Dr. John Touissant is a leading figure in healthcare reform in the United States, and I interviewed him in advance of his appearance at a lean management conference in Baltimore.
John S. Toussaint, MD, is CEO emeritus of ThedaCare, and CEO of the ThedaCare Center for Healthcare Value. Dr. Toussaint served as president and chief executive officer of ThedaCare, Inc. from March 2000 until April 2008.
HAMILTON: I realize that it’s a few months off yet, and you probably haven’t finalized your remarks, but what are some of the challenges that you intend to address in your keynote speech in Baltimore?
Dr. Touissant: I think that this is about leadership behavior. The tools are the tools, the tools are important, you’ve got to learn the tools, but you can learn the tools. The hard part is the people part. What does a lean leader look like? That’s what I’ll be focussing on, what it takes to be an effective lean leader. It means, pretty much, that you have to change everything that you’ve learned in business school, or medical school, or nursing school, and you have to pretty much retool yourself, because our existing education system is turning out autocratic control freaks who manage by the numbers, and they don’t know anything about quality improvement, and they don’t know how to manage a group of people to actually achieve 100% reliable results. If we don’t change ourselves as leaders, we will never be able to transform our companies.
HAMILTON: You have had a wide range of experience not only in running hospitals, you’ve also become a lean expert. What were some of the first places you first heard about lean and what did you think of it?
Dr. Touissant: First of all, I’m not sure that anyone ever becomes a true lean expert. There’s always some thing new to learn. I think that we clearly started in manufacturing, around 2002, 2001, and were looking for… in health care, our problem still is today, we are very unreliable in terms of the service, quality, and financial results that we deliver, and I was looking at that time, when I took over as CEO to learn, find a methodology that allow us to create a 100% reliability for our patients, because everywhere I went in healthcare, I didn’t see that. There wasn’t any place that actually was able to do that, to create 100% reliability, so we made the decision to go out and scour the world, really, looking for the best manufacturing practice, so to speak, and we defined that as who was actually delivering 3.4 defects per million quality performance in whatever it is that they make. After going to a number of companies, we ended up just going forty miles down the road from us where there’s a snowblower factory called Ariens. Ariens had been on the lean journey for about five years – it basically saved the company – and were very successful in reducing quality defects, improving their overall cost structure, and becoming really one of the great manufacturers of lawn and snow removal products. We went out there, I took the senior team out on the shop floor – Dan Ariens had invited us – and saw how they built snowblowers, and we saw a lot of similarities between what we were doing in patient care and how snowblowers were being built, believe it or not. We felt that after what we saw there, whatever this lean thing was that we needed to learn more about it, and head down that path.
HAMILTON: What were some of the most surprising things to you about what the lessons from lean could do for a hospital?
Dr. Touissant: I think that the most surprising thing was that you could improve quality, lower costs, and improve staff satisfaction all at the same time. To me, that was like, Why didn’t anybody ever introduce this before, because when we boil it all down, that’s what this whole thing is about. If you can do those three things, you’re going to have a satisfied customer. It’s surprising to me that in an industry so full of highly trained, intelligent people, that this methodology could have slipped by all these years without anybody latching on to it.
HAMILTON: Where are some of the obvious parallels for those who are maybe still working out whether their hospital system might benefit from taking a look at the world of Toyota manufacturing, lean and continuous improvement tactics? What are some of the points where the world of the hospital and the world of the factory floor are quite similar?
Dr. Touissant: Certainly the simplest way to describe is where we the before and after pictures at Ariens. The before picture was some fifty staff members, kind of in a line building snowblowers, none of them talking to each other, all of them sort of putting their bolt on and moving the thing down the line, versus the after picture of five years of lean, where they had two U-shaped cells with snowblowers on carts, and 16 workers making the same number of snowblowers that fifty-some workers did, with dramatic reduction in defects. What I saw there was that there was not a lot of difference between patients on carts and snowblowers on carts if you add caring and compassion. It really is a process. The way that we’re doing the process today is much like the before picture at Ariens, where nobody was talking to anybody, it was sort of do your own little thing and then pass it on, and, of course, if there were any defects, the defects were passed on, and that’s why the quality performance was poor. It’s certainly why our quality performance is poor in healthcare – we just keep passing those defects on and we don’t any way of having a cellular kind of activity in which defects are identified, that there’s discussion about it, root causes are done, problems are solved right there on the frontline. We don’t have anything like that in healthcare.
