June 15, 2009

Lean Management — Wisconsin’s ThedaCare Improves Its Radiation Oncology Care Process
By Beth W. Orenstein
Radiology Today
Vol. 10 No. 12 P. 14

The patient goes through the simulation and any magnetic resonance images they might need the same day. Before the patient leaves the center, the physician reviews the images to be sure they are accurate and the proper views.

Cancer patients at ThedaCare, Inc, a community health system based in northeastern Wisconsin, were waiting nearly one month from the time they were told they needed radiation until their first treatment. That was before the health system’s radiation oncology department implemented so-called lean management strategies designed to provide the best quality, lowest cost, and shortest lead time to provide a service. Now, patients typically undergo their first treatment within seven days of referral, and the goal is to reduce it to five.

“We started with what was a 26-day process, and after our first pass implementing ‘lean thinking,’ we collapsed it to 16,” says Kim Barnas, ThedaCare’s vice president of radiation oncology. “Then we did a second value stream pass, where we actively sought out anything that didn’t add value to the patient’s experience. At the end, we reduced referral to treatment times to seven days. We’re sustaining it at seven, so we went from a 26-day process to a seven-day process.”

Eventually, Barnas would like to reduce the wait time from the initial consult to treatment to five days. “But I’m not sure you can get it much lower than that with the current technology,” she says. “Hopefully, in the future, there will be a way, but with the logistics of running a treatment plan and the computer time that it takes, there are some limiting factors. Still, we will strive to reduce it even further.”

Productivity and Revenue Gains
The reduction in wait time for starting treatment is one of several accomplishments since the department began rethinking how it cares for patients. It also has improved productivity by 30%, increased gross revenues by 24%, and helped relieve staff, allowing them to focus more on patient care.

The radiation oncology department is just one in the healthcare system, which is comprised of four hospitals and 21 physician clinics, to look for ways from within to improve what it does every day for its patients. The radiation oncology department sees about 800 patients a year, 95% of whom have cancer. With three physicians and a staff of 24, it provides conventional radiation therapy, tomotherapy, and radiosurgery.

In 2003, led by then-president and CEO John Toussaint, MD, ThedaCare hired Simpler Healthcare, a division of Simpler Consulting, LP of Ottumwa, Iowa, to help reduce costs and, at the same time, improve patient care by implementing quality improvements. (A little more than one year ago, Toussaint stepped down as CEO to become head of the ThedaCare Center for Healthcare Value. The center plans to bring together leaders from business and healthcare to find and promote ways to make the national healthcare system more efficient. Dean Gruner, MD, is now president and CEO of ThedaCare, which has 5,400 employees.)

Toyota Production System
Simpler specializes in the Toyota Production System, which was developed by the Japanese to provide the best quality, lowest cost, and shortest lead time through the elimination of waste. The production system is a precursor to lean manufacturing, which became popular in the 1980s and 1990s in the United States when manufacturers were faced with increased foreign competition.

“Its basic principles of lean can be applied to any industry, including healthcare,” says Michael Chamberlain, general manager of Simpler Healthcare. “Our division works with about 75 hospitals across the country; of those, approximately 20% have applied the management system specifically to radiation oncology.

“When lean principles are applied to healthcare, the results can include improved patient outcomes and reduced costs,” he adds. “Many might assume the two are trade-offs, but they are not. Rather, they complement one another. By focusing only on the value that is created, unnecessary steps are removed and the patient’s experience is greatly enhanced.”

Administrative Beginning
John Poole, senior vice president responsible for ThedaCare’s lean transformation, says the healthcare system has approximately 16 areas where it has been working to implement lean principles. It started six years ago with accounts receivable, a nonclinical area, “because it was seen as a safe environment,” he says. The impressive results encouraged the health system’s management to expand to patient care areas, including radiology and radiation oncology.

ThedaCare was not in dire financial straits or facing a quality crisis when it hired Simpler Healthcare. “In fact,” Barnas says, “we were pretty much considered to be in the top quartile in all areas, but the vision of our leadership team was that we needed to create value to our customers [the patients].”

The impetus to apply lean principles to the radiation oncology department came in 2005 when it purchased a $3 million Accuray CyberKnife, a sophisticated robotic system used to treat lesions and tumors anywhere in the body with radiation rather than open surgery.

“We wanted to improve our processes and our flow so we would minimize the number of employees that we would need to hire to run that new technology,” Barnas says. “So there was a driver there beyond the traditional driver of quality. We wanted to be sure we had the best processes, the best quality to implement this new technology at the least cost.”

The lean process that Simpler has developed involves a specific set of steps. It starts with a team of employees and patients making a “value stream map” of every process provided in the area’s service line being addressed. Then it holds one-week events, known as rapid improvement events, to focus on fixing one defect or problem that the team has identified and wants to improve.

