SummaryThe ThedaCare health system used Toyota Production System principles to redesign clinician roles, acute care processes, and the physical inpatient setting, with the goal of improving efficiency and quality. Known as Collaborative Care, this new inpatient care model includes a bedside visit by a multidisciplinary clinical team at admission and each day; use of comprehensive, individualized plans to guide and monitor care; and physical facility and staffing changes to support high-quality care. On the first two units implementing this approach, Collaborative Care reduced costs per case and average length of stay, improved adherence to clinical best practice standards, increased nurse productivity, and enhanced patient, staff, and physician satisfaction.Moderate: The evidence consists of comparisons of key outcomes measures, either pre- and post-implementation or between units implementing Collaborative Care and those not implementing it. Metrics include direct cost per case, average length of stay, adherence to recommended care processes, nurse productivity, and patient satisfaction. Additional evidence includes anecdotal feedback from employees and physicians related to their satisfaction.
Date First Implemented2007
Problem AddressedHospitals face major challenges in delivering high-quality care while remaining financially viable. Like many other hospitals, ThedaCare found that its patients were at risk for medical errors that could lead to potential harm, that its clinicians did not communicate effectively because of "siloed" practices, and that nurse productivity and efficiency lagged. These problems frequently led to longer-than-necessary patient stays and costs.
- Significant risk of medical errors: Between 2007 and 2009, Medicare patients experienced approximately 709,000 total safety events, at a cost of $7.3 billion.1 Medication errors alone injure at least 1.5 million Americans each year, costing the nation more than $3.5 billion.2 An internal analysis at Appleton Medical Center revealed that inpatients were at greater risk of a medical error than those treated in outpatient facilities.3
- Poor communication among clinicians: At ThedaCare, the patient's plan of care and understanding was often disjointed because the clinical team members did not collaborate to create a single, comprehensive care plan for each patient. This resulted in patients being confused about their care and frustrated that they needed to provide the same information to different clinicians. Furthermore, surveys revealed that nurses often faced difficult work situations to deliver quality care and expressed dissatisfaction and frustration because this led to treatment errors and delays.3
- Inefficient nursing care: Nursing care at ThedaCare had become somewhat inefficient, due both to lack of a clear understanding of the plan of care and an inefficient work environment, especially related to supply processes. For example, the typical nurse spent roughly 3 hours of an 8-hour shift obtaining and transporting supplies.3
- Leading to lengthy stays and high costs: The aforementioned problems resulted in longer-than-necessary inpatient stays and excessively high costs.3
Description of the Innovative ActivityThe ThedaCare health system redesigned clinician roles, acute care processes, and the physical inpatient setting, with the goal of improving efficiency and quality. Known as Collaborative Care and based on Toyota Production System principles, this new inpatient care model includes a bedside visit by a multidisciplinary team of clinicians at admission and each day; ongoing use of comprehensive, individualized plans to guide and monitor care; and physical redesign and staffing changes to support high-quality care. Key elements of the new model include the following:
- Bedside visit by clinician team at admission: A physician, nurse, and pharmacist visit the patient within 90 minutes of admission. Together, this admission team reviews the patient's history, health status, medications, and care goals, and answers any questions the patient or family members may have.
- Creation of unified care plan: With input from the patient, the admission team designs a single, coordinated care plan, which includes a comprehensive treatment plan (e.g., diagnostic testing, specialty consults, physical/occupational therapy, pain management, home health arrangements). The care plan is documented in the electronic medical record (EMR) so that it can be accessed by all providers and orders can be generated. The patient's primary registered nurse (RN) serves as the overall manager of the care plan.
- Daily bedside conferences by multidisciplinary team: Each day, a physician, nurse, pharmacist, discharge planner, and ancillary service representatives who care for the patient hold a bedside conference to reevaluate the care plan, communicate in real time, and make adjustments as necessary.
- Periodic reviews to monitor progression: At least twice a day (6 and 12 hours after the bedside conference) but often more frequently, RNs review the patient's progression toward discharge. Known as "tollgates"4 (or "time-outs"), these reviews confirm that all interventions in the care plan have been provided and that the patient continues to progress as expected. For example, for a patient requiring ongoing blood counts, the tollgate would include making sure that timely blood draws have been obtained and that timely results have been received from the laboratory. Nurses address gaps in care as they occur.
- Physical design and staffing enhancements to support better care: Various physical design and staffing enhancements have been made to improve care (particularly nursing care), including the following:
- Private rooms: Units have only private rooms to facilitate private communications between patients and all the care providers.
- No nursing stations: Central nursing stations have been eliminated and replaced by "huddle areas" throughout the unit to encourage nurses to spend time in patient rooms and allow for mini-workspaces in close proximity to patient rooms for the clinical team to collaborate.
- Easy EMR access: Clinicians can access a patient's EMR using computers in the alcoves or in patient rooms.
- Supplies and white boards in patient rooms: Approximately 80 percent of supplies are now located in patient rooms rather than in centralized storage closets. Whiteboards hang in patient rooms so that nurses can easily provide information to other clinicians, patients, and families about the status of the care and treatment plans.
- Colored lighting to signal test information: Colored lights and flags by each patient room serve as visual cues for various care steps, such as that a test has been ordered, medications have been delivered, or to signify a patient safety status.
- Addition of low-level staff to support nurses: The units have added lower-cost staff to support the RNs, changing from a more RN primary care model to a team-based staffing model. Licensed practical nurses and certified nursing assistants now round out the team. As a result, each unit has fewer RNs, with the average RN caring for 6 patients on Collaborative Care units, compared to 3.5 on other units.
