Lean: The Best Medicine

Thursday, April 19, 2012

ONLINE EXCLUSIVE: Lean: The Best Medicine
Wisconsin Health Care System Transforms Using Lean Strategies
Adam Madison

  Dr. John Toussaint has written a series of books including Potent Medicine, which provides the framework for health care system transformations using lean principles.

While costs of health care plans continue to rise for those lucky enough to have them, the quality of that care is at an all-time low. Patients lose entire days being ushered through the system. When tests are administered, it can take days to hear the results. And when the results bring scary news, too often patients are forced to blindly entrust their fates with practitioners with cloudy backgrounds. 

Dr. John Toussaint, MD, recognized this and has made it his passion to reverse the stigma, using strategies very familiar to the manufacturing world. Between 2000 and 2008, he served as president and CEO for a Wisconsin-based network of hospitals and health care systems called ThedaCare, which is unique for employing the lean strategies developed by Toyota Motor Corp. 

Time is Money and Lives
The first step to applying lean was to identify the value stream. In identifying those steps, ThedaCare discovered that no resource was more squandered than time. Usually it was the patient’s time lost in cramped and lonely office spaces, as they waited to talk to members of the medical team one-by-one and answer the same questions again and again.

Toussaint said the leaner approach was to bring together the essential parties to meet the patient simultaneously. With everyone in one room, the experts are free to collaborate, and the patient only needs to tell his or her story once. This minimizes miscommunication between specialists. Files are reviewed the night before, so the needles, plastic cups and X-ray machines are ready when the patient arrives.

Toussaint promises less than five minutes in the waiting room and says test results are ready within 15 minutes via electronic health records. And if patients want to see the doctor that day, they can. Before, patients had to wait to hear results over the phone. Sometimes it would take days to connect with the patient. That’s a problem when a test has abnormal results.

“We get tests with immediate results for immediate treatment,” Toussaint said. “By reducing the amount of waiting, you have taken the waste out, and the customer is much happier.”

In 2011, 99 percent of patients of ThedaCare rated their service as 5 on a scale of 1-5. Health Affairs journalreported a 25-percent reduction in cost for the patient in the health care network. What ThedaCare describes as “collaborative care” also has been effective in bringing in more customers, Toussaint said.

Too Many Hands Weaken the Heart
ThedaCare also reduced door-to-balloon time for heart-attack victims from 90 to 37 minutes. This time is critical because heart muscles die while arteries are clogged. In some instances, time in the emergency room can be eliminated completely. It’s a matter of educating and empowering the right people, Toussaint said. If the diagnosis can be made in the ambulance, the heart-attack victim can be delivered straight to the table for treatment. Before, patients were seen by paramedics, then the emergency room doctor and, finally, a cardiologist before a treatment was prescribed. Ninety minutes is too long for a heart that has stopped beating.

Fear is Toxic
Another lean fundamental Toussaint brought to ThedaCare was an environment free of fear, so employees could openly discuss the state of the system. This is not present in health care today, Toussaint said. Working with a team of nurses, he discovered that ThedaCare’s rate of medication errors was much higher than what was actually reported. The barrier was fear of termination. Although he could never document an actual case of a nurse being fired for a medication error, he said, “Perception is reality.”

Toussaint immediately promised the staff that no one would be terminated for making an error, and the acting CEO was present to reinforce that message. Also, the method for reporting such errors has been changed from a 15-screen process to one. Now, neither time nor anxiety stands in the way of finding solutions.

Transparency is Key
Other reports already are making their way to the public. Wisconsin Collaborative for Healthcare Quality regularly reports quality data that is maintained by the Wisconsin Hospital Association. Pages of charted statistics are made available, such as the percentage of patients who have had heart attacks and are administered aspirin upon arrival. Toussaint said the page is not entirely patient-friendly, but it is a step in the right direction.

Toussaint would like to see full disclosure of such reports to the public. For example, prospective clients should know the rate of infections among competing knee surgeons. He predicted that in the next few years, very specific data regarding doctor performance would be available. When patients have the ability to exercise informed decisions, the medical industry will have no choice but to improve. Manufacturers can then celebrate affordable health plans for employees and rejoice in being part of the solution.(, attribute to Toussaint?)

Read the Books
The Lean-driven transformation of the ThedaCare System is well documented in two books written by Dr. John Toussaint, On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry and Potent Medicine: The Collaborative Cure for Healthcare.

On the Mend, co-written with Roger A. Gerard, PhD, describes the triumphs and stumbles of the seven-year journey to transform the five-hospital health care system in northeastern Wisconsin. It’s a continued effort that already has reduced medical errors, improved patient outcomes, raised staff morale and saved more than $27 million. On the Mend recently earned the Shingo Research Award, an annual prize recognizing operational excellence that is part of Jon M. Huntsman School of Business at Utah State University.  

The follow-up book, Potent Medicine, offers practical advice and revolves around three core elements: delivery of care designed around the patient, transparency of treatment quality and cost, and payment for outcomes. These books have been described as manifestos, providing the framework for system transformations using lean principals. Toussaint says his first book is akin to Jim Womack’s Lean Thinking.

“Lean health care exemplifies operational excellence and value for our patients, in terms of quality over cost,” Toussaint said.

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