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P R E S E N T E D B Y
Achieving Effective Lean Knowledge
Transfer in Healthcare
Name Rebekah Gregory MBA
Title Director Transformational Care PMO
Lean Summit New Orleans May 12
Track J 250-335pm
Catholic Healthcare West
1
55000 employees
10000 active physicians
Further the Healing
ministry of Jesus
Catholic Healthcare West (CHW) is the eighth largest hospital system in the nation
and the largest hospital provider in California with 40 acute care facilities in California
Arizona and Nevada
P R E S E N T E D B Y
Words Matter
2 words about Transformational Care Leadership Development
3
4
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
5
Context for Transformational Care
Part of ldquoMinistry Transformationrdquo to change the way we care for our
patients families and communities
Delivering the right care at the right time in the right place for all of our
patients
You have been chosen to participate in the Transformational Care rollout
ndash You have the perspective energy and ideas to create and sustain a
better patient care model
ndash Need your help to diagnose barriers to care implement solutions and
lead sustainable change
6
Objectives of CHW Transformational Care
Objectives
Improve quality of care we deliver optimize patient flow
and financial sustainability
Provide our management teams and employees with new tools
rooted in lean thinking
Develop organizational infrastructure and capabilities to
sustain improvements and successfully expand
7
The recent shifts highlight a few emerging lessons that will shape
the future of care and how providers will need to respond
SOURCE McKinsey analysis
Addressed by Transformational Care
Drive strong physician alignment in efforts to manage costs and
coordinate care and to drive increased referrals
Explore innovative payor models to align incentives manage costs
and risks gain access to greater volumes through narrow networks
Emerging strategic priorities
Create new service offerings to target the uninsured
Ensure timely and effective implementation of IT programs to capture
value from clinical IT
Ensure strong capabilities are built to enable above strategies (eg
design value proposition to payors amp physicians) and to drive continued
cost control and efficiencies
8
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
Catholic Healthcare West
1
55000 employees
10000 active physicians
Further the Healing
ministry of Jesus
Catholic Healthcare West (CHW) is the eighth largest hospital system in the nation
and the largest hospital provider in California with 40 acute care facilities in California
Arizona and Nevada
P R E S E N T E D B Y
Words Matter
2 words about Transformational Care Leadership Development
3
4
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
5
Context for Transformational Care
Part of ldquoMinistry Transformationrdquo to change the way we care for our
patients families and communities
Delivering the right care at the right time in the right place for all of our
patients
You have been chosen to participate in the Transformational Care rollout
ndash You have the perspective energy and ideas to create and sustain a
better patient care model
ndash Need your help to diagnose barriers to care implement solutions and
lead sustainable change
6
Objectives of CHW Transformational Care
Objectives
Improve quality of care we deliver optimize patient flow
and financial sustainability
Provide our management teams and employees with new tools
rooted in lean thinking
Develop organizational infrastructure and capabilities to
sustain improvements and successfully expand
7
The recent shifts highlight a few emerging lessons that will shape
the future of care and how providers will need to respond
SOURCE McKinsey analysis
Addressed by Transformational Care
Drive strong physician alignment in efforts to manage costs and
coordinate care and to drive increased referrals
Explore innovative payor models to align incentives manage costs
and risks gain access to greater volumes through narrow networks
Emerging strategic priorities
Create new service offerings to target the uninsured
Ensure timely and effective implementation of IT programs to capture
value from clinical IT
Ensure strong capabilities are built to enable above strategies (eg
design value proposition to payors amp physicians) and to drive continued
cost control and efficiencies
8
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
P R E S E N T E D B Y
Words Matter
2 words about Transformational Care Leadership Development
3
4
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
5
Context for Transformational Care
Part of ldquoMinistry Transformationrdquo to change the way we care for our
patients families and communities
Delivering the right care at the right time in the right place for all of our
