Lean Thinking in Health Care at UMHS Creating the Michigan Quality System

1. Lean Thinking in Health Care at UMHS Creating the Michigan Quality System Jack Billi, M.D. jbilli@umich.edu Michigan Quality System: med.umich.edu/mqs • Michigan Quality System: • Quality • Safety • Efficiency • Appropriateness • Service

2. Background SEMI has problems in quality, safety, efficiency, appropriateness, service Problems harm patients, raise costs, frustrate workers Economy: short & long term Current state at UMHS >20,000 faculty, staff, trainees >100,000 processes, all have problems Great workers trying to do a good job Goals Ideal Pt Care Experience Ideal Clinician/Staff Experience Ideal Research/Trainee Experience Safest health system in US Financial stability Analysis Workers/mgrs: +/- trained in problem solving; little std work Problems complex, cross units; work often invisible Unclear responsibility for problems Unclear priorities Time, cost pressures: stress Strategies Spread a consistent QI model across UMHS -Build on our CQI base -Study lessons from Lean Thinking 20,000 problem solvers Michigan Quality System Plan: (UMHS workers help build it) Lean Thinking in Health Care at UMHSSummary A3 J Billi 10/8/10

3. The Ideal Patient Care Experience Our future state vision: Based on Institute of Medicine Report “Crossing the Quality Chasm” • Patient Centered Medical Home • Patient and Family Centered Care • Clinical Quality • Safety as a System Property • Service Excellence • Care Coordinated Around the Needs of the Patient • Facilities, Amenities for a Healing Environment

4. The Ideal Patient Care Experience • The IOM “Chasm” Report gives us a vision of where to go • Lean Thinking gives us the holistic approach and business system to get there

5. The Ideal Patient Care Experience • The IOM “Chasm” Report gives us a vision of where to go • Lean Thinking gives us the holistic approach and business system to get there

6. Goal: All 20,000 UM “workers” can: • Do our work every day in a standard way that we created • Not just the way the work evolved! • Be alert to things going wrong • They always do! • Fix the problem now • For this patient or co-worker • Find and fix the root causes of the problem • So it never happens again! Modified after Spear; Billi

7. Go See. Go to the real place where real work is done Ask Why. Seek deep understanding of causes Show Respect. Workers solve their own problems -John Shook, quoting Fujio Cho Three Keys to Problem Solving… and leadership 7

8. Psychiatry Referral Process Current State Map 8

9. Value Stream Mapping:Learning to See • “Ah ha” moments: • I never knew this is how it worked! • I can’t believe what a mess this process is! • No wonder we’re frustrated! • It’s a miracle a patient ever gets through it!

10. “20,000 Problem Solvers” Every worker applying the scientific method to every part of daily work. Turn all daily work into an experiment and every worker into an investigator. -Steven Spear

11. Lean Thinking - Likegreat medical care • Tackle work problems with the rigor and systematic thinking we use for patient problems. • Help every worker become an skilled clinician.

12. How can we create (liberate)“20,000 problem solvers”? • Help each worker take initiative to find and fix causes of problems he/she faces daily • This means each of us has two jobs: • Do the work • Improve the work • Managers role: • Support improvement work (time, mentoring) • Align improvements so value flows to the customer Modified from J Shook

13. Patients referred for brain metastases From 3 visits over 5 days (consult, simulation, treatment) To 95% of patients have all 3 parts within 24 hours Getting Lab Results to the Right Physician From 13% lab requests had no ordering physician, To Less than 2% Better Discharge Planning – appointment in hand Decreased readmissions by 33%; ER visits by 81% Redesigned Handoffs from Cardiac Surgery to ICU Standard work resulted in 2 day decrease in LOS CT scheduling and throughput for inpatients Like drycleaners: In by 9AM, out by 5 PM for inpatients Some Results from the Michigan Quality System

14. Michigan Collaboratives& Lean Thinking • Many hospitals and physicians! • PGIP Lean Collaborative (BCBSM) redesign care of chronic illness • Collaborative Quality Initiatives (BCBSM) – use process redesign • Michigan Quality Improvement Consortium – prioritizes across MI, uses RCA, PDCA • MHA’s Keystone ED Collaborative • GDAHC’s SaveLivesSaveDollars ED Collaborative: avoidable visits

15. Save Lives Save Dollars: Southeast MI’s Collaborative • Convened by GDAHC • Many stakeholders: employers, labor, payers, hospitals, physician organizations, public health, community • Goals: competitive health region through compliance with evidence based guidelines & bending cost curve • Means: common public reporting, coordinated quality improvement • Current Collaborative Initiatives: • ED Collaborative: avoidable visits • Low back pain: reduced imaging and surgery • Diabetes: worksite education • Common public reporting: www.mycarecompare.org • RWJ Aligning Forces For Quality (3rd cycle application) • HHS Charter Value Exchange

16. Our Challenge Lean thinking: successful in manufacturing, service, banking, airlines, and increasingly in healthcare. Isolated results in healthcare have been great but systematic uptake across organizations has been slow. The Challenge: "What specifically do we recommend that Southeast Michigan groups do to accelerate the use of lean thinking to transform health care to improve quality and control cost?" Each table volunteers to address 1-2 of the 6 questions

17. Our Deliverable Action Group 5 recommendations to encourage the use of lean thinking to improve value in Southeast Michigan: • Common Definition of Quality - adopt/revise: • Physicians, PO's, MSMS and MOA: • Hospitals, health systems, and MHA: • Insurers/payers, and MAHP: • Employers: • Coalitions/SLSD: