1. Creating the Michigan Quality System John E. Billi, M.D. Associate Dean for Clinical Affairs, University of Michigan Medical School Associate Vice President for Medical Affairs, University of Michigan jbilli@umich.edu Michigan Quality System: http://med.umich.edu/mqs Michigan Quality System: Quality Safety Efficiency Appropriateness Application of Lean Thinking to Health Care

2. Outline Introduction to UMHS Need for change Applying lean thinking to health care –Case examples –Spear framework –Lean tool examples –Waste in health care UMHS lean journey –Decision to implement ‘lean thinking’ –Development of Michigan Quality System –Learning projects and results

3. UMHS in a Slide Integrated Academic Health System, within major public research university: UM Hospitals and Health Centers –817 beds –1.6 million outpatient visits –10,000 employees UM Medical School –1500 faculty physicians –995 resident physicians –690 medical students

4. Mission Synergy Patient Care Research Education

5. Good-to-Great in Health Care “Greatness is not a function of circumstance. Greatness, it turns out, is largely a matter conscious choice and discipline”. ---Jim Collins, Author Good to Great

6. Burning Platform for Change?

7. Traditional Health Care …or, the way I was trained Episodic Requires patient initiation Not well coordinated (patients & doctors) Sporadic communication among clinicians Sporadic patient education Variable process of care Clinicians’ opinions drive decisions Systems do not prevent errors Outcomes not measured Expensive

8. Burning Platform for Change? Gaps at UMHS: Quality: Not all diabetic patients on statins, aspirin Safety: - Wrong site surgery - Fatal medication errors - Preventable wound infections Efficiency: Days waiting for a CT scan Appropriateness: Generic drug rate around 55%

9. Burning Platform for Change? Bottlenecks –ORs –Inpatient beds Stress of overwork (muri): - Physicians, nurses, clerks running faster - Nurse and physician shortage Financial pressures - Troubled State economy - Health care costs burden employers - The uninsured

10. HEALTH AFFAIRS January/February 2001 – Volume 20, Number 1 Interview: A Founder of Quality Assessment Encounters A Troubled System Firsthand “ At the University of Michigan, the outpatient and inpatient teams are entirely separate…There are areas where no one takes responsibility, where planning is weak, where I am left on my own …The system is the problem…Things won’t improve until something is done about the design of the system…The system is the responsibility of the doctors and the hospital leadership. ……. tell the committee that Donabedian said they have a problem.” By Fitzhugh Mullan, p137-141

11. Transitional Care = Hand-offs Discharge Problems ProblemExampleConsequence Appointments Timely appointment not made Patient unaware of appointment Health deteriorates Missed appointment Contact Information Discharge destination unknown Unable to contact patient Discharge counseling Patient confused about medications Patient confused about tests Does not take medications Does not go to tests Social Lacks transportation Cannot afford medications Misses appointment Does not take medications Home care Visiting nurse not available Health deteriorates

12. Where Do We Want to Go? Our future state vision: Based on Institute of Medicine Report “Crossing the Quality Chasm” Care that is: Safe Effective Patient-Centered Timely Efficient Equitable

13. Crossing the Quality Chasm The IOM “Chasm” Report gives us a vision of where to go Lean Thinking gives us tools and methods to get there

14. The IOM “Chasm” Report gives us a vision of where to go Lean Thinking gives us tools and methods to get there Crossing the Quality Chasm

15. What is Lean Thinking? “The endless transformation of waste into value from the customer’s perspective”. ---Womack and Jones, Lean Thinking

16. The 5 Steps of Lean Thinking Applied to Healthcare Specify value from customer’s perspective Identify the value stream for each product, and remove the waste Make value flow without interruptions from beginning to end Let the customer pull value from our process Pursue perfection - continuous improvement –Do this every day in all our activities Source: Womack & Jones: Lean Thinking

17. The Clinic Appointment You call the clinic, go through 3 voice prompts, are put on hold, and leave a message. The clerk calls you back and sets a date next week. You arrive for the visit, check in, sit in waiting room. You are called into the exam room, wait for doctor. The doctor sees you, saying she’s been waiting for you to arrive; diagnoses a URI, and BP is worse. The doctor prints an antibiotic prescription, goes to the staffroom to get it. You are allergic to that drug. The doctor says to return in a week for the BP. The medical assistant does an EKG. At check out you ask the cost – clerk says they’ll bill you, no appointment is available next week. Pharmacist says your insurance prefers a different drug. Is there a problem?