patients
You have been chosen to participate in the Transformational Care rollout
ndash You have the perspective energy and ideas to create and sustain a
better patient care model
ndash Need your help to diagnose barriers to care implement solutions and
lead sustainable change
6
Objectives of CHW Transformational Care
Objectives
Improve quality of care we deliver optimize patient flow
and financial sustainability
Provide our management teams and employees with new tools
rooted in lean thinking
Develop organizational infrastructure and capabilities to
sustain improvements and successfully expand
7
The recent shifts highlight a few emerging lessons that will shape
the future of care and how providers will need to respond
SOURCE McKinsey analysis
Addressed by Transformational Care
Drive strong physician alignment in efforts to manage costs and
coordinate care and to drive increased referrals
Explore innovative payor models to align incentives manage costs
and risks gain access to greater volumes through narrow networks
Emerging strategic priorities
Create new service offerings to target the uninsured
Ensure timely and effective implementation of IT programs to capture
value from clinical IT
Ensure strong capabilities are built to enable above strategies (eg
design value proposition to payors amp physicians) and to drive continued
cost control and efficiencies
8
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
2 words about Transformational Care Leadership Development
3
4
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
5
Context for Transformational Care
Part of ldquoMinistry Transformationrdquo to change the way we care for our
patients families and communities
Delivering the right care at the right time in the right place for all of our
patients
You have been chosen to participate in the Transformational Care rollout
ndash You have the perspective energy and ideas to create and sustain a
better patient care model
ndash Need your help to diagnose barriers to care implement solutions and
lead sustainable change
6
Objectives of CHW Transformational Care
Objectives
Improve quality of care we deliver optimize patient flow
and financial sustainability
Provide our management teams and employees with new tools
rooted in lean thinking
Develop organizational infrastructure and capabilities to
sustain improvements and successfully expand
7
The recent shifts highlight a few emerging lessons that will shape
the future of care and how providers will need to respond
SOURCE McKinsey analysis
Addressed by Transformational Care
Drive strong physician alignment in efforts to manage costs and
coordinate care and to drive increased referrals
Explore innovative payor models to align incentives manage costs
and risks gain access to greater volumes through narrow networks
Emerging strategic priorities
Create new service offerings to target the uninsured
Ensure timely and effective implementation of IT programs to capture
value from clinical IT
Ensure strong capabilities are built to enable above strategies (eg
design value proposition to payors amp physicians) and to drive continued
cost control and efficiencies
8
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
4
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
5
Context for Transformational Care
Part of ldquoMinistry Transformationrdquo to change the way we care for our
patients families and communities
Delivering the right care at the right time in the right place for all of our
patients
You have been chosen to participate in the Transformational Care rollout
ndash You have the perspective energy and ideas to create and sustain a
better patient care model
ndash Need your help to diagnose barriers to care implement solutions and
lead sustainable change
6
Objectives of CHW Transformational Care
Objectives
Improve quality of care we deliver optimize patient flow
and financial sustainability
Provide our management teams and employees with new tools
rooted in lean thinking
Develop organizational infrastructure and capabilities to
sustain improvements and successfully expand
7
The recent shifts highlight a few emerging lessons that will shape
the future of care and how providers will need to respond
SOURCE McKinsey analysis
Addressed by Transformational Care
Drive strong physician alignment in efforts to manage costs and
coordinate care and to drive increased referrals
Explore innovative payor models to align incentives manage costs
and risks gain access to greater volumes through narrow networks
Emerging strategic priorities
Create new service offerings to target the uninsured
Ensure timely and effective implementation of IT programs to capture
value from clinical IT
Ensure strong capabilities are built to enable above strategies (eg
design value proposition to payors amp physicians) and to drive continued
cost control and efficiencies
8
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
5
Context for Transformational Care
Part of ldquoMinistry Transformationrdquo to change the way we care for our
patients families and communities
Delivering the right care at the right time in the right place for all of our
patients
You have been chosen to participate in the Transformational Care rollout
ndash You have the perspective energy and ideas to create and sustain a
better patient care model
ndash Need your help to diagnose barriers to care implement solutions and
lead sustainable change
6
Objectives of CHW Transformational Care
Objectives
Improve quality of care we deliver optimize patient flow
and financial sustainability
Provide our management teams and employees with new tools
rooted in lean thinking
Develop organizational infrastructure and capabilities to
sustain improvements and successfully expand
7
The recent shifts highlight a few emerging lessons that will shape
the future of care and how providers will need to respond
SOURCE McKinsey analysis
Addressed by Transformational Care
Drive strong physician alignment in efforts to manage costs and
coordinate care and to drive increased referrals
Explore innovative payor models to align incentives manage costs
and risks gain access to greater volumes through narrow networks
Emerging strategic priorities
Create new service offerings to target the uninsured
Ensure timely and effective implementation of IT programs to capture
value from clinical IT
Ensure strong capabilities are built to enable above strategies (eg
design value proposition to payors amp physicians) and to drive continued
cost control and efficiencies
8
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
6
Objectives of CHW Transformational Care
Objectives
Improve quality of care we deliver optimize patient flow
and financial sustainability
Provide our management teams and employees with new tools
rooted in lean thinking
Develop organizational infrastructure and capabilities to
sustain improvements and successfully expand
7
The recent shifts highlight a few emerging lessons that will shape
the future of care and how providers will need to respond
SOURCE McKinsey analysis
Addressed by Transformational Care
Drive strong physician alignment in efforts to manage costs and
coordinate care and to drive increased referrals
Explore innovative payor models to align incentives manage costs
and risks gain access to greater volumes through narrow networks
Emerging strategic priorities
Create new service offerings to target the uninsured
Ensure timely and effective implementation of IT programs to capture
value from clinical IT
Ensure strong capabilities are built to enable above strategies (eg
design value proposition to payors amp physicians) and to drive continued
cost control and efficiencies
8
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
7
The recent shifts highlight a few emerging lessons that will shape
the future of care and how providers will need to respond
SOURCE McKinsey analysis
Addressed by Transformational Care
Drive strong physician alignment in efforts to manage costs and
coordinate care and to drive increased referrals
Explore innovative payor models to align incentives manage costs
and risks gain access to greater volumes through narrow networks
Emerging strategic priorities
Create new service offerings to target the uninsured
Ensure timely and effective implementation of IT programs to capture
value from clinical IT
Ensure strong capabilities are built to enable above strategies (eg
design value proposition to payors amp physicians) and to drive continued
cost control and efficiencies
8
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
8
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
9
Several core value drivers are recommended
OR or Preadmission Process
(eg on time 1st case starts)
Core initiatives chosen based
on potential for financial impact
Decision to customize should be primarily
based on value tradeoffs (financial and non-
financial)
ED front-end
ED admissions
ED throughput for discharged pt
ED ancillary services turnaround time
Discharge turnaround times
Discharge throughput
OR on-time starts
OR turnaround time
Clinical resource consumption
Outpatient Imaging
Cath Lab
Medical determination 1- inpatient vs
obs status assignment
Medical determination 2- IP only
procedure list
Durable medical equipment rentals
ED Registration Process
Medical Determination (IPObs)
for patients entering from the ED
5 value drivers for most hospitals
Insurance denials
Customization options
Potential
to customize
Core initiatives
ED (eg front end or throughput)
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
10
Important considerations in choosing value drivers