Hamilton: What are some of the big achievements that you’ve been able to make that you attribute to following some of the precepts of lean?
Dr. Touissant:: There are some spectacular improvements. For three years in a row, having to medication reconciliation errors. That means that the patients in the collaborative care unit receive exactly the medications they are supposed to be receiving every single time, 100% reliability for three years in a row.
HAMILTON: How would that compare to the average or most common measure that would apply in most hospitals?
Dr. John Touissant: Medication reconciliation is the thing that’s measured, and before this redesign, we would have one error per patient’s stay, one error for every single patient who came into the hospital. We reduced that to zero. That’s 100% reliability. We’ve had dramatic improvements in mortality rates in elective coronary heart surgery, so, coronary artery bypass surgery, bypass surgery. We’ve dropped the mortality rate some jjjjj 95%. I think that there was one death in the heart surgery program last year, which is out of 350 some heart surgeries, which is the best benchmark performance in the country. The goal is get to zero, and they’re getting there. It started where we might have 3% of all patients who had heart surgery might die, and that’s down to less than 1% now, probably about 0.5%, which is remarkable. These kinds of radical improvements, clinically, and financially… ThedaCare has tripled its operating income over the last five years, and there’s $100 million increase in cash on hand.
HAMILTON: So, one of the things you’re fighting there is a tradition. We’re doing it this way because, frankly, that’s how things have been done, and if you measure us against others, well, we do that fairly well in comparison. What are some of the things that you’ve been able to learn about how to make more systemic change or cultural change?
Dr. Touissant: That really gets back to leadership behaviors. I think that ThedaCare today has really focussed heavily kon… Dean Gruner, who’s the CEO now, has made it his key objective to have every single person that works at ThedaCare be a problem solver, so he wants 100% of the employees – doctors – to be solving problems everyday, and I think that’s ultimately how you start to identify defects, and actually fix problems. That takes some time, to actually get people to report errors, because in healthcare, reporting an error is usually consider to be a sign of weakness, that that error occurred on your watch, and you’re responsible for it, and so we’re going to blame you for it, versus reporting an error, which is then considered to be a good thing, because now you won’t pass that defect on to the next patient, and actually solve the problem. Our command and control management system in healthcare is a huge part of the problem that doesn’t allow for this push down to the frontline to get problems solved. Instead, the manager’s in control, the vice president is in control, the president’s in control, and it’s a leadership defect, really. I look at it as there’s the typical healthcare management process, which is autocratic, top-down, and controlling, and then there’s the Toyota management process, which is that the leader’s job is to actually mentor, facilitate, teach, remove barriers for problem solving for frontline staff. I can guarantee you that that isn’t going on in very many places in American healthcare, or any healthcare around the world, and I’ve been to a lot of different places.
HAMILTON: One of the things that the organizers of the AME conference have done is try to map out some of the characteristics of excellence, and your example relates to many of those themes that are built into the idea of excellence, and the idea of lean. One is that if you’re engaging in cultural care, that you need to set a goal that is extremely high, and then reward people as long they move towards it. Would you say that’s true, and how important was picking ambitious targets to your success at ThedaCare?
Dr. Touissant: We couldn’t get to zero without ambitious goals. I was always more worried when there were more greens than there were reds on our performance measures. If everything is green, it means that you haven’t set the goal high enough. On the other hand, if everything is red, then that isn’t the best moral generator. There has to be a happy medium there. My personal philosophy is that I like to see 50% of our performance metrics red, because that means that we’ve set pretty high goals, and it means that there’s a lot of improvement
HAMILTON: Are there any particular observations or lessons that you’ve been trying to reflect back to the manufacturing community?
