As shown in Healthcare Reform That Can’t Be Stopped, the Toyota Production System has found a home in healthcare. The Wisconsin-based TPS pioneer, ThedaCare, has been employing Toyota’s industrial efficiency principles in its hospitals to great effect for more than 10 years. Thedacare is now seeing great interest from other organizations, as the healthcare industry moves to reap the rewards of its move to digitize information. So much interest, in fact, that it has created the ThedaCare Center for Healthcare Value to help other organizations realize the promise of continuous performance improvement. Its head, former ThedaCare CEO Dr. John Toussaint, doesn’t mince words when he talks about what’s bringing all those organizations to his door — and it’s not federal legislation.
“Healthcare performance was and still is unreliable,” he says flatly. “Those who are honest about what they’re doing recognize that. Twelve years ago, ThedaCare compared manufacturing and healthcare quality and found healthcare to be far worse: 90,000 to 100,000 defects per million opportunities [versus the three defects per million norm in manufacturing]. That’s quite frankly still how U.S. healthcare performs. A 2010 HHS Study said we were killing 15,000 Medicare patients per month with medical errors. The NIH’s Crossing the Quality Chasm in 1999 showed the same thing. When you peel back the onion, we’re doing really lousy; maybe it has even gotten worse. Those of us who have been in the business of quality improvement have been trying to understand why that is and implement processes to change that.”
As proof of the effectiveness of its data-driven reform efforts, Dr. Toussaint points out that ThedaCare’s Collaborative Care has reduced medication reconciliation errors — that is, errors from incorrect or conflicting orders for medications — to zero and maintained that number for four years. Toussaint also points out that their published thirty-day readmission rate of under 9% is less than half the national average.
Whether reform is repealed or not, Toussaint says, “The reform initiatives in the private sector have already begun and there’s no going back because there just isn’t any money left. Healthcare delivery organizations are going to learn to live with less revenue. We have big problems that won’t be solved by throwing more money at them. We can either cut the healthcare workforce by x percent while reducing quality or we can use data and a proven methodology to make it less expensive and maintain quality. This transcends whatever happens in Washington.”
Does the Toyota method work in smaller, specialty healthcare? Seattle Children’s has been focused on the need to reduce variation in care. Dr. Howard Jeffries is the Medical Director of Continuous Performance Improvement and a practicing cardiac intensivist. He believes that regardless of the outcome in Washington, hospitals will be required to assume risk in the form of bundled payments models where both government and commercial insurers will pay a fixed amount for a specific treatment cycle. “The only way to survive is to predict cost. We can’t negotiate these rates until we know what our costs are, so our goal is to reduce variation as much as we can.”
Jeffries states that Seattle Children’s wants the only variation in process to be around the patient’s response to treatment. “What’s unique about us is that other care providers are trying to standardize as much as they can around the patient visit in peripheral ways, but we’re standardizing what we’re doing when we’re making clinical decisions for seeing a patient. We’re also looking at standardizing all other aspects of care from how you move through the system to what types of medication you’ll receive, including discharge and follow-up visits.”
Jeffries’ data-focused approach has the goal of standardizing care for 50% of Seattle Children’s patients within five years, up from the current 18%, but far higher than the 8% they discovered when they started one year ago, a number very common in the industry. They’ll need to tackle increasingly challenging care paths as the laws of diminishing returns kick in.
Asked how they create standards and reduce variation, Dr. Jeffries says, “We talk about it a lot, about the goals and why doctors practice. Are you a doctor to do what you want or to provide good care to your patients? The only way you can know is to measure and to have a standardized practice. If you don’t have a standard practice, anything you do differently is just noise.”
Dr. Jeffries also expects the rise of the Accountable Care Organization (ACO) where healthcare will be paid a fixed amount to manage a population of patients, including their outpatient needs. “This will require efficient networks of providers working with tight collaboration toward a common goal.”
Even though the notion of ‘Staff engagement is difficult to be measured’ may be true, we should constantly attempt to try. As an example, the production units can be measured before and after a series of EAP sessions, which can indicate a change in production, therefore engagement. The expected production units can be measured by taking the average of the team, and determining the reasons for any staff that produce below this average. These can range from lack of training, health-related issues, the relationship between the co-workers or phsychological, each of which has a potential solution.
The design of tightly integrated systems around these topics is critical. Without a good system, the measurement of KPIs may indeed be nearly impossible.
there are activities which can be evaluated with numerical indicators as soon they are done.
There are activities that cannot. Healthcare, education, military, and so on. We should not even think of applying the tools of the first ones to the other ones. It won’t work.
