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Wednesday, May 21, 2014

Just DO it.

Yes, there's a lot about the U.S. healthcare "system" comprising legitimate targets for criticism, complaining, and outrage. We all know that. Crappy, workflow-inimical, silo'd Health IT, intractable reimbursement system misalignments, maddening "government mandates," looming provider shortages, and on and on and on...

I started blogging about the issues back in 2009. See, e.g., my post The U.S. health care policy morass

But, given that we go to Rumsfeldian healthcare delivery "war" every day with the healthcare system we have, and not the one we'd like to have, it helps to give close study to the folks out there who are leading the way --  doing rather than bitching.

I just finished this book.

This is the 3rd book release I've studied from the ThedaCare Center for Healthcare Value, following these prior two:

The reference to "heroes" goes to the notion of the valiant, adroit "firefighters" who repeatedly have to drop in to save the day in the dysfunctional healthcare delivery system. I call them "Quadrant One" people, those called upon to deal with the seemingly never-ending, chaotic "Important and Urgent."

The layout of "Beyond Heroes."
Over the next eight chapters, we will examine each of the elements of our business performance system in detail, since all have been critical in helping us to create a business performance system that is transforming ThedaCare.

Here, I would like to draw a big picture, describing how each element links to the others to create a system, not just a pile of discrete tasks. Think of this as the engineering drawings, showing the bare structure of ThedaCare’s business performance system and how the elements become interlocking gears.
1. Status Reports. At ThedaCare, we call this a stat sheet meeting, and it is the most transformative element in our system. Short for “status of the business,” this conversation, usually between a manager and a supervisor or clinical lead, begins with a series of standardized questions on a single sheet of paper intended to provoke a dialogue about improvement opportunities and roadblocks. This daily, focused discussion about the business, taking place hundreds of times each day with different players all over our hospitals, is the cornerstone of our business performance system. This is about preparedness, about planning our days instead of firefighting our way through them.

2. Team Huddle. Every day, every leader gathers his or her team members into a huddle to widen the conversation about opportunities for improvement, roadblocks, and ongoing projects. This is where we teach and practice standardized problem solving using A3s and the plan-do-study-act cycle and then employ these tools to work through issues and improvements.

3. Managing to the Established Standard. This is the discipline of auditing standard work for both clinical and leadership processes in order to keep it from changing or falling to the wayside. By auditing or observing standard work, we also work to spread best practices. It is difficult to maintain any standardized process, clinical or administrative, so auditing must be hardwired into the business performance system and every manager’s day. This is where we emphasize that standard work is not a weapon or critique but is the best currently known way to do the work. Standard work is the best practice, and auditing or observing the work is a method for teaching and coaching.

4. Problem Solving. We used the A3 or PDSA (plan-do-study-act) as our guide to problem solving with the scientific method. But these tools are as much about mentoring the team on ways to solve problems as they are about finding the best countermeasures for a specific problem.

5. Transparency. A visual workplace— where area defects are as visible as team accomplishments— is difficult to establish, but it is the way we keep everyone focused on reality while looking for new opportunity.

6. Advisory Teams. For every manager we created a board-of-directors-style team of advisors to help fill in gaps in the manager’s areas of expertise and provide fresh perspectives. Advisors might be from finance, human resources, or pharmacy and are responsible for the overall performance of drivers in that area. At ThedaCare, drivers refer to the targets or goals on an area’s scorecard that lead much of the work of improvement teams. Every unit, clinic, or area has drivers that are tied to the organization’s main goals. In general, each advisor on the team “owns” one of the area’s drivers and is responsible for understanding problems that affect performance toward the goal. Advisors may come from inside or outside the manager’s area.

7. Scorecard. Every manager had a monthly scorecard developed and maintained by the advisory team to help keep track of progress against drivers. The scorecard’s vital few metrics help us focus deeply to solve problems and improve performance.