Context of the InnovationThedaCare is a community health system in Wisconsin consisting of four hospitals (Appleton Medical Center, Theda Clark Medical Center, Riverside Medical Center, and New London Medical Center), a physician network, and other health care services. The 185-bed Appleton Medical Center is the second largest hospital in the system, treating 8,400 inpatients annually, while the 160-bed Theda Clark Medical Center treats 8,350 inpatients annually. For a number of years, ThedaCare leaders had been reviewing the existing inpatient care model, concluding that ample room for efficiency and quality improvements existed. They initiated a number of discrete quality improvement initiatives, but they did not yield meaningful results. In 2006, ThedaCare participated in an Institute for Healthcare Improvement/Robert Wood Johnson Foundation initiative called Transforming Care at the Bedside, which led health system leaders to recognize the need for a wholesale redesign of the inpatient care model (as opposed to the past approach of "tweaking" current processes). ThedaCare leaders became aware of the Toyota Production System methodology, which incorporates different tools and techniques to enhance quality and productivity while reducing waste and costs. Initially embraced by manufacturing companies and known as "Lean manufacturing," this approach is increasingly being adopted by health care organizations. ThedaCare leaders decided to adopt it after learning of its successful application in other inpatient and outpatient settings.
ResultsOn the first two units implementing this approach, Collaborative Care reduced costs per case and average length of stay (ALOS) and improved adherence to recommended care processes, nurse productivity, and patient, staff, and physician satisfaction.
Moderate: The evidence consists of comparisons of key outcomes measures, either pre- and post-implementation or between units implementing Collaborative Care and those not implementing it. Metrics include direct cost per case, average length of stay, adherence to recommended care processes, nurse productivity, and patient satisfaction. Additional evidence includes anecdotal feedback from employees and physicians related to their satisfaction.
- Lower cost per case and ALOS: The first two units implementing the model (one in Appleton Medical Center and a second at Theda Clark Medical Center), achieved monthly direct cost per case decreases between 15 and 20 percent between 2006 (before implementation) and 2010 (after implementation). Over the same time period, ALOS on the two units decreased by 10 to 15 percent.
- Better adherence to recommended care processes: Collaborative Care units have eliminated all admission medication reconciliation defects by having a pharmacy extender perform the admission medication reconciliation task and a pharmacist participating on the admission team review it. This is compared to a previous average of 1.25 to 1.5 defects per admission medication reconciliation performed by either a nurse or physician. Collaborative Care units have also achieved 100 percent adherence to the Centers for Medicare & Medicaid Services (CMS) pneumonia care bundle of interventions, compared to 75 percent on other non-Collaborative Care units.
- More productive nurses: Thanks in large part to the staffing and physical layout changes, nurse productivity is 11 percent higher on Collaborative Care units than on regular units. This was measured using salary expense pre- and post-implementation.
- More satisfied patients, staff, and physicians: On Collaborative Care units, the proportion of patients rating their satisfaction as "excellent" increased from 68 percent in 2006 to 95 percent in 2010. Anecdotal reports from nurses, physicians, and other staff members suggest that employee satisfaction has increased and nurse turnover has declined on units after implementing Collaborative Care.
Planning and Development ProcessKey steps included the following:
- System leader buy-in and promotion of Lean methodology: In October 2003, Health system leaders embraced the Lean system as a way to promote change and encouraged mid-level managers to support it as well. ThedaCare contracted with a consultant (Simpler, located in Ottumwa, IA) to train staff on Lean methodologies and tools so that they could serve as Lean facilitators.
- Staffing project: The health system created a department staffed by quality improvement facilitators to support ongoing Lean work throughout the organization in February 2004. Specifically for the design of the Collaborative Care model, a project manager and several nurses were reassigned to serve full-time on the project.
- Staff forums: During July 2005, health system leaders and managers held forums to gather input from frontline staff (physicians, nurses, therapists, and other clinical and non-clinical staff) about the quality of current patient care processes and needed changes.
- Value-stream mapping: In October 2005, a team comprising a facilitator, the project manager, health system executives, nurses, and other staff performed a "value-stream mapping" exercise (a strategy to evaluate every step in a process to identify inefficiency and waste) of the existing inpatient care process. During this exercise, the team redefined the goal of care as hospital discharge, rather than justifying why the patient should be kept in the hospital. This exercise helped the team to identify bottlenecks, duplicative steps, unnecessary complexity, and instances of ambiguity, and to highlight opportunities for improvement.
- Developing project plan: Based on the value-stream mapping exercise, the team developed a project plan in November 2005 that included areas in need of improvement, including key care processes, the EMR, and physical design of the units.
- Rapid improvement events on test unit: Between December 2005 and December 2006, a test unit underwent 24 rapid-improvement events or projects, with each geared toward solving a specific problem. Team members included a facilitator and different clinician and non-clinician stakeholders who took time from their regular duties to participate. The rapid improvement events and projects yielded process and design improvements that were incorporated into the redesigned model of care, which became known as the Collaborative Care model.
- Offsite practice: In January 2007, select physicians, nurses, and staff were chosen to participate in offsite training based on an application and interview process. Those selected underwent training, including role-playing exercises, at an offsite location to learn the new roles, responsibilities, and care processes associated with the model. Participants practiced Collaborative Care for a 6-week period along with specific team formation exercises.
- Pilot testing in redesigned unit: A 14-bed unit in Appleton Medical Center served as a pilot site for the model, with testing beginning in February 2007. The unit underwent physical redesign to eliminate the nursing station and incorporate private patient rooms, consultation alcoves, in-room supply cabinets, and visual message lighting above patient doorways.
- Expansion across system: After the successful 11-month test at Appleton, a second 19-bed unit at Theda Clark Medical Center implemented Collaborative Care. ThedaCare is expanding the model to all medical-surgical inpatient units, with full rollout expected by early 