Lean Healthcare Transformation Summit 2013, John Toussaint Keynote



Things are underway at the 2013 Lean Healthcare Transformation Summit. We have 600 attendees from 39 states and 8 countries.

I will be tweeting, as will others, at the hashtag #HCsummit13.

John Toussaint, MD will be doing his keynote at 8:30 AM EDT. I will be taking notes live in this public google document  (also see completed notes below).


  • We need to revitalize this industry

  • The people in this room are trying to transform the industry

  • 3 pillars for this summit and transformation

    • Care redesign (including Lean)

    • Paying for value

    • Transparency

  • Tish's story (80 year old patient)

    • Many, many errors and problems in her care

    • “Her morning meds were given at night and her night meds were given in the morning… but they [the nurses] ignored her.”

    • Surgery to correct a hospital-acquired infection

    • Waiting, waiting, waiting

    • Cultured specimens were lost by the lab

    • “Tish noticed nobody who entered the room washed their hands other than the phlebotomist. The antiseptic dispenser was empty.”

    • “It takes guts to tattle on your nurse.” Nothing changed.

    • Her wishes and concerns were ignored

    • A major hospital well known for good safety

    • “Is this your health system??” – rhetorical Q

    • “After two weeks in the system, she was WORSE then when she started.”

    • After three weeks, she was finally better.

  • “It doesn't have to be this way.”

  • Tish is John's mother in law

  • What's the problem? Unfortunately, this is going on a lot in patient care… harming patients.

  • What are some of the root causes?

    • The overall value stream of cancer care is not viewed as an overall system

    • Even though we claim to be highly integrated, we are not

    • Lack of an operating system to help fix things – see article

    • We've got a problem with our management system – the most important critical factor missing in healthcare is a management system that supports improvement.

    • Need to shift from the top-down command and control model to a lean management system

  • What can we do about it?

    • Shows a ThedaCare cancer value stream map for the entire care process

    • Lean management system – connects people and process working for a purpose

    • “Management by process” – not “management by objective”

      • A3 thinking

      • Daily status sheet

      • Daily performance and defect review huddle

      • Unit-based leadership teams

      • Standardized work for leaders and supervisors

      • Standardized work audits

      • Visual process tracking

      • Andons

  • “No meeting zones”

    • 2 hours each morning – so what happens?

    • People leading in the gemba, leading by asking questions

    • One Iowa org implemented 12,000 staff ideas

  • Video of a team “defect huddle”

    • Lab orders remaining on care plans – RNs don't know if they've been done or not – why do they remain there?

      • Do we have a timeline for when we can come up with a suggestion?

      • Asking employees to help solve the problems and improve the process

    • Our job as leaders is to help them unravel the giant hairball of problems

  • Standardized work for leaders – daily stat sheet (status sheet)

    • Asking questions, going off a guide of what to ask and investigate

    • As a CEO, are you going to the gemba for 15 minutes every day? (at least?)

    • Examine your management system – can it actually support the continuous improvement your staff are trying to make happen?

    • Good (in Mark's opinion): staff tracking metrics by pencil at the gema

      • Bad (in Mark's opinion): simplistic “red/green” analysis around an (arbitrary?) target. Need better SPC analysis to avoid overreacting to every up and down in the data (see here)

  • John talks about the mentoring from Paul O'Neill (he is speaking later today)

    • 3 questions – can you say yes every day?

      • Is everybody treated with dignity and respect by everyone?

      • Does everybody had the tools, training, and encouragement to do the work that gives their life meaning?

      • Have people received recognition?

  • Results

    • NYC HHC has saved nearly $250M over 5 years, for example

      • It's management by process so we can get results

    • Reduced cardiac mortality through use of Lean methods (2.5% lower… not much, but it's lower)

  • “This operating system is critical for delivering results.” But we need more than the management system too. Also requires:

    • Transparency of patient outcomes:

      • Study – MDs that report quality of care measures improve more quickly (Health Affairs)

      • The systems that would create this transparency are a mess – no standards, information is locked up for experts to get out

      • Much of Tish's story could have been improved by having better information flow

      • Need more “Business Intelligence” applied to healthcare

    • Payment reform

  • Has anybody put it all together?

    • HealthPartners in MN – web and mobile transparency… rating the MD clinics on cost and quality, star rating

    • Paying differently based on results

      • Withhold payment portion and then pay if they hit metrics

      • Bonus and public recognition for top 1%

      • Triple Aim savings (cost, quality, etc.) – shared savings

      • Trying to “pay for value” in MN and WI

    • Involving the patient to redesign care

  • Wisconsin Statewide Value Committee

(end of talk)


Q&A comments:

  • Most organizations haven't mapped out their existing state. They don't know how they are performing.

  • Reimbursement is a challenge and a problem in every country

  • How many of Tish's problems could have been avoided? 90-95%? One or both hospitalizations could have been avoided?

  • Q: How do we get MDs to follow standardized work?

    • John says we need to look at the system… the system is designed for people to not follow SW

    • (Mark's commentary… we can't force anybody to do anything)

  • don't just Plan and Do and Run – focus on Study and Adjust!

Photo below by Bobby Gladd. See his blog post about the Summit here.

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