HARVARD BUSINESS REVIEW: by Leonard L. Berry and Jamie Dunham | 9:30 AM September 20, 2013
It’s a common patient complaint about the people involved in their care: “Sometimes the left hand doesn’t seem to know what the right hand is doing. I don’t feel everyone is working together.” To address this issue, nurses at ThedaCare employed lean techniques to create a patient-centered, team-based model that’s producing solid results.
Based in Appleton, Wisconsin, ThedaCare is a five-hospital health system with 26 clinics, other allied services, and more than 6,000 employees. It has been a pioneer in applying lean methodology in health care in order to tackle quality and cost issues. It began its lean journey in 2003 and has made considerable progress. For example, its accountable-care-organization partnership with Bellin Health, a health care system in Green Bay, Wisconsin, presently has the lowest cost per Medicare beneficiary among 32 pioneer ACOs, and the ThedaCare Physicians group was ranked first in quality performance statewide in 2013 by Consumer Reports.
ThedaCare opened its first “collaborative care” hospital unit in a medical-surgical unit at Appleton Medical Center in 2007 after 18 months of interdisciplinary planning led by nurses. A second was introduced in a medical-surgical unit at Theda Clark Hospital in Neenah in 2009, and a third in another medical-surgical unit at Appleton Medical Center in 2010. By 2013, all eight medical-surgical units in the two hospitals had been converted to the collaborative-care model.
The results to date show that the inpatient-care model is succeeding in improving safety, efficiency, and effectiveness. For the first three units, costs and length of stay declined, and quality and patient and nursing satisfaction improved. Some metrics improved immediately (within the first month); others over a period of six to nine months. A new process that required the pharmacist, rather than a nurse, to be responsible for “admission medication reconciliation” (a process that ensures that the patient’s list of medications that he or she is taking at home is accurate and can be used as a baseline for prescribing medication during his or her hospital stay) reduced the errors per patient admission to zero from between 1.25 and 1.5.
Team Care at the Bedside
The collaborative-care model replaces inconsistent, fragmented hospital care. A bedside-care teamcomposed of a physician (“medical expert”), nurse (“care-progression manager”), pharmacist (“medication expert”), and discharge planner (“transitional-needs coordinator”) collaborates — with patient and family input — to develop a single care plan that is continuously updated in daily team huddles. On admission, the team gathers the patient history, performs a physical assessment, determines an anticipated discharge date, and works backward from this date to build a coordinated plan of care.
Using evidence-based guidelines linked to the electronic medical record, the nurse manages the patient’s care progression, and the bedside pharmacist contributes to optimizing management of the medication. The physician leads the clinical assessment and planning process but as a team member/partner. The discharge planner assists the team in devising the best transition plan post hospitalization.
This patient-centered approach minimizes duplication of effort, puts people in roles that leverage their skills and accelerates clinical learning as teammates teach each other. Staff use “tollgates” — purposeful timeouts that are a lean concept — to analyze the patient’s status and remove obstacles in delivering care.
Struggles — and Lessons — from the Journey
Despite the progress, the collaborative care model has had its challenges and remains a work in progress. For example, program designers learned belatedly that the new model requires a different kind of unit leader: a team-builder, coach, and mentor. A “collaborative-care spread team” consisting of clinical experts in the model, a project manager, organizational development specialists, and others guide the nurse managers through their unit’s preparation and implementation phases, supporting their leadership development every step of the way.
One challenge that’s currently being addressed is how to both maintain essential standard work across units and accommodate the requirements of clinical specialties. Some adaptation for certain patient types, like the short-stay surgical patients, has been needed to continue to meet the model goals. As with the original design, these adaptations were made using lean tools for ongoing process improvement.
Another ongoing challenge is getting private-practice physicians who use ThedaCare hospitals to fully engage. To help address this issue, hospital medical directors meet with independent physician groups to share essential elements of the model and determine how they can be applied to doctors’ workflows. (Garnering the full participation of ThedaCare-employed physicians has gone more smoothly.)
ThedaCare’s experience with collaborative care offers salient lessons:
Start from scratch. ThedaCare started by designing a new delivery process rather than adding to the existing process. Starting fresh sparks uninhibited creativity; it encourages “why can’t we” instead of “we can’t” thinking.
Follow a methodology. The design team fully used lean methods such as rapid-improvement events, value-stream maps, and visual-management concepts. That ThedaCare turned to hospital nurses to lead the program design reflects the lean tenet of asking people closest to the work to improve it. (For more information on how to apply lean techniques in health care, see this article.)
Fully use the talent. Collaborative care addresses one of health care’s greatest sources of waste and defects: the underutilization of skilled labor. Too often, highly trained staff work below their scope of expertise — for example, doctors doing what nurses not only can do but also probably do better. Nurses coordinating patients’ care progression and pharmacists managing medications represent big wins for patients and other stakeholders.
Involve the patient. The voice of the patient was a critical input in developing the collaborative-care approach. Patients participated in rapid-improvement events and were members of the development team. Patients anxious to know when they would likely go home were the impetus to providing a discharge goal on admission and focusing on the course of care needed to meet that goal. Patients voicing distrust because they were asked the same question multiple times by different clinicians during their admission laid the foundation for an admission process conducted jointly by the care team.
Invest in intentional thinking. Another lean tenet is assessment before action. Two examples: the 18 months that ThedaCare spent planning the new model and the care team huddles before, during, and after patient visits to assess and reassess the patient’s care plan.
Support strategy with infrastructure. Changes in the hospital facility were made to implement the new approach. They included converting semi-private patient rooms to private rooms and replacing the traditional nursing stations with decentralized alcoves located just outside of the patient rooms, where teams can huddle before and after visiting patients. A whiteboard was put in the patient’s room so staff could summarize the care plan, timeline, and other relevant information for patients and families. And the supply server was redesigned so it could be restocked outside patient rooms but would be easy for care providers to access medications (kept in locked compartments) and other things. This reduces the time that it takes for nurses to gather supplies, allowing them to spend more time with patients.
Communicate quality. In general, patients have basic expectations about their hospital experience — they want reassurance that providers care about them, communicate with one another, and are competent. Involving the patient in care planning, summarizing the plan on the in-room whiteboard, and following work standards that provide reliable outcomes communicate to patients that they are receiving quality care.
The progress to date of ThedaCare’s collaborative care model is evidence that patient-centered teamwork can improve the quality and lower the cost of care.
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