Patient Flow
“The first thing we did in radiation oncology was to develop at a high level a map of how a patient flows through our system, and then we identified where potential improvement opportunities would exist,” Barnas explains. The value stream mapping involved 10 to 15 stakeholders in the process. “You have customers [patients] there. You have leadership there. You have physicians there. And you have staff representing all the different departments that are involved in the management of cancer patients,” Barnas says. The meetings are facilitated by a leader from ThedaCare and a Simpler “sensei,” which is Japanese for teacher or leader.

It took the group 31⁄2 days of working from 8:30 am to 4 pm to map out every process in radiation oncology. “We also had eight weeks of prep time for that step and three weeks of follow-up time,” Barnas says.

The group determined that the department had 180 steps in its processes and examined each one. Then it asked some of its customer-patients for input about which processes they valued. Barnas says the results were somewhat surprising. “Inevitably, they [the patients] will tell you, the only place they find value is when they’re getting a procedure and are face-to-face with a doctor or face-to-face with a nurse,” she says. “So you break it down further, and maybe 30 out of those 180 steps actually add value to the patient. We’re not saying you don’t have to do all those other steps, but it’s shocking to the staff and the physicians when the patients say they really don’t care about how long it takes to get their blood work. They don’t really care about being weighed or that you need three weeks to make a treatment plan for them. All they care about is seeing you and getting a plan and getting their treatment started.”

Thus, the group’s No. 1 goal became reducing the patients’ waiting time for every step along the way, including when they first call for an appointment. “Anytime a patient had to wait, that was not a patient satisfier,” Barnas says. “It was not a staff satisfier, and it was not a physician satisfier. So our goal was to collapse the flow time.”

Action Plan
The second step in the lean process is to develop an action plan to fix the problem that has been identified in the first step. The third step is to implement that plan. Once the plan is in place, the final step is to continue to improve on a daily basis. Lean is seen as a journey, not a destination.
The radiation oncology group wrote an action plan to reduce the time from the patients’ initial call to their first appointment. That part of the cycle had been taking seven days. “Now it’s down to three,” says Karen Flom, business unit manager of ThedaCare’s cancer and radiation oncology center. “We did that by looking at how we organize schedules and physician time, as well as the information we needed before we could see anyone.”

The group was able to reduce the wait time even further when it realized that a large part of the delay was the lack of communication. The old way required the patients to come for an initial consultation, go home, come back for a simulation, go home, and come back for another appointment to see whether the treatment was right. The patients would go home again and come back a fourth time to finally start their treatments. The group was able to condense those four appointments into two by having everyone involved share information while the patients were still at the center rather than after they left. The patients may be at the center longer for those two days, but it’s still two vs. four separate days, and the wait between appointments is much shorter, which means less anxiety for the patients, Barnas says.

Shaving Days
Scheduling was revised so that the dosimetrist and the radiation oncologist were able to speak right away.

“In the past, it took an extra two to three days because the dosimetrist would leave a message for the physician and the physician would have to track down the dosimetrist, and they would play tag back and forth just to transfer information about the planning directives,” Flom says. “We reduced all that to a single process so they could share the information each needed without having to hunt anybody down for questions.”

All members of the patient care team—nurse, dosimetrist, radiation physicist, and radiation therapist—block their schedules so that when a patient comes for a consultation, everyone knows what the potential diagnosis will be, Flom says. The patient goes through the simulation and any MR images they may need the same day. Before the patient leaves the center, the physician reviews the images to be sure they are accurate and the proper views. This way everyone is certain that all the information needed for treatment planning is obtained, and it eliminates the possibility of delays because something is missing or incorrect, she says.

 Barnas says the rapid improvement team reviewed the process twice. That’s how it was able to reduce the time even further—from 26 days to 16 days and then to seven days. The difference the second time, she says, is that everyone was buying into the management process. “We had our physicians much more engaged,” she says. “The first time we did the value stream, they didn’t trust what we were doing very well yet, so they wouldn’t give up some of their processes. Once credibility and trust were established, once they realized that we would listen to them and never do anything to compromise patient care, they were willing to work with us and change their processes to help us collapse that time even further.” The first time through, Barnas says, “We learned how to dance. The second one, we were doing some pretty advanced steps.”

Continuous Improvement
Now the task is to continue looking for ways to improve. “Our goal is to eliminate waste from the process every single day,” says Barnas, hoping that, with advancements in technology, it can be done in as little as five days.

The staff are enthusiastic about the continuous improvements, Barnas says, because they own the process. “Ninety-four percent of our employees can initiate and demonstrate competency in the lean tools we use for problem solving. Our goal is to get it to 100%,” she says.

While lean management has resulted in significant cost savings and increased productivity, most importantly, it has meant that patients are happier because they are getting the same quality of care with better service, according to Barnas.

“One thing I would really stress is the tremendous benefits to the patient,” adds Chamberlain. “If you’re a patient in the process today vs. before, there have been great breakthroughs, and they’re very pleased with the outcomes.”

— Beth W. Orenstein is a freelance medical writer based in Northampton, Pa. She is a frequent contributor to Radiology