Primary care case study: Quality at every step

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Before he even walks into an exam room to greet a patient, Kimberly, Wis., family physician Montgomery “Monk” J. Elmer, MD, already has a good indication of how the patient's health is holding up. On a rainy day this spring, he had good news for Jim DeBruin, a jovial 79-year-old patient with diabetes visiting for a routine follow-up visit.

“So you're still passing,” Dr. Elmer said as a smile spread across his face. In his hand, he held a printout of DeBruin's laboratory test results, showing his glycated hemoglobin reading of 7.6%.

“As long as we're under eight, you're OK,” Dr. Elmer added. DeBruin's blood had been drawn only minutes earlier by a medical assistant at the clinic, which is part of the ThedaCare health system in Appleton, Wis. The sample was analyzed at a lab on site at the clinic.

This just-in-time approach to lab testing and patient care is a principal example of how physician leaders at ThedaCare have earned an outsized reputation within health care for their widespread implementation of the so-called lean-management methods that helped Toyota Motor Corp. become the world's biggest automaker. Although taking a manufacturing approach to medicine is most commonly associated with hospitals, ThedaCare is implementing the idea aggressively in primary care.

A few minutes into the visit, Dr. Elmer swiveled a flat-panel computer monitor toward DeBruin so the patient could see the progress he had made since his last visit.

“I know I haven't been behaving myself. I know I've gained a little weight,” DeBruin said. Nonetheless, his daughter had helped DeBruin take his medications faithfully and his A1c had dropped from 7.8% six months earlier.

Soon, Dr. Elmer left the room for another appointment, and medical assistant Megan Gudex returned. She reviewed the patient's prescription renewals and scheduled his next appointment, printing out a copy of his visit summary for him to take home with the improved A1c results. At ThedaCare's clinics, 70% of patients get new appointments the same day, and most phone calls are answered by a person within 20 seconds.

This is all part of what lean-management proponents call “one-piece flow.” That is the creation of a seamless series of steps that get the job — in this case, the delivery of primary care — done more efficiently for everyone involved. The approach is helping ThedaCare physicians and other health professionals achieve outstanding clinical quality results.

Highly ranked care

The tools of quality improvement at ThedaCare are low-cost: Post-it notes and easel pads usually suffice in place of iPads or pricey planning software. The most valuable ingredient, officials say, is physicians and other health professionals' willingness to brainstorm together as teams to improve care. Photo by Ted Grudzinski / AMA

In the most recent results publicly reported by the Wisconsin Collaborative for Healthcare Quality, ThedaCare's 22 primary care clinics earned the top ranking on half of the chronic disease and preventive care measures, such as the proportion of diabetics with good blood-sugar control and the percentage of eligible patients screened for cervical cancer. Of the 25 measures in the report, which draws on data from July 1, 2011, to Dec. 31, 2012, ThedaCare was among the top three performers 21 times.

In 2006, Dr. Elmer's four-physician clinic was the first ThedaCare site to explore using the lean approach to redesign care. The changes came as physician leaders examined where the system was falling short in primary care, said John Toussaint, MD, the ThedaCare CEO who pushed for implementation of lean management. In 2008, he moved to a position as CEO of the ThedaCare Center for Healthcare Value, an independent nonprofit that helps leaders at other health care organizations learn how to use lean techniques.

“We had done a lot of work with the outpatient setting,” Dr. Toussaint said. “What we found is that the patients who came into the office generally didn't leave the office with a single plan of care, and the reason they didn't was because we didn't have any lab results, x-ray results or results, period. We made everybody come in the week before to take their blood tests, etc., then at the time of the exam they needed five other things. Then they had to come back for the results, days or weeks later. … We said, 'It could work a lot better than that.' ”

Now, about 90% of the lab tests or imaging studies typically needed in primary care practice can be done on-site.

“Ninety-five percent of the time, the patient should now walk out of the office with the plan of care, with medication changes, referrals and follow-up items done right then and there,” Dr. Toussaint said. “We're using these principles to streamline flow, to reduce the waste in the system, all focused on delivering a better patient experience.”