Dr. Touissant: I think manufacturers in general have been very supportive of trying to get their local healthcare providers on the lean journey, and I would highly encourage them to continue to do that, because now we have some very good examples in healthcare. The healthcare providers can’t say, We’re not going to apply tools that work to make cars, or to make furniture, or to make widgets, because that’s not going to work in healthcare. Guess what – it does. I still believe that most of what’s going to be learned about lean in the healthcare world is going to be learned from manufacturing.
Hamilton: What might be one other key characteristic of leaders who excel at creating quality?
Dr. Toussiant: Humbleness. I think leaders who are humble have a much higher likelihood of being successful in changing their culture than ones that aren’t.
HAMILTON: Why is that?
Dr. Touissant: You look at your world totally differently if you realize that you don’t have all the answers, because despite the people that think they do, they don’t. It encourages this inquisitive thinking, So how could we do this differently, and if we did do it differently, what kind of impact would that have?
With a top-down leader who has all the answers it’s unlikely that they’re ever going to discover anything new. I think that it takes a level of humbleness to discover new things, and identify defects that would otherwise not be identified if they weren’t thinking differently about the work. The manage-by-numbers guys, once they meet their numbers, that’s all that matters, and that tends to kill innovation, kill creativity, and thinking about problems differently. I think that being humble, no matter how good you are… quite frankly, I think Toyota lost some of their humbleness along the way – that’s one of the issues they’re dealing with now: We’re going to be Number One, we’re going to make the most money… It’s almost becoming a Sloan management system, losing that inherent curiosity that actually identifies defects and solves problems, they’re suffering from a lack of that now. That trait in a leader is really important.
Hamilton: What would you say to someone who was considering coming to the conference?
Dr. Touissant: I think that the AME conference is a fabulous way to get immersed in people who are really doing lean. When I first started coming to AME six years ago, I thought that it was the best quality improvement conference that I could go to. I told people that these healthcare quality improvement things are useless. Go to AME if you want to learn something. We’re also running a healthcare lean transformation summit in combination with the Lean Enterprise Institute in June. We’re actually trying to get healthcare people to come to a real lean conference for people who are really doing lean in healthcare, and we’ve carefully chosen everybody so we know that they’re really doing it. But I think that going to AME and listening to the quality of the presentations around… I particularly like the presentations that deal with the cultural transformation. I think that there are some terrific speakers usually every year who really address – nail – some of the really tough people issues that you deal in transforming your organization. These manufacturers are just so much further along in the journey than most healthcare organizations, and that’s where healthcare can learn.
Hamilton: Could you share one tidbit of when you thought to yourself, I know I need to change.
Dr. Touissant: I think that when we started within the first year, year and a half, it was, Well, if those middle managers would just get this stuff, we could move this thing along a lot more quickly. We placed all the blame – here we go again, we’re going to blame somebody for not knowing something or making a mistake – and as I started to go on kaizen events, get to the frontline, see all the barriers, it became just so crystal clear that I was the problem. I was on high, placing all of these priorities on everybody, basically crushing them, without having any input from them as to what really matters to our patients. I was the problem. That top-down attitude of manage by the numbers, that we’re all taught to do, was crushing any ability for our people, our staff, our frontline doctors, to actually make change happen. I had to go back and learn a different management system. I had to learn A3 thinking, I had to learn enough about lean to be an effective facilitator, an effective teacher. It actually became fairly obvious fairly quickly that I was the problem.
Hamilton: I guess that the rarity is that you decided to own up to whatever deficiencies, however large they were, and change your own behavior, which is perhaps one of the hardest things we all face when we find ourselves running into obstacles.
Dr. Touissant: I’d be the first to admit that I didn’t change it 100%. There are still a lot of bad habits in there. It’s a constant struggle. If you’re really serious about transforming your whole organization, you have to transform yourself first. I’m absolutely convinced that’s why most organizations fail in implementing lean, because it’s senior leaders, and particularly the CEOs, who are unwilling to make those changes. Until you get a change in CEO, or somebody who’s actually looking at this differently… or, hopefully, over the next few years, as ThedaCare build its internal bench strength, they get a CEO who actually was a lean facilitator somewhere along the way. It’s all about the leaders.