Give staff ldquoquick winsrdquo to build excitement -gt Processes amenable to rapid
change and visible improvement are best choices
All value driver areas will require a strong team leader and
physicianclinician input (if they are clinically facing)
Each value driver requires a cross-functional team to address the issues
Areas that require longer lead time to demonstrate impact can be
considered (eg Medicare LOS patient safety issues Clinical Quality
issues) but should be complemented with areas amenable to immediate
results
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
11
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
12
bull Very ldquobottoms-uprdquo approach to problem solving led by you because you know what does not work and how to improve patient care
bull Collaborative problem solving involving physicians nurses and non-clinical staff to address both clinical and non-clinical processes
bull We will serve as your ldquoarms and legsrdquo to prove your ideas and help implement your solutions
bull We will have a ldquobias toward actionrdquo which means we will always ask ldquoGreat idea Why not make this change tomorrow morningrdquo
This program will feel different from previous efforts in 4 significant
ways
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
13
What to expect from the Transformational Care Team
A professional group that is committed to seeing CHW succeed while
upholding your values and working style
TC will not ldquocome with all of the answersrdquo but will always offer a
perspective and work to build the right system for you
The team will always push for making real physical changes quickly not
just coming up with new ideas
We strongly believe in the dual mission of demonstrating sustainable
impact as well as investing in building the capabilities of your organization
The working team will be at the frontline with you from Monday through
Thursday for the duration of the effort
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
14
installing systems to
manage operating system
bull Performance management
bull Capability building
processes
optimizing
processes and
resources
bull Waste elimination
bull End-to-end design
bull Focus on value
levers
bull Variability reduction
(six sigma)
giving people clear
direction and skills to get
job done
bull Leadership role modeling
bull Alignment amp communication
bull Deep skill sets
bull Continuous improvement
infrastructure
A sustainable Transformational Care system has 3 elements
Maximize value to the patient and the health
system by
Performance
management
infrastructure
Mindsets
behaviors amp
capabilities
Operating
system
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
15
What TC is and what TC isnrsquot
bull Remove unnecessary work
bull Design systems to enable better care
bull Permanently eliminate waste
variability and inflexibility
bull Build capabilities for continuous
improvement
bull Create a culture of continuous
improvement
TC organizations do this Not this
bull Ask people to ldquojust work harderrdquo
bull Improve one department by harming
the whole system
bull View improvement as a short term
project
bull Undervalue the role of some team
members
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
16
Augmenting staffrsquos capabilities ndash Proposed 12-week curriculum
to teach lean operations and management skills
All modules are 90-120 minutes unless otherwise noted
121110987654321
Week
Activity
Sustainability
Meeting and Time Management
Change Management
Performance management
Influencing skills
Feedback and coaching
Management skills
Standard Work
Continuous flow
Lean reporting (ie TC-1s and TC-2s)
Root-Cause Problem Solving
Lean training
2-day TC Boot Camp
TC Intro and Aspiration Setting
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
17
5-Jan 6-Jan
Reflection Recap of previous day
Reflection Opening amp Intros
TC Director lunch panel
Break
Break
Recap and Next Steps
DEPARTUREPerformance Management
JIT One Piece Flow (with Lego Game)
Value Stream and
Process Mapping
TC-1 Reports
Introduction to TC and TC Playbook
(including lessons learned)
Best Practice Solutions ED throughput
Registration Medical Determination OR
and Keys to Success for TC
Feedback and Coaching
Problem Solving
(Root Cause and Issue Trees
Prioritization)
Standard Work (Including Tshirt Game)
Aspiration Setting Exercise
(Disc-changing game)Influencing Skills
Working Lunch Solving the Change
Management Challenge
We will give you a preview of the 12 week curriculum
with a 2 day ldquoBoot Camprdquo
TC Fundamentals
Managementcommunication skills
Introteam learningteam building
Approach and solutions
a packed 2-day preview of Transformational Care that covers
the approach and trains on general management problem-
solving and lean tools
PRELIMINARY
