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Successful Application of Lean
Thinking in the Health Care and
Education Sectors
Barbara Coniff
Lean Practitioner
ThedaCare, Inc.
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 Theda Clark New London Family Riverside
Medical Center Medical Center Medical Center Medical Center
160-Bed Acute Care 260-Bed Acute Care 25-Bed Acute Care 25-Bed Acute Care
Medical Center Medical Center Medical Center Medical Center
ThedaCare Orthopedics Plus ThedaCare at Home ThedaCare at Work
Physicians The New Standard for Home Health, Hospice, Occupational and
Employing Over Quick, High Quality DME, Respiratory Employee Health
118 Physicians Orthopedic Services Therapy, Infusion, Services, Employee
At 20 Locations In The Fox Cities Pharmacy Services Assistance Program
Ingenuity First Fox Cities The Heritage/ ThedaCare
Offers Innovative Community Clinic Peabody Manor Behavioral Health
Solutions to Employers A Free Clinic Jointly Continuing Care Inpt and Outpt Mental
For Health Care Costs Owned With Campus for Older Health, Substance
St. Elizabeth Hospital Adults Abuse Services
Gold Cross
Ambulance Service
Jointly Owned With
Affinity Health
Systems
July 2006
Mission
the reason we are together
―ThedaCare’s mission is to improve the
health of our communities‖
Vision
a picture of the ideal state to be achieved
―To always set and deliver the highest standard
of health care performance in measurable and visible
ways so our customers are confident they are
making the right decision in choosing us.‖
Shared Values
the internal compasses that guide our day-to-day
decisions; the glue that holds the organization together
Compassion Integrity
Courage Respect
Honesty Teamwork
Innovation
ThedaCare Goals
6/30/06
Quality Decrease Defects and Waiting
Time by 50% each year
Customer
Business Engagement
Increase Productivity 10% All staff and physicians
each year participate in 2 or more RIE’s
Industry/Process Defect Defects Per Million
Opportunities
Commercial Large Jet Travel Crash 3.4
Nuclear Industry Reactor malfunction 3.4
Blood Transfusion Wrong blood or patient 3.4
Anesthesiology (low risk patient) Death 3.4
Chemical Industry Spill 6,210
Road Safety Death 6,210
Heart Attack Care – 2005 performance 91% Not providing all 6 key 91,476
components of care
Heart Attack Care 2006 performance 94% Not providing all 6 key 54,000
components of care
Heart Attack Care – 2007 target - 95% Not providing all 6 key 28,500
components of care
Heart Failure Care - 2007 target – 95% Not providing all 4 key 44,600
components of care
Microlight Aircraft or Helicopters Crash 66,807
Incoming call to Physician Clinic Dropped call 96,800
dropped (10% abandon rate)
Himalayan Mountaineering Death 388,537
ThedaCare Improvement System
Model: Collaborative Care
A vision of hospital care with nursing at its center
A new model of inpatient care delivery based on:
• Change in team roles and responsibilities (people)
• Innovative processes
• Principles of poka-yoke; pull production and visual
management
Provided in environment designed specifically for
the model, to reduce waste, to ensure safety and to
promote healing.
RESULTS:
Collaborative Care is the Model Which Will Transform Us
From Current to Future State
KEY ATTRIBUTE CURRENT FUTURE
Patient Experience Disjointed. May be confusing, even Single plan of care developed with
contradictory. patient – is visible, continuously
updated with patient driven schedule
and goals.
Clinical Quality Admirable, but not 100% reliable. Reliable, standard work, using
Manage errors. Dependent on heroic evidence-based quality and real time
effort. problem solving to prevent errors.
Toll gates.
Physician Role Hierarchical Partner in care team
Nursing Role Task oriented. Care manager. Expanded and
empowered role in decision making
and patient care progression. Bedside
management of quality measures.
Environment Semi-private, dated. Private. Designed for patient/staff
safety, and to support collaborative
processes.
Medical Record/Plan of Care Multiple Care Plans, developed One plan, developed by team in room
separately by clinicians at different with patient.
times.
Collaborative Care Results to Date
Measure Pre Desired End 2007 Compares to non-
collaborative care
units
Defect- Free Admission 1.05 per chart 0 0.01 1.05 defect per chart
Med Reconciliation
Quality Bundles 38%Pneumonia 84% 100% Pneumonia 90.63% Pneumonia
Pneumonia through November 2007
No baseline for
CHF 95% CHF 92.5 % CHF-2 pts 92.04% through
failed bundle during November 2007
the yr.