18. Using the 5 Steps in the Clinic Visit Specify value from customer’s perspective –A quick, effective clinic visit Identify the value stream for each product –Request > appointment > arrival > seeing doctor > check-out …and remove the waste –Time on hold, callbacks, walking, wrong/unnecessary drug/test Make value flow without interruptions from beginning to end –Staff and patient move continuously from check-in to exit –No waiting room, no staff waiting –Errors surface immediately Let the customer pull value from the process –Pull the appointment or med refill when you want it Pursue perfection – continuous improvement –Every day, every clerk, doctor and nurse thinks about how to redesign work to improve value to the customer

19. UMHS Example: Orthopaedic Outpatient Consults Chronic problem: Long delays just to get an appointment Frustrated referring physicians/patients/orthopedists Incomplete records, phone tag Physician review records prior to scheduling Lots of hidden processes, downstream consequences of the way work was done Patients/referring physicians seek care elsewhere Project scope: Orthopaedic consult – from request to scheduling

20. Using the 5 Steps Orthopaedic Consults 1. Specify value from customer’s perspective Patients/referring physicians: quickly scheduled appointments 2. Identify the value stream for the service Request > review> schedule appointment …and remove the waste Variation in request, time on hold, callbacks, physician reviews

21. Orthopaedics MedSport Appts. Current State Map

22. Orthopaedics Taubman Appts. Current State Map

23. Using the 5 Steps Orthopaedic Consults 3. Make value flow without interruptions from beginning to end Staff scheduling appointments on first phone call Uniform intake process No waiting for appointments; errors surface immediately

24. Orthopaedics Appts. Future State Map

25. Using the 5 Steps Orthopaedic Consults 4. Let the customer pull value from the process Same day appointments After school sports, till 7PM 5. Pursue perfection – continuous improvement Every day, every clerk, doctor, and nurse thinks about how to redesign work to improve value to the customer

26. Orthopaedic Consults Project Results Orthopaedic consult – from request to scheduling –Results: Pre project: –process time = 27 min –wait time = 23 days Post project: –MedSport = 91% of appointments made on first call (2.5 min) – Still true a year later! Attending and staff freed to create more value: –After school, same day appointments till 7PM

27. How To Get It “Right Every Time” Steven Spear’s 4 Part Process: 1.Design work to surface problems –“Generous processes” tell us where problem is –Embed testing in work: immediate signals –Tell normal from abnormal right now (Mr. Cho) 2.Fix the problem now –For this case and for future –Improve work as close as possible to problem »in time, person, place, and process –Learn and correct the root causes –No workarounds, lots of small steps 3.Disseminate learning (the problem and the fix) 4.Management must support 1-3 Steven Spear. Fixing Healthcare from the Inside, Today.

28. “The leader must know everything that went wrong, every day”. ---Paul O’Neill

29. How To Get It “Right Every Time” Catheter-related sepsis – a lot of little things: –No sink, no soap, no sanitizer, no doormat reminder or buzzer –Gloves missing, wrong size, old and rip, on other side of patient, at bottom of kit –92% of nurses faced with impediments constructed ad hoc workarounds Laryngoscope detects misplaced tube –signals the operator –downloads to QI lead Steven Spear. Fixing Healthcare from the Inside, Today

