1. Creating the Michigan Quality System John E. Billi, M.D. Associate Dean for Clinical Affairs, 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 Service Application of Lean Thinking to Health Care

2. Outline Introduction to UMHS Need for change Applying lean thinking to health care –Case examples –Clinical 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. Burning Platform for Change?

6. 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

7. Burning Platform for Change? Gaps at UMHS: Quality: Not all CAD patients on statin, aspirin Safety: Wrong site surgery Serious medication errors Preventable wound infections Efficiency: Days waiting for a CT, OR slot Weeks waiting for appointment to the right clinic Appropriateness: Generic drug rate around 55%

8. Burning Platform for Change? Waste: time, motion, errors (muda) Uneven workload, variability (mura) –Busy Monday, light Friday –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

9. 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

10. 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

11. 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

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

13. A Quick Summary of Lean Thinking 1.Do our work every day in a standard way that we created - Not just the way the work evolved! 2.Be alert to things going wrong - They always do! 3.Fix the problem now - For this patient or co-worker 4.Find and fix the root causes of the problem - So it never happens again

14. Womack’s 5 Steps of Lean Thinking Applied to Healthcare 1.Specify value from customer’s perspective 2.Identify the value stream for each product, and remove the waste 3.Make value flow without interruptions from beginning to end 4.Let the customer pull value from our process 5.Pursue perfection - continuous improvement - Do this every day in all our activities Source: Womack & Jones: Lean Thinking

15. The Clinic Appointment Call the clinic, 3 voice prompts, on hold, leave message. Clerk calls back and sets a date next week. Arrive for the visit, check in, sit in waiting room. Called into the exam room, wait for doctor. Doctor sees you, saying she’s been waiting for you Diagnoses a URI, and BP is worse. Doctor prints antibiotic prescription, goes to the staffroom to get it. You are allergic to that drug. Doctor says to return in a week for the BP. 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?

16. 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, nurse thinks about how to redesign work to improve value to the customer, and ease for us

17. 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

18. 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

19. Orthopaedics MedSport Appts. Current State Map

20. Orthopaedics Taubman Appts. Current State Map

21. 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

22. Orthopaedics Appts. Future State Map

23. 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

24. 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 more than a year later Attending and staff freed to create more value: –After school, same day appointments till 7PM

25. How To Get It “Right Every Time” 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 (Cho, Toyota) 2.Fix the problem now –For this case and for future –Learn and correct the root causes –Improve work as close as possible to problem »in time, person, place, and process –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.

26. 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 Steven Spear. Fixing Healthcare from the Inside, Today

27. How to Get It “Right Every Time” Endotracheal tube detects an intubation error –signals the operator –downloads to QI lead ICU bed automatically adjusts to 30° (vent) –signals when not at 30° “CPR disc” signals the defibrillator to speak: –hand position & depth, ventilation rate & depth –stores for QI “Do not accept, build, or ship a defect” –General Motors

28. 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

29. We know half the plan is wrong, we don’t know which half. We have to watch it unfold, detect normal from abnormal right now, and fix it. Americans think of a plan - as a prediction of what will happen. Toyota thinks of a plan - as an experiment to be conducted - to tell us what we didn’t know about the work - the result will improve understanding of the work. –Paraphrase of Steven Spear, Fixing Healthcare… HBR’05 Plans are useless, planning is essential. (Eisenhower)

30. 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

31. 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 10 minutes a day to fix root cause of one problem –Frees up time, so next week it will be 20 min. –Then it will be 30 minutes…

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

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

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

35. Lean Tools in Health Care … some intuitive, many not used 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 ED 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

36. 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:

37. 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

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

39. Why Lean Thinking? 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 “Work as Discovery” of new knowledge Can be used to align the organization from top to bottom

40. Why UMHS Chose Lean Thinking 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

41. “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 5 goals of Michigan Value : –Quality –Safety –Efficiency –Appropriateness –Service

42. 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

43. MQS Learning 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

44. MQS Learning Project Results Radiation Oncology: Delays in scheduling and treatment planning. Now treating 61% of brain met patients day of call. 96% of patients with brain metastases seen, consulted, simulated & treated within 24 hours (down from 5 days) Overtime in simulator reduced from 20h/month to zero Charge capture first-time-quality increased 0%->70% Applying to other kinds of referrals

45. MQS Learning Project Results Results Reporting: ~ 99,000 lab results had no ordering physician, radiology requisitions lost, extensive rework Preprinted labels on requisitions implemented (12/06) Imaged requisitions increased by 880% (from 957 in July to 9380 in September)

46. MQS Learning Project Results Orthopaedics Project: Reduced time to schedule MedSport appointment from 23 days to 2-1/2 minutes.