8. Leadership Standard Work. This is the most effective weapon available against heroics. When a supervisor, manager, or executive adopts standard work, she promises to be reliable and accountable to her team. Standard work tells the team where a manager will be and when, what questions she will ask and when she will be available to work through issues. According to Toyota, work is standardized when the precise elements of the job are done the same way every time and at a repeatable cycle time. Our stat sheet conversations and huddles are not as precisely timed or repeatable as a mechanized process, so maybe it is more correct to say that our standard work is more like a fixed schedule of activities. We are, however, still evolving, and our goal is a repeatable, reliable system of managing for improvement.
Here is how it all fits together. We use stat sheets to see the business, plan our day, and see the trends developing. We widen the conversation with the team huddle, where we look for trends in performance and use standards to find the gaps between our goals and our performance. This leads directly to problem solving and using the scientific method to close the gaps. Information gathered in huddles and problem solving is then published to the area improvement center— whether that is in an outpatient clinic, an inpatient unit, or a finance office— allowing for transparency so that everyone can monitor progress. The advisory team gathers around the area improvement centers to monitor progress and advise the leader, who monitors the team’s performance through the monthly scorecard. Standard work at all levels ensures that everyone stays on track and that we have a measurable norm for leadership performance.
Reduced to seven words, these elements add up to developing people, solving problems, and improving performance...
Barnas, Kim (2014-05-09). Beyond Heroes: A Lean Management System for Healthcare (Kindle Locations 523-568). ThedaCare Center for Healthcare Value. Kindle Edition.
They're doing ACO. They use Epic. They consistently hit high on HEDIS. They have to comply with all of the regulations and clinical reporting measures that bedevil everyone else.

They're obviously doing something right. This book and the other two antecedent works I cited will give you a good idea of precisely what. Imagine going to work every day within an organization where an ongoing priority for everyone is scientifically improving the work processes.


Highly recommended, if a bit pricey (that ticked me off somewhat). I bought the $35 hardcover straight away ("First Mover Disadvantage"), but it's now available on Amazon in $9.99 Kindle edition. Yeah, I bought that as well.

Concluding observations from "Beyond Heroes."
The future at our door
...Just a few decades ago, hospitals were the centers of catastrophe. We saw victims of sudden illness and accidents. We generally offered short courses of treatment that the patient either survived or did not. For lesser maladies people saw a family doctor and, even there, care was usually targeted at a particular complaint with a limited time horizon.

Now, we have entered into long-term relationships with our patients. Longevity is increasing. Diabetes, obesity, asthma, arthritis, and mental disorders such as depression and bipolar disease now call for regular, ongoing treatments that can last a lifetime. Many cancers are becoming chronic conditions, joining HIV/ AIDS as a disease we can live with for decades.

This means that much of healthcare will focus on helping patients to help themselves in managing and improving their lives. Out of absolute necessity, we will finally begin to focus— as an industry— on wellness instead of illness. We will pay more attention to the life needs of the patients, to keeping people independent and able to care for themselves well into old age. This will require new tools and more time and patience. We will spend more time counseling people on how, for instance, specific diets and exercise affect their chronic disease, and our information will be based on solid scientific evidence rather than fads. We will talk more about staying out of the exhausting cycle of hospitalization and recovery and less about what new, short-term treatments we can offer.

We will focus on patient wellness because it is the right thing to do and because we will be paid that way. In the near future, healthcare organizations will most likely receive a pool of funds to look after the healthcare needs of a population of patients, as I noted in the previous chapter. A number of experiments have been running around the United States and the value-based, or population-based, payment concept has emerged as the most likely method for controlling costs while improving patient outcomes and experiences.

Using this system, independent healthcare providers will be profitable only if they offer good care with a minimum of defects and waste. If patients in an organization’s population pool suffer from runaway obesity, asthma attacks that require hospitalization, and births complicated by a lack of prenatal care, that will cost the organization. A lot. That means we will see a major push by the healthcare industry to offer better preventive care.

Physicians and administrators will have a vested interest in knowing which tests and procedures are the most effective for patients, as opposed to the most billable. So how does this relate to the business performance system? Healthcare organizations that practice continuous improvement will have the advantage in this system because they are already accustomed to increasing profit margins by eliminating waste and creating more efficient processes. If medical group A investigates its treatment path for stroke victims and creates better outcomes by reducing the time it takes to administer clot-busting drugs, for instance, it will spend fewer resources on patient recovery time than group B and therefore earn a better profit margin and reputation. (This will also save the family and community from the costs and heartbreak associated with long-term care of a person who can no longer function at full capacity.) Saving money by offering better treatment also means a medical group could afford to attract the best providers and reinvest in its facilities and people...
One nice thing about the book is the way these Lean deployment principles, management strategies, and process improvement tactics are illustrated via the stories of individuals at work, doing their jobs and working to improve their jobs as a matter of course. It's a good, conversational read.


Recall my February 6th, 2014 review of this book? See Meaningful Use 2013 review, ONC Working Group Stage 3 draft report, and discussion of KP's book "Connected for Health"

Another bunch out there successfully doing.

The VA Scandal: Implications for Health Reform and a Call for Clinical Research into the Reported Death Rate

More to come...

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