30. How to Get It “Right Every Time” ICU bed automatically adjusts to 30° (vent) –signals when not at 30° “CPR disc” signals the defibrillator to speak: –hand position, depth, ventilation rate and depth, –stores for QI Manufacturing corollary: “Do not accept, build, or ship a defect” –General Motors

31. Fixing Health Care from the Inside, Today – Steven Spear Americans think of a plan as a prediction of what will happen. Toyota thinks of a plan as an experiment whose result will improve understanding of the work. –Paraphrase of Steven Spear

32. Fixing Health Care From the Inside, Today – Steven Spear Work is designed as a series of ongoing experiments that immediately reveal problems Problems are addressed immediately through rapid experimentation Solutions are disseminated adaptively through collaborative experimentation People at all levels of the organization are taught to become experimentalists

33. Fixing Health Care From the Inside, Today – Steven Spear Short on Time??? Can’t find time to fix root cause??? Rather fix the problem every day for the rest of your life? Steven Spear: Just take 5 minutes a day to fix root cause of one problem –Frees up time, so tomorrow it will be 10 min. –Next time it will be 15 minutes…

34. Find it, Fix it “Cultivate a ‘Find it, Fix it’ mentality for overcoming challenges in your area”. ---G. Richard Wagoner, Jr. Chairman and CEO

35. New Way of Thinking Cultivate –Accountability –Collaboration –Teamwork Weed out –Silos –Tribalism

36. “Act your way to a new way of thinking”. ---John Shook, Ph.D. Senior Advisor, Lean Enterprise Institute Author, Learning to See

37. Lean Tools in Health Care Standard work – 4 ways lab results get to me Pull systems – no signal when OR ready One piece flow – 36 steps to make an ortho appointment – Process Time = 27 min., Lead Time = 23 days; Visual workplace – each exam room has forms in different colored, opaque folders – common ones gone Cellular layout – Mirror image ORs – half not optimal Multi-process (cross-trained) operators – RN clean OR Iterative questions (5 “whys”) – The ER patient… -left without being seen because of a long wait, -because of a long stay patient -because of the lack of an inpatient bed -because of a gap in discharge planning… Andon cord – “Stop the Line” in surgery or meds

38. Eight Forms of Waste in Healthcare Overproduction and Production of Unwanted Products: Material Movement: Worker Motion: Waiting: Over-processing: Inventory: Correction of defects: Wasted creativity of employees:

39. Not All Waste Is Equal Production of Goods and Services Not of Value to the Customer: Most important form of waste: –Worsens all the others Appropriateness – key dimension of quality in health care! –Eliminate tests, treatments, steps, processes that do not add value Better to eliminate work than to improve how it’s done –Hard to beat the efficiency or safety of a cardiac cath that’s not done because it wasn’t needed –If its not worth doing, its not worth doing well. -Donald O. Hebb

40. Eight Forms of Waste in Healthcare Overproduction and Production of Unwanted Products: The most important form of waste – worsens all the others. Any health care service that does not add value to the patient Antibiotics for respiratory infections CT screening for coronary disease Medication given early, testing and treatment done ahead of time to suit staff schedules and equipment use Appropriateness – key dimension of QI in health care! Material Movement: Moving patients, meds, specimens, samples, equipment Worker Motion: Searching for patients, meds, charts, supplies, paperwork Long clinic halls No printer in exam room for prescriptions, patient education Adapted From Long, Mersereau, Billi

41. Eight Forms of Waste of Healthcare Waiting: ER staff waiting for admission, can’t see next patient Waiting for test results, records, information Nurse waits for med, blood draw, transport, OR cleaning Over-processing: Bed moves, retesting, repeat paperwork, repeat registration, multiple consent forms, logging requests Inventory: Bed assignments, pharmacy stock, lab supplies, specimens awaiting analysis Patient waiting for anything – tests, visits, discharge, phone cues Correction of defects: Medication errors, wrong patient, wrong procedure, missing or incomplete information, blood re-draws, misdirected results, wrong bills Wasted creativity of employees: Resident trying to find a Livonia infusion center