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
18
Transformational Care is divided into distinct phases
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
19
SUSTAIN PHASE A TC Steering Committee will provide ongoing
oversight beyond the initial 12 week Wave
TC Steering Committee membership
Principal members
TC Champion
TC Director
Quality Director
TC Analyst
VPMA COO
CNE
Governance for Transformational Care
Maintain current performance on TC initiatives
Drive continuous improvement
Mission
PRELIMINARY
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
20
Key deliverables and activities for each phase of Transformational Care
Prepare for
launch
Assessment
of opportunity
areas
Transfor-
mation
Performance
management and
integration
Duration
Activities
ldquoPreparerdquo ldquoDiagnoserdquo ldquoTreatrdquo ldquoSustainrdquo
Leadership
alignment meeting
Clearing of
calendars and
divesting
responsibilities
Complete data
request
Set up working
teams
Build
communication
strategy
Identify
performance
baseline
Build 4-5
working
teams
Launch daily
performance
tool
2-3 training
sessions
Wave of
operational
change in the
selected
areas
Launch daily
performance
tool
5-6 training
sessions
Refine
implementation
Launch
Performance
Improvement
Committee
Prioritize further
performance
improvement
2-3 training
sessions
4-6 weeks 2-3 weeks 5-6 weeks 2-3 weeks
Where we are today
The ldquo12 weekrdquo initial TC program
Continuous
improvement
cycle
Perpetual
Sustain and
build on initial
improvements
Embark on
improvements
in new areas
Monitor
improvements
in metrics and
take corrective
actions if
needed
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
21
After the initial 12-week roll-out CHW will continue to provide support
Sustainability
check-ups
Follow-up
training
Follow-up visits by the CHW TC team
to facilities after the initial launch
As requested visits to provide
counsel and suggest course
corrections Dedicated Corp lead for
each region
Refresher trainings workshops Web-
based trainings and other programs
(eg certification program) beyond
the 12-week initial training provided in
each Wave
Rewards and
recognition
Examples include TC newsletter
recognizing contributors exposure to
senior leadership TC Academy and
epery level trainings Annual TC
Director Summit
Description
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
22
The end result is a measured pace of changes with gradually
increasing scope
Stabilize
improvements
Roll out new
initiatives in
existing areas
Roll out full
initiative in
existing areas
Initiate initiatives
in new areas
4-6 8-12 16-20
Moving to next phase
indicates stability of all
previous phases
~6 months
2-4
PRELIMINARY
Weeks
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
23
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
24
TC is structured initially into ldquoworking teamsrdquo that meet 2xweek
TC Champion
TC Director
TC Analyst
ED registration Med Det - ED OR Denials
1 working team
leader
2-3 Registration
clerks
1 triage nurse
1 billing analyst
1ED chart
revieweranalyst
1 working team
leader
1 dataIT or
Finance Analyst
1-2 case
managers
1 nurse director
1 ER staff
member ndash RN or
manager
1 billingcoding
analyst
1 Physician
1 working team
leader
2-3 OR nurses
ndash 1 Preppre-op
nurse
ndash 1 OR nurse
1 Anesthesiologist
1 Surgeon
1-2 housekeeping
staff
1 OR manager
1 working team
leader
1 case manager
1 business office
representative
1 member from
CBO (via phone)
1 nursecase mgr
who does appeals
1 registration
admitting rep1
1 financial
counselor
Choosing the right leaders and team members to drive the TC effort is crucial to the success
of the transformation select based on talent and not necessarily tenure
ED throughput
1 working team
leader
2-3 nurses
1 charge nurse
1 ER physician
1-2 housekeeping
staff
2-3 ancillary staff
ndash 1 from lab
ndash 1 from
imaging
EXAMPLE
1 If initial notification of admission to the payor is not done by registration then also need to add representative from
group that does initial notification
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
25
The working teams will be the vehicle for transforming the area
and instilling the continuous improvement mindset
Increasing our
patientsrsquo access
and flow to care is
critical to serving
our patients and
community
Assess
current access
and flow
metrics
Prioritize and launch
completely a portfolio
of initiatives to improve
performance
Track progress and
refine initiatives as
part of a
continuous
improvement
process
3
1
2
Begins with a broad
evaluation of ldquothe
problemrdquo and quickly
narrowing down on
the most critical
highest impact areas
ldquoBias towards
actionrdquo strive to
achieve immediate
measurable impact
Performance
monitored daily on
an ongoing basis
ldquoCourse correctrdquo
as necessary