Patient Satisfaction 68% rated as top Increase of 86.6% Baseline not available
box 20%
Length of Stay* 3.71 Decrease 2.96 3.78
Case Mix Index* Used top 16 1.08 Increase 1.12 1.11
DRG’s that match across cc and non-cc
Avg Cost Per Case *(using $5699—fully Decrease $4467 (-21%)—fully $6266-fully loaded
Medicare RCC) loaded 20% loaded
* Financial Indicators represent a subset of the patients to demonstrate impact of the delivery model.
Excluded from both baseline and pilot are: observation patients, ICU patients, and LOS >15 days.
Pilot numbers includes: Admits from ED to Unit, or direct admits to unit. 2006 is updated baseline.
RESULTS:
Mean Time to PCI – AMC
(Door to Balloon)
140
120
100
80 Key Events:
2-6-06 Door to Balloon RIE
60
2-15-06 Standing orders AMI
40 2-27-06 Code STEMI initiated
20
0
ay
ay
ar
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No
Ja
Ja
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M
Se
M
M
Jan 05-Jun 06 Goal
Results to date
2007 TC Door to Balloon Times
80
70
60
Time to PCI (minutes)
50
Stemi Cases
40
Goal 60 minutes
30
20
10
0
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16 #17 #18
Cases
Remote Code Stemi
9:36 90 Minute National Standard
9:31
9:27 77
9:23
9:18 7
9:14
9:10
9:05
D2B Times
9:01
8:57
8:52 TC-Air
8:48
8:44 AMC-Air
8:39
8:35
8:31
8:26
8:22
8:18
8:13
8:09
8:05
8:00
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RESULTS:
Consumer Choice Award
Quality/Image
Total Total
Total Total Affinity Aurora
Respondents ThedaCare Health Sys Health Care
Best Overall Quality 440 59.3% 14.4% 11.3%
Best Doctors 439 57.2% 15.9% 11.2%
Best Nurses 442 55.3% 20.3% 11.2%
Best Image/Reputation 439 62.6% 13.4% 10.6%
Care For Those Unable to Pay 378 41.3% 32.5% 10.2%
Latest Technology and Equipment 441 59.0% 14.3% 10.5%
Widest Range of Services 435 59.1% 14.1% 11.0%
Hsp Most Conveniently Located 442 52.1% 26.0% 10.4%
Highest Patient Safety 405 57.0% 17.3% 10.9%
Source: National Research Corporation Health Care Market Guide
Productivity
Gross Revenue/FTE
ThedaCare Consolidated (in 000's)
226
223
220
217
214
211
208
205 YTD: 4.9%
202 Improvement
199
Jul-06
Jul-07
Jan-06
Feb-06
Mar-06
May-06
Jun-06
Jan-07
Feb-07
Mar-07
May-07
Jun-07
Oct-06
Nov-06
Dec-06
Oct-07
Nov-07
Sep-06
Sep-07
Apr-06
Aug-06
Apr-07
Aug-07
Rolling 12 mo. 10% Target Budget
2005 2006 2007
Net Patient Revenue 417,311 465,277 518,149
Operating Margin 2.7% 3.3% 4.5%
Excess Margin 3.6% 7.1% 7.1%
Op CFL Margin 11.7% 11.5% 12.1%
2002 2003 2004 2005 2006 2007
Days cash 106.0 113.0 140.0 164.4 164.6 185.0
ROA 2.4% 3.2% 4.0% 3.0% 5.2% 5.7%
Unrestricted
Fund Balance 212,932 240,139 270,379 282,015 363,516 351,133
Accomplishments:
STRATEGIC DEPLOYMENT
MATRIX
A tool used by leadership to deploy the key
strategies of the organization to all levels of
the organization
At ThedaCare we have prioritized 16 value
streams.These value streams receive most
of the ThedaCare Improvement System
resources.
