 $1,387.30 $1,387.30 $1,387.30 $1,387.30 down Actual > $1,302.70 $1,320.60 $1,482.20 $1,148.40 $1,518.00

Financial Stewardship TN Productivity for Device Clinic Pam 1.67 1.72 12/31/2012 Plan > 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 down Actual > 1.59 1.72 1.63

Financial Stewardship TN Productive hours/UOS Mike 12/31/2012 Plan > 4.50 4.50 4.50 4.40 4.40 4.40 down Actual > 4.20 4.50 4.60 4.20 5.60

Financial Stewardship TN Clinical Staff Hours for 4501 Pam 4663.00 4523.11 12/31/2012 Plan > 4,523.11 4,523.11 4,523.11 4,523.11 4,523.11 4,523.11 4,523.11 4,523.11 4,523.11 4,523.11 4,523.11 4523.11 down Actual > 4,158.00 4,663.80 4,494.50 4409.5

Financial Stewardship TN Plan > 0.95 0.95 down Actual > 1.00 0.97

Financial Stewardship TN Productivity Tom 6.72 6.93 12/31/2012 Plan > 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 6.72 down Actual > 6.76 6.76 6.42

Financial Stewardship TN Expense/UOS Tom 12/31/2012 Plan > down Actual >

45


Daily Stat Sheet

Daily Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

Review Meeting

PDSA and

Countermeasures

Leader Standard

Work

Visual Management



Thru Training

and Managing to SW

46

PDSA Problem Solving And Countermeasure

Summary

47

The Countermeasure Summary

• Are you meeting target, improving, consistent?

• What is your stratification telling you?

• What are the top contributors to the problem? (and how did you find them?)

• What will you do in the next 30 days to improve performance?

Please answer the following questions

48


Daily Stat Sheet

Daily Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

Review Meeting

PDSA and

Countermeasures

Leader Standard

Work

Visual Management



Thru Training

and Managing to SW

49

Leadership Standard Work

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To Reduce Variation and Drive Improvement: Standard Work is The Glue that holds it all together •  Is there Standard Work? •  Have you trained

to the Standard Work? •  Is the Standard Work

being followed? •  Are we managing to SW? •  Is there a process

to improve SW ?

51

Ex: Manager Morning Standard Work – Daily Stat Sheet 8-8:30 am: §  Update stat sheet with Supervisor §  Remove barriers-escalate when appropriate

52

Ex: Manager Morning Standard Work – Defect Huddle 8:30-8:45 am: (See huddle SW) §  Identify defects §  Create assignments §  Establish daily priorities with the team §  Establish the discipline of daily follow through

as a team

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Ex: Manager Morning Standard Work – Go To Gemba 9:15-10:00 am:

•  Understand the work of the day •  Communication •  Coaching/Mentoring •  Audit: Use SW process to audit priority work •  Problem Solving: Managing improvement

related to capacity and flow

54


Daily Stat Sheet

Daily Huddle

Leadership Team

Monthly Scorecard

Monthly Performance

Review Meeting

PDSA and

Countermeasures

Leader Standard

Work

Visual Management



Thru

Training and Managing to SW

55

Visual Management

56

Process Map

57

Leader Metric Wall

58

CV Inpatient Unit Target Improvement List

59

Diagnostic Metric Room

60

Key Processes (i.e. standard work) are regularly selected for review at daily huddles

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Standard Work Observation Calendar

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How we teach the BPS system

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Business Performance System Deliverables •  Daily Stat Sheet •  Leadership Team •  Monthly Scorecard •  Monthly

Performance Review Meetings

•  Standard Work Calendar

•  PDSA (A3) tool •  Visual tracking and

escalation •  Lead and Supervisor

Standard Work •  Observing/Managing

to Standard Work

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If You Want To Learn More… 1.  Type “ThedaCare BPS” in google. One resource will

be an extensive article describing BPS in the Sept 2011 issue of the Joint Commission Journal On Quality And Patient Safety

2.  The past CEO of ThedaCare, John Toussaint, has written a book about ThedaCare’s LEAN journey:

3.  The ThedaCare Center For Healthcare Value offers one and a half day learning sessions to visit ThedaCare and see this work in action. Go to:

www.createvalue.org/delivery/ceo-site-visits/

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No Blaming Allowed!

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Questions?

How To Manage In A Lean Environment And Link Organizational …fall2012.medaxiom.com/images/SOBAL_Integrated_BPS.pptx.pdf · 2012-10-03 · need to stay balanced and keep our ...

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