Maintaining this cycle is the most crucial component of preserving
the momentum which the transformation effort seeks to instill
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
26
in supporting your teams through a standard ldquoTCrdquo approach
It is the responsibility of the working teams to improve the metrics in their area
Agree on opportunity
areas
Create and launch
portfolio of initiatives
Track performance
and continuously
improve
Discuss areas of responsibility for working team
Understand baseline data and metrics
Uncover bottlenecks and agree to collecting meaningful sub-
metrics to diagnose barriers
Review metrics and new sub-metrics for our area of
responsibility
Collectively brainstorm improvement initiatives
Communicate with key stakeholders (staff and physicians) in
our areas (eg ED nursing units)
Launch pilot initiatives
Communicate successes from initiative launches
Implement full initiatives
Review daily metrics and discuss with key stakeholders
Refine initiatives as necessary
Transition refinement leadership to key stakeholders
Work with front-line staff and key stakeholders to ensure
culture of responsibility for continuous improvement
Key activities Timing
Weeks 1-2
Weeks 2-4
Weeks 5-10
Weeks 10-12Sustain performance
and continuously
improve
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
27
After the initial 12 week roll-out of TC CHWrsquos TC Team will support
you and provide a network-wide foundation for TC over time
Objective
Support individual sites through
launch and sustainability of
Transformational Care
Activities
Participate in pre-launch
session with leadership
Participate in 2-day TC Training
Lead one of the TC teams on-
site during the 12-week roll out
Provide coachingfeedback for
TC Director on an ongoing basis
Provide onoging education and
training
Support of TC efforts for
individual sites
Foundation for TC across the
network
Objective
Build a consistent and
continuously improving
foundation for TC across the
network
Activities
Compile compendium of best
practices for different processes
Provide support in definition of a
common set of metrics across
all facilities
Update and share TC Playbook
as continuously improved with
roll-out to new facilities
Convene TC meetings for
sharing of best practices
CHW
TC Team
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
28
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the process
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
29
Questions you may havehellip
So is it really working
Is it worth the trip
What happens next
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
30
What Wersquove Been Able To Achieve ndash step change not incremental
improvements
Value Stream Metric Measure Baseline May Improvement
Emergency
Department
ED Discharged
LOS
Minutes 311 223 25
Emergency
Department
ED Admitted
LOS
Hours 90 69 25
Pressure ulcers HAPU
occurrences
of occurrences
per 1000 pt
hours
41 14 66
Emergency
registration
Co-pay collected Rate 55 68 25
Emergency
registration
Left without
being registered
Rate 158 28 80
Emergency
Department
Left without
being registered
Rates 20 04 80
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
Each Site has seen 2 frac12 X return on investment
Implementation of TC in 29
facilities so far
FY 11 annualized 64 million to the
bottom line (18months)
More than 1500 people trained
Integration with quality risk
finance
31
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
32
Are mindsets and behaviors changing
ldquoI really like the new process because it makes
all of the staff focus on moving patients in
and out of the ED in a timely mannerrdquo ED Physician
ldquoI always know what is next for my patients
at any given moment The way things are
organized just makes it feel as if things are
running smoothlyrdquo
- ED Nurse
ldquoBefore I would go to the ED 2 or 3 times for
the same patient Now I know when the patient
is ready for me and I donrsquot have to waste time
making unnecessary tripsrdquo
- Imaging Technician
ldquoThings are working with the new changes
because we can see it in the data and it just
feels like we are less busy even though we
have the same number of patientsrdquo
- Charge Nurse
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
33
Presentations of team work shared at each site
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
34
Mindset and behaviors ARE Changinghellip
ldquoI notice the nurses asking each other ahead
of time for help with the assessment when
they are getting an admissionrdquo
-Charge nurse
It is amazing to see people
with different roles all meet
together to discuss a plan for
the day
-OR Nurse
ldquoTransformational Care gave us
the ability to fix problems instead
of blaming each otherrdquo - ED registration clerk
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
35
Specific keys to Success for staff