47. MQS Learning Project Results Emergency Department –“door to balloon” within 90 minutes increased from 75% to 85% –time to discharge decreased 10 minutes with use of new process (Before, nurses prioritized sickest, never got to discharges) ACE (Appointment, Credentialing and Enrollment) –Credentialing Application website completed (was 72 signatures) –Online Recommendation Letters implemented –Mandatory Criminal Background Checks required 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

48. MQS Learning Project Results CT scheduling and throughput –Physicians “protocol” (review) every request Care transition –Right drugs at discharge –Timely appointment in hand at discharge –Management until the first follow-up visit Wound care –Multiple management models, dressing changes before rounds Timed Blood Draws –New sample time frames for critical blood draws implemented –Nurse / Clerk / Phlebotomy communication enhanced Institutional Review Board –Less than 1% of time spent acting on grant

49. 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.

50. VAS Supply Cart 5S

51. Drawer: Pre-5S

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

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

54. 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

55. Just-In-Time Overview/MQS Philosophy (All Missions) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, Park-Nicollet /jmk 04.09.07 Michigan Quality System MQS UMHS Values: Respect, Compassion, Trust, Integrity, Collaboration, Leadership Built-in Quality

56. Using the fewest resources to consistently deliver exactly what the customer needs Just-in-Time Built-in-Quality Error-Free Don’t Make, Accept, or Send on an Error MQS House – Master version (All Missions) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, J. Womack, Park-Nicollet /jmk 04.09.07 MQS Make Value Flow by Eliminating Errors and Waste Leveled Workload Continuous Improvement (P-D-C-A) and Learning Standardized Work Michigan Quality System Quality – Safety – Efficiency – Appropriateness – Service Customer Defines Value

57. Using the fewest resources to consistently deliver appropriate care Right Care, Right Time, Right Setting Just-in-Time Built-in-Quality Error-Free Don’t Make, Accept, or Send on an Error! MQS House (Clinical Mission) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, J. Womack, Park-Nicollet /jmk04.09.07 Michigan Quality System Safe - Effective - Efficient - Patient-Centered - Timely - Equitable Health Care MQS Make Value Flow by Eliminating Errors and Waste Leveled Workload Continuous Improvement (P-D-C-A) and Learning Standardized Work Ideal Patient Care Experience

58. Just-in-TimeBuilt-in-Quality QUANTITY QUALITY MQS Error Proof Surface Problems Stop and Respond to Abnormalities Solve Problems at Root Cause Pacing by Demand Continuous Flow Pull Systems Work Force - Skilled, Capable, Flexible - Engaged, Motivated - Design Work, Solve Problems Technology and Equipment - Reliable, Tested - Serve People and Processes - Preventive Maintenance -TPM Materials - Materials Readiness - Supplier involvement Make Value Flow By Eliminating Errors and Waste STABILITY MQS Methods (All Mission) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, Park-Nicollet /jmk 04.09..07 Methods - Robust Processes - Organized Workplace (5S) - Visual Control Leveled Workload Continuous Improvement (P-D-C-A) and Learning Standardized Work Customer Defines Value Michigan Quality System Quality – Safety – Efficiency – Appropriateness – Service

59. References Books: Womack J and Jones D. Lean Thinking. Liker J. The Toyota Way. Liker J and Meier D. The Toyota Way Fieldbook Rother M and Shook J. Learning to See. Keyte B & Locher D. The Complete Lean Enterprise: VSM for Office Marchwinski C and Shook J, eds. Lean Lexicon. Articles: Bush R. Reducing Waste in the US Healthcare System. JAMA 2007;297:871. Spear S. Fixing Health Care from the Inside, Today. HBR. 9/05. Spear S. Learning to Lead at Toyota. HBR 4/04 Spear S. Decoding the DNA of Toyota Production System. HBR 9/99 IHI Whitepaper: “Going Lean in Health Care” www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm Web: Lean Enterprise Institute www.lean.org webinars, books, meetings…www.lean.org Michigan Quality System med.umich.edu/mqsmed.umich.edu/mqs Crossing the Quality Chasm: A New Health System for the 21st Century newton.nap.edu/catalog/10027.html

60. 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 with no symptoms 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

61. 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

62. MQS Project Selection Criteria Critical UMHS 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

63. MQS Project Selection Process Select 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

64. 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

65. 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

66. 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?

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

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