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

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

P R E S E N T E D B Y

Words Matter

2 words about Transformational Care Leadership Development

3

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

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