Performance Management Tool
Daily Performance Huddles
Standard Work-PO ownership
Executive GEMBA walks
Rewards amp Recognition
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
36
Common features of successful implementations are clear
Strong champion at the senior leadership level
A credible facility TC Director
Engagement at the staff level
Physician involvement
Picking the right process areas
Time for team leads to do the work
Participation by all managers in the TC training
sessions
Appropriate participation by department
managers in implementing the solutions for the
teams
Communication and celebration
Timely IT support to develop the performance
management tool and system
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
Address the mindsets and behaviors
Success = Total transparency
Tell the stories
Celebrate the successes
Share the mishaps and lessons learned
We learn from each roll out and we change and become more
sophisticated PDCA
Sayhellip ldquothatrsquos a good idea try it tomorrowrdquo
Practice exactly what you preach
Be Present all levels must go to the GEMBA
Respond to daily metrics
Support donrsquot interfere Remove barriers
37
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
38
Topics for Discussion
Introduction and TC program objectives
Value drivers and standard work areastailoring
The ldquoTC Playbookrdquo overview of the structure
TC Team
Key next stepscritical path items
Okay thatrsquos great now how do we change the
culture
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
What are we doing
bullThe pressures to change far
out way the risk of standing
still healthcare reform 2trillion
in Medicare cuts need I say
more
bullQuality we are still killing
people and spending a fortune
on professional liability
Healthcare we have a burning
platform
Sohellipin the tradition of
healthcare letrsquos write a policy
and educate NO STOP THE
MADNESS
39
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
Thatrsquos all Great but how
We have a burning platform
We have tools and methodologies but we still have questionshellip
Q
How do we integrate this into the way we work
How do we excite the front line staff
How do we teach front line staff
How do we ask managers to be involved and support but not sit on the working
teams
How do we ensure leadership is committed
A
The answer is ldquoculture changerdquo and this happens one story
and experience at a time
Letrsquos talk about what ldquowonrsquot workrdquo
ndash LEAN everything
ndash Pure Replication-EDICS
ndash Education
ndash Green yellow red bop it on the head
40
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
Let me tell you a story about the Emergency Department
41
We had an unfortunate event
A young girl died after waiting 5 hours in
the ED-You may have seen it on Nancy
Grace
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
Guess which one was successful and which one failed
42
bull Perform RCA-leadership
bull Root cause no one watching patients in waiting room
bull Solution Put RN in waiting room
bull Call them waiting room liaison
bull This is a ldquoquick fix or work aroundrdquo
Traditional method
bull Put a team of ED staff together owner
bull Determine the RCA and the GAP
bull Determine a new process to eliminate the GAP
bull Create standard work for the new role (people performing the standard work)
bull Test re-do training plan implementation plan
bull Repeat
TC method
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
Change the culture
We love to say this but what
does it mean
David Mann says ldquoCulture is
an idea it is the result of a
organizations management
systemrdquo
What do you reward Work
arounds
What do you do when the new
process isnrsquot followed
Nothing When the data isnrsquot
moving Nothing
43
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
Culture change today
Can we change the culture today Tomorrow
How do we change a culture
One step at a time one person at a time one project at a time one patient at a
time one story at a time one experience at
at time
It all adds up to a new efficient effective
Culture
44
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
How do you change a culture
45
Targets you can see
visual controls
Specific expectations
Tools Routine practices
Leaders behavior
In 2 words ldquoManagement
Systemrdquo
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
They are watching you
As a leader in lean every decision is watched
Are you walking the walk or just talking the talk
Case Study
You are the Process Owner of the ED throughput team
Your daily metrics are showing an increased
Length of stay
What do you do
46
47
To answer your questionshellip
So
It is really working
and
It is worth the trip
47
To answer your questionshellip
So
It is really working
and
It is worth the trip