Hence I have been suggesting that the current mindset of the teams – their “social captal” becomes the indicator for them (according to the definition of Prof. Paul F.Whiteley for Social Capital – in Political Studies, Vol. 48 Issue 3 Page 443 June 2000, Economic Growth and Social Capital.)
Mindset is upstream of symptoms (or results) that are downstream. Hence we measure the same, but cutout the time factor. Save on education. Brilliant results during 20 years, and then ? Save on healthcare, same thing.
My work in Research has been to develop instruments that map minsdet and quantify gaps, because otherwise, our financial can’t grasp the causal link between mindset and financial performance, and worse, our organizations get crippled, because they are set up this way: “”No evidence for financial performance, hence no budget can be allocated, and we’ll see what’s missing at the end of the year !”"
Some (many) activities do not follow the agricultural cycle of the four seasons, a historical deviance.
Need to know more ? I’ll be pleased. Rene
When doctors can focus on the patient instead of being concerned with ‘aspects of care’ such as reducing the costs of patient visits, we will see an improvement in what we can’t measure immediately, which is informed customer face-time. If your doctor is distracted with his iPad because he is learning a new standardized system, you feel ignored. Not good. The best take-away from this article is that “This will require efficient networks of providers working with tight collaboration toward a common goal.” If we place this in the big picture context of the Healthcare system in general getting more face-time to patients, we really see what it means. Working towards a common goal of more informed patient face-time, all health care providers can see the benefits of implementing something like an EMR. The informed comes from the fact the doctors could potentially have the patients entire medical history on on iPad. The doctor can now spend time really getting to know what is going on with the patient and make inferences from their history. The future of patient care is soon my friends.
@Mark. The identification of KPIs within a health care delivery setting and subsequently managing the business aspects around these provides for the tools to manage the 10 ton gorilla.
We teach practice managers how to identify critical measurement factors within their practice that have a direct bearing on the outcome on patient care. The KPIs so identified are not necessarily cast in stone. Neither, we have found, universally applicable from one practice to the next.
The purpose is to identify some factor pivotal to controlling the business process, giving management a measurable outcome to work with. This is infinitely getter than the alternative, which is akin to taking stabs in the dark, hoping (praying) for a positive outcome.
The article’s proposition of a standardized practice is a brilliant concept. I think a caveat that needs to be added is that it must have the flexibility to be changed to fit external environmental conditions. Example, rural vs urban practices.
It’s certainly true that efficient, cost effective and standardized clinical processes in provider facilities can be achieved without adversely affecting quality clinical outcomes. To achieve these improvements, processes must be analyzed to determine which processes achieve desirable outcomes for the least cost.
Healthcare workers are motivated to provide the best quality possible but I’ve learned from experience that many physicians and clinicians don’t know what things actually cost. Although committed to quality, there is little knowledge of how much things cost or how to efficiently and effectively find and remove waste from their processes for delivering healthcare services.
Physicians want to provide excellent care as efficiently and cost effectively as possible. If they are not achieving this goal, it is most likely because they have not been sufficiently informed of the effect of their decisions on both cost and outcomes. Provider facilities must present them with this information so they can achieve cost effective, high quality outcomes.
To meet current and future financial challenges, provider facilities must learn lessons from industry in employing business process reengineering by utilizing continuous quality improvement, six sigma, lean processes or whatever tools are required to continuously seek out and eliminate waste and inefficiencies and remove them from the system.
If provider facilities are not setting goals, establishing the necessary metrics to gauge the efficacy of their improvement initiatives and monitoring these metrics to continuously move toward those goals, they’re missing opportunities to remove unnecessary costs from our healthcare system.
MIke, I tend to think that physicians are humans and as such, they fall into the same traps as others…of taking the easy course of action rather than the best, not staying up to date on the most current care pathways, etc. I tend to think it is more than just giving people information…they must be managed to better results as well. Believing a physician doesn’t need to be managed is reinforcement of the idea that they are artisans and not part of a value stream that needs to be monitored and improved. I welcome your comments.
First off, I agree Dr. Toussaint is doing amazing work. Measurement is critically important to understanding if we are improving.
But I disagree with what’s become a business cliche’ (often wrongly attributed to Dr. W. Edwards Deming): “If you can’t measure it, you can’t improve it.” I believe Dr. Deming’s teaching that some of the most important things in a system can’t be measured — but we have to work to improve them anyway.
Think of measures of staff engagement — this is critically important, but any of our measurement methods have flaws or can be skewed. It can’t be boiled down into a simple single number.
So while I agree with your post, I respectfully disagree with the title.
Mark, you make good points that there are things you can improve that you can’t measure. I would argue, though, that often the ‘measurement’ of something like staff engagement may not be a simple, single number, but there are creative ways to get a view of whether something is improving or not. Thanks for your comments.
Chris