Accomplishments:
The A3
A tool which is used for business planning
Generally takes days to complete (not
months)
Requires clear metrics
Multidisciplinary approach
Accountability tool
Iterative
Accomplishments:
The 7-Week Cycle of an R.I. Event
3 weeks before – Value Stream review, Event
Selection, Select Team Leader/Co-Leader and team
members estimated financial, quality and staff impact
1-2 weeks before – RI Checklist, preparation .. Cell
Communication, aim statement, measures
day 1 - current conditions
day 2 – create the future
day 3 - run the new process
day 4 - standard work
day 5 - presentation
1st week after - Capture the savings
•Step 1 “Identify” waste 2nd week after – Update Standard Work
•Step 2 “Eliminate” waste 3rd week after – CFO validation
Accomplishments:
Continuous Daily Improvement
A set of tools used by front line workers and
supervisors to solve problems, and track
them
GEMBA
Accomplishments: CELEBRATION
TIMES [Area Name]
AREA
OPPORTUNITY TRACKING CENTER
SAFETY QUALITY PEOPLE DELIVERY COST
Tracking Tracking Skills Matrix Service Timeliness Tracking
Tracking Tracking
Pareto Pareto Actionable Items Pareto Pareto Pareto
Suggestions
Safety A4 Binder Quality Staffing Service Timeliness Cost A4 Binder
& Master A4 List A4 Binder Challenges A4 Binder A4 Binder
6S Process Flow Ideas Gemba Deviations from Standard Work
Implemented Attendance Log Standard Work for Processes
STD Y N
No of ideas
implemented – 1
completed A4s n
and AIL 50%
Accomplishments:
Learning to See training sessions
Day long session for all ThedaCare staff
Focus on the need for change
Our vision for six sigma performance
Hands on learning
Accomplishments:
Learning to See – % Shift to ―Top Box‖ (―Strongly Agree‖)
No LTS/No LTS LTS – 4 mos.
Item RIEs (235) No LTS (705) Post-session Post – March –
March ‘07 July ‘07 (1800) Oct 2007
1 I believe that ThedaCare is fully 39.6% 43.3% 60.7% 53.4%
committed to patient safety.
2 I better understand why we must be 37.8% 45.2% 49.2% 55.4%
urgently focused on making improvement.
3 Our efforts to improve processes creates 17.6% 22.7% 31.0% 27.9%
opportunities for me to develop my skills,
and to grow.
4 The changes we are making are necessary 13.6% 21.8% 36.6% 32.5%
for my job security.
5 ThedaCare’s goals and my goals are 29.8% 35.0% 41.9% 51.0%
aligned re: providing quality patient care.
6 My manager has my interests in mind 12.0% 17.3% 21.6% 29.9%
when making changes to patient care.
7 I am able to give input into the changes 18.3% 21.9% 28.9% 35.8%
and improvements being made in my work
area.
8 I am proud of ThedaCare’s efforts to 30.6% 38.0% 53.9% 48.3%
improve healthcare in the community.
9 I agree with the strategy of providing 32.8% 40.9% 53.5% 49.8%
measurably better value to our customers
(high quality/low cost)
10 Overall percentages 25.8% 31.8% 41.3% 42.7%
Lessons Learned:
RIE Participant Survey
I would recommend this organization to a friend as a good place
to work
Overall, I think this is a great place to work
My manager or someone at work seems to care about me as a
person
My manager shows appreciation for the work I do
At work, my opinion seems to count
People here are willing to give extra to get the job done
My manager provides me with sufficient opportunities to
improve myself
I am satisfied with my job security
People are encouraged to balance their work and personal life
Management has kept promises made to us
Lessons Learned:
Summary
Statistically significant differences in satisfaction for
those involved in 2 or more RIEs
Habits
Safety
• Does the staff member understand and know the safety concerns of his
or her business unit?
• Is work being stopped and remedied if a safety issue is identified?
Taking responsibility for results
• Does the staff member know what is expected?
• Does he/she follow standard work?
• Does he/she effectively communicate the need to change to the
manager/supervisor?
• Does the staff member seek help from colleagues, managers and
supervisors in implementing desired change?
We improve something every day
• Does the staff member use and support PDSA in the workplace?
• Does the staff member measure and share results with the team?
We work as one
• Does the staff member know the system measures?
• Does the staff member ask for help?
• Does the staff member anticipate patient/customer needs across the
continuum?
• Does the staff member anticipate the impact of actions on team members ?
Our customers come first
• Does the staff member ask our customers if we are meeting their
expectations?
• Is the staff member designing business models to meet our customer/patient
demand?
We capture learning
• Does the staff member celebrate successes and failures in big ways and in
small?
• Does the staff member recognize changes within people that drives changes?
• Is the staff member coaching/willing to be coached?
• Is the staff member helping people to be successful?
• Does the staff member forgive people if they make a mistake
We are candid and respectful
• Is the staff member open to new information?
• Does the staff member have regular, open, honest communication with
others?
• Does the staff member put all issues on the table right away?
• Does the staff member use the 5 whys?
• Does the staff member get data that clarifies?
• Does the staff member work to develop common understanding with the
right people?
Lessons Learned:
Standard work for performance
development
Assessment of compliance to habits
Quarterly coaching by supervisor
Two page development document which is
standard work from CEO to administrative
assistant
HR/OD oversight
Lessons Learned:
Create Pull for Physicians
Average Encounter Turn Around
Outpatient surgery center (economic partnership
with physicians)
Physicians and staff report on their improvement
results to boards,medical staff,and the
community
Lessons Learned:
Good
• Hospitals and Physicians working together can
prompt huge change
• ThedaCare is on the cutting edge in our
approach to solving problems
Bad/Ugly
• The degree of our non-compliance with
national standards
Issues With Suggestion
Managing change related to professional staff
• The fear of the loss of autonomy of decision making by
our professional staff is mitigated when they establish
standard work and prove to themselves that patient care
improves
• Lack of trust of administration will only be improved
by getting staff and physicians engaged in daily
problem solving that fixes THEIR problems
RESULTS: All Divisions
TIS Jan-08 TIS2008 Life To Date
# of Value Streams - - 83
# of Events-First Pass 2 2 395
# of Events-Second Pass - - 40
# of Events-Third Pass - - 4
# of Projects 10 10 296
# of 2P's 1 1 1
# of 3P's - - -
QUALITY
# of Defects Reduced 37 37 262,306
Minutes of Wait Time Reduced - - 3,642,811
Safety - - 38
EMPLOYEE ENGAGEMENT
Total Empl Engagement 11 11 4,594
New Empl Engagement 3 3 2,258
# of Empl Engaged for 2nd Time 9 9 913
FINANCIAL
FTE Reduction 0.00 0.00 123.23
Savings $ 56,000 $ 56,000 $ 10,261,783
AR $ - $ - $ 738,575
Capital Avoidance $ - $ - $ 477,000
Revenue $ - $ - $ 8,877,403
Supplies $ - $ - $ 701,301
# of UOS Increased/FTE 0 0 187
Other Savings + $ 24 $ 24 $ 2,831,856
Total Savings $ 56,024 $ 56,024 $ 23,887,918
ThedaCare Center for Creating
Value in Healthcare
Mission: to create a healthcare marketplace that
rewards provider for delivering value (quality of
outcome/cost) to their customers.
Work with purchasers and providers to develop
specific new models for care and reimbursement
that produce greater value for patients.
Engage businesses and organizations in sharing
expertise and promoting value based care and
value based purchasing strategies and tactics.
Lean Thinking In Education
Lean Education
Milwaukee School
of Engineering
Technical Colleges
University of
Wisconsin system
Education: My Observations
Focus is more on
TEACHING Lean than
BEING Lean
(If you know
otherwise, tell me!!)
Valuable partners with
manufacturers and
service providers
Opportunity
―The current state of lean teaching is very
similar to the current state of lean
implementation out in industry—some
islands of excellence, but a huge sea of
opportunity.‖
--Helen Zak, COO, Lean Enterprise Institute
Need for Lean Thinkers
―When you go out in industry now, you’ll find
a base level of knowledge of lean. If we’re
going to put people in the employment
market, we need to meet or beat that base
level.‖
--William Parr, Professor of Statistics,
Operations and Management Sciences,
University of Tennessee
Lean Education Academic
Network
40 professors teaching Lean in United
States, Mexico, United Kingdom, Sweden,
France
1 from Wisconsin
Brooke Wendy
University of Wisconsin Platteville
Source: www.teachinglean.org
Columbus Schools Experiment
Improved scores of
diagnostic tests that enable
teachers to revise and
improve methods
More efficient collecting,
grading and analyzing of
tests freed up teachers to do
enrichment and
intervention with students
to improve learning
Columbus Update
―Unfortunately, the partnership ended along with funding. My impression
is that some of the individuals continue to use some of the tools but
there is no sustained effort.
―I think that the leadership Columbus Public Schools is committed to
improving without changing and I'm afraid I don't know much about how
to do that.
―It is a shame because most of the teachers and principals that I have met
are passionate about teaching kids despite very difficult circumstances.‖
--Peter Ward, Professor, Department of Management Sciences,
The Ohio State University
Summary—Lean Thinking
Improves health care quality and has
potential to reduce cost—if the
reimbursement model is changed to take
advantage of it!.
Can improve education (the value for
students) by accelerating their learning
Requires commitment to cultural change to
obtain and sustain the gains
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