One example of waste reduction in primary care is that whenever Dr. Elmer or another physician needs to remove a mole, he pushes a button in the exam room that beeps overhead. A medical assistant responds, and he asks for a ready-to-go, mole-removal kit with everything he needs to get the job done. He does not have to leave the exam room, and the medical assistant does not have to waste time looking high and low for supplies.

Streamlined but still time to talk

This approach to care is not just about patient convenience or efficiency, as the publicly reported quality results attest. Primary care physicians working at ThedaCare say the just-in-time availability of lab results helps them get the message through to patients.

Family physician Montgomery "Monk" J. Elmer, MD, says there is room for flexibility within the lean-management system used at ThedaCare. "We do not dictate to every one, 'Thou shalt do it this way,' because everyone's style of medicine is different. We recognize that factor." Photo by Ted Grudzinski / AMA

“If I had to go back to where I had to wait for the lab work, I'd think, 'What a wasted visit,' ” said Jennifer Frank, MD, a family physician at ThedaCare's 10-physician clinic in Neenah, Wis. “And when patients know they are getting their labs done at the time of the visit, it can reinforce changes because, see, the A1c is at goal. It helps the patient. … It's very meaningful for them.

“And I can go through it with them personally, and talk with them about their goals,” she added. “I think it improves compliance, and we know what's going on at the time of the visit and can have a face-to-face visit rather than the patient having a conversation about the results later with my nurse. … You have this feeling as the patient that you're actively managing what you're there for, and it's actually a meeting about my diabetes and we have everything we need.”

This primary care redesign is not over. Rather, under the lean-management approach, every element of care delivery is open to constant betterment.

“Lean is really just the scientific method applied to daily work,” Dr. Toussaint told a group of about two dozen physicians and administrators at ThedaCare for a two-day site visit this spring. “In this process, there are no solutions, only new experiments to be run.”

As an example of the commitment to continuous improvement, each clinic has corkboards used to track targeted metrics such as patient satisfaction, how often lab results are completed within 15 minutes, and the percentage of eligible adult patients getting the pneumococcal vaccine. And in the break room, there is more than just coffee and a watercooler. There, physicians and others track improvement ideas big and small from conception to completion. At all of ThedaCare's clinics and five hospitals, thousands of staff improvement ideas were implemented in 2012.

The doctors and other team members also hold a daily morning huddle to review patients who are scheduled that day and anticipate problems that throw things off schedule or present special coordination challenges.

Physicians also are expected to participate in at least one “rapid improvement event” each year. That comes when a clinic has identified a problem that is harming quality, driving up costs or in some other way creating a situation in need of significant change. An interdisciplinary team of people at the clinic is given a week off from normal duties to scrutinize a given process, how it works, how it would function ideally, and what would be pragmatic to change, given time and cost restraints.

Department cuts 29 steps

The professionals participating in the improvement event use a standard problem-solving framework developed at Toyota, where they outline the problem, propose solutions and identify how to implement and track progress. They then present the findings at an organizationwide meeting so others can learn. This spring, for example, professionals in the ThedaCare billing department took one week to eliminate 29 steps in their work process that were contributing to costly billing mistakes.

For Dr. Frank, an openness to change is necessary for working within the lean approach to medicine.

“The idea is, let's just try doing things this new way for one week to see how it goes,” she said. “That's a normal thing to do around here. It does not have to be that big a deal.”

And despite “buying into the Kool-Aid a little bit” about how the lean methodology can improve care delivery, Dr. Frank sounded a note of caution.

“It's important to remember that this is a manufacturing process in its purest form, and health care is not manufacturing,” she said. “You have the inherent variability of patients, with all their complexities and nuances. They are not widgets; they are not cars. There's a certain point at which you have to accept that variability and that the system won't be as clean as you might like it. We shouldn't get so focused on the process that we lose sight of our mission, our goals and our professionalism.”