42. Lean Thinking at UM Health System 1.Why Lean Thinking? 2.“Michigan Quality System” concept 3.Learning projects: seeking a Model Line

43. Why Lean Thinking? Why do we believe Lean Thinking is best way to: –Reduce errors? –Address quality problems? –Eliminate stress? –Increase efficiency? It is a learning approach –Empowers workers to redesign their work –Uses “Work as Learning” It is a research-based approach –Uses study of work to discover new knowledge Can be used to align the organization from top to bottom

44. Why Lean Thinking? Can healthcare use the lessons of Toyota and GM to transform waste into value? Can a health system use: - fewer inputs (time, human effort, materials) - than traditional care process - to produce a wide variety of “products” - with fewer “defects” more quickly - with less stress? Lean is not about working harder or faster, it is about finding waste and transforming it into value our customers want.

45. Why UMHS Chose Lean as the Best Uniform Approach Key Attributes: Builds on traditional Continuous Quality Improvement Uses first-hand knowledge of the work Analyzes root causes of problems (5 whys) Starts with value as defined by the customer Uses “one piece flow” to surface problems Creates new future state value stream map, not just a better current state map Value stream maps useful for invisible work of health

46. “Michigan Quality System” Concept Create –a health system-wide consistent approach to quality and process improvement adapting the principles of the Toyota Way building on CQI base Incorporate 4 goals of Michigan Value : –Quality –Safety –Efficiency –Appropriateness

47. Michigan Quality System: The Value Proposition Uniform process improvement across UMHS –Across missions: education, research, clinical/service Example: Medical students in clinic flow –Across goals: -Quality - Efficiency -Safety - Appropriateness Example: Map created to improve “efficiency” can be used to improve “safety” (root cause analysis following an adverse event) –Spread to adjacent areas: merging projects ED => Radiology => OR –Training synergy: Transferability of training received for one project when working on other projects Teach residents and medical students to think lean

48. Learning Projects What are they? Why use them? –Institutional examples of lean in healthcare –Proof of concept at UMHS –Can expand upstream, downstream and laterally Why not train all managers first? –We Learn Lean By Doing –Training long before use is less valuable –“Learn-do-reflect-discuss” cycle of a learning organization

49. MQS Project Selection Process Areas: –Prioritization Committee (COO, CFO, CMO, Chief of Nursing, Ambulatory Director, Group Practice Director) Project leads: –Determine scope, participants and timing Leadership panel: –All the leaders who need to approve the Future State Value Stream Map and the plan to get there –They support the implementation

50. MQS Project Selection Criteria Institutional priority Opportunity for improvement – large gaps between optimal and current practice Opportunity to expand upstream and downstream; and to translate sideways Existence of a ‘clinical champion’ Visibility - potential for creating an exemplar Quality of Care Patient Safety Efficiency Appropriateness

51. UMHS Learning Projects Faculty appointment, credentialing, insurance enrollment –72 signatures Care transition –Right drugs, appointments at discharge –Management until the first follow-up appointment Emergency Department – Patient flow –Series of projects for patient journey: –Discharge of patients to home: Nurses prioritize sickest, never get to discharges –Admission to an inpatient bed

52. UMHS Learning Projects Wound care Timed blood drawing CT scheduling and throughput –Physicians “protocol” (review) every request Orders Management Project (CPOE) – Medication management end-to-end –New IT - Redesign new workflow –High institutional visibility and impact Institutional Review Board

53. Selected Project Results Vascular Access: Increased PICC lines placed within 12 hours by nurses from 35% to 71%; reduced by 46% cases needing to be place by interventional radiology.

54. VAS Supply Cart 5S

55. Drawer: Pre-5S

56. Drawer: Post- 5S Saved nurses an hour a day

57. Selected Project Results OR ENT Cases “decision to incision”: 99% of history and physicals are now complete at pre-op visit compared to 75% prior to workshop. EKG leads left on: pre-op, OR, post-op Adopted at new ambulatory surgery center

58. Selected Project Results Radiation Oncology: Delays in scheduling and treatment planning Now treating 61% of brain metastases patients on the first day of call. Applying to the rest of their referrals

59. Selected Project Results Results Reporting: Pre-workshop, ~ 99,000 lab results had no ordering physician identifiable after extensive rework, implementation now 80% complete.

60. Selected Project Results Orthopaedics Project: Reduced time to schedule MedSport appointment from 23 days to 2-1/2 minutes.

61. Clinic ED Radiology OR Admitting Transition Planning PICC A UMHS Patient Patient Journey

62. Clinic ED Radiology OR Admitting Discharge Planning PICC Orders Management Project UMHS Lean Learning Projects Ideal Patient Flow CT Scheduling Ortho Scheduling OR ENT Cases Vascular Access Patient Journey Care Transition Wound Care Misdirected Results Sched. Admits

63. References Books: Keyte B and Locher D. The Complete Enterprise: Value Stream Mapping for Administrative and Office Processes Liker J. The Toyota Way. Liker J and Meier D. The Toyota Way Fieldbook Rother M and Shook J. Learning to See. Marchwinski C and Shook J, eds. Lean Lexicon. Womack J and Jones D. Lean Thinking. Articles: Spear S. Fixing Health Care from the Inside, Today. Harvard Business Review. Sept 2005 Spear S. Learning to Lead at Toyota. Harvard Business Review. May 2004 Spear S, et al. Decoding the DNA of the Toyota Production System. Harvard Business Review. Sept 1999 Institute for Healthcare Improvement Whitepaper: “Going Lean in Health Care” http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm

64. Additional Materials Health Care is not Manufacturing Waste categories Barriers to using Lean Thinking in healthcare Value Stream Mapping slide

65. Can Lean Thinking Work In Healthcare? How is it Harder to Use Lean Thinking in Health Care than Manufacturing? How is Health Care Similar to Manufacturing? What Advantages Does Lean in Health Care Have Over Manufacturing? What do you think?

66. How is it Harder to Use Lean Thinking in Health Care than Manufacturing? Who is “customer” and what do they value? –Patient/family vs. Employer, Payer, Government –But patient and doctor insulated from cost of choices A “distortion of value” As if the driver didn’t pay for the car Lots of invisible work –Patient encounter often involves a process or decision as the outcome -- not a tangible “product” –Examples: decision to operate, clinic scheduling, lab results ordering & reporting More privacy issues

67. How Does Health Care Differ from Manufacturing? Organizational and professional culture issues –Physicians, some world renowned –Nurses, many irreplaceable –Other health professionals Professional autonomy –vs. teamwork and systems thinking Mission-driven (at least some) –Non-profit orientation –Production of social goods

68. How is Health Care Similar to Manufacturing? Process dependence Huge variability, often unjustified –Aversion to standardization Pressure to innovate and use new technology Need for high reliability systems (patient safety leaders learn from airlines, nuclear power industry) Lack of embedded testing –No “instant awareness of every error” Trillion dollar industry Continuous Quality Improvement orientation

69. What Advantages Does Lean in Health Care Have Over Manufacturing? We expect change: new treatments, drugs, devices We have scientific literature to guide us We accept standardization in research protocols We (mostly) accept standardizing treatment of common conditions: –“evidence-based medicine” and practice guidelines We accept standardization to improve patient safety We use root cause analysis in safety and quality We are working on transparency to improve safety We have external pressures for efficiency, safety and quality –Pay for performance –Public reporting

70. Eight Types of Waste in Heath Care Waste Category DefinitionHeath Care Examples CorrectionRework because of defects, low quality, errors. Requisition form incomplete/inaccurate/illegible. Order entry error. OverproductionProducing more, sooner, or faster than required by the next process. Inappropriate production. Unused printed results/reports. Unnecessary labs/visit. MotionUnnecessary staff movement (travel, searching, walking). Walking to and from copier/office/ exam room. Searching for misplaced form/ equipment/chart. Material Movement Unnecessary patient or material movement. Multiple patient/paperwork transfers. Temporary locations for supplies. WaitingPeople, machine, and information idle time. Patient in waiting room. Wait for lab results. InventoryInformation, material, or patient in queue or stock. Patient waiting in exam room. Excess stored supplies. ProcessingRedundant or unnecessary processing.Reentry of patient demographics. Repeat collection of data. UnderutilizationUnderutilized abilities of people.Nurses refilling Rx or making appointments. Doctors doing simple patient education. From Elsa Mersereau

71. TYPES OF WASTE I I C C O O M M W W P P M M CURRENT THINKING WASTE NOT DEFINED REACT TO LARGE EXAMPLES REACTIVE IMPROVEMENT REQUIRED THINKING CONTINUOUS IMPROVEMENT Correction Over Production Over Production Motion Material Movement Material Movement Waiting Inventory Processing WASTE IS "TANGIBLE" IDENTIFY MANY SMALL OPPORTUNITIES LEADS TO LARGE OVERALL CHANGE GM’s Categorization of Waste WASTE Unreasonable -ness Unevenness Source: GMS Training

72. Waste in the Current State: Causes and Countermeasures Type of WasteCause(s)Countermeasure Correction of defects and rework Procedure information incomplete or inaccurate; 20% of scheduled, authorized procedures cancelled or rescheduled Reduce lead-time to eliminate rescheduled or cancelled procedure (no-shows only) InventoryBacklog of schedule, authorized procedures Reduce wait-time. Over- processing Process time too long; scheduling and authorization not coupled One-piece flow Over- production Procedures scheduled weeks or months in advance Reduce lead-time to 3 days or less. WaitingPayer authorization too slow and days after scheduling Reduce process and wait time for pending process; 24 hr. in-patient insurance information From John Long

73. Perceived (and Real) Barriers to Application of Lean in Health Care “Just the Management Flavor of the Month – this too shall pass.” –Must show it is a learning approach, not just some projects “We’ve done well, why change?” “The autos had to do it” –Lack of a burning platform/overriding reason to change (national v. personal) “Let each unit choose QI process it finds most useful.” –Some see no value in uniform QI approach; miss the synergy “Who can lead this?” –Lack of expertise/clinical champions “I’ll join when I see that the leaders are on board.” –If not led from the top, many will not engage “How much are we spending on this new program?” –Will the “return on time invested” be there? “A 3 day workshop??!!” –They’ll spend 3 days over 3 years and not change anything

74. Perceived (and Real) Barriers to Application of Lean in Health Care “Is this cost cutting disguised as QI?” –The term Lean is misunderstood –1990s CEP (Cost Effectiveness Program) = lay offs “I can’t do this on top of my day job.” –Isolated projects will not change the corporate culture – it will never become management’s job I can’t risk my area’s performance to optimize the whole product line throughput –Accountability, teams, and incentives must cross silos and levels of the organization –Evaluation of middle management must match corporate goals –The Peace Health example “Creativity is our most important asset – standard work will stifle creativity.” –Can you innovate if you have not first standardized??? –Do you want your cardiologist innovating or giving you statin and aspirin?

75. Perceived (and Some Real?) Barriers to Application of Lean in Health Care OR, People are not automobiles…

76. Using the Value Stream Mapping Tool Understanding how things currently operate. This is the foundation for the future state Value Stream Scope Designing a lean flow through the application of lean principles Current State Drawing Implementation Plan Determine the Value Stream to be improved The goal of mapping! 30, 60, 90 day follow-up Implementation of Improved Plan Future State Drawing Developing a detailed plan of implementation to support objectives (what, who, when) Standardize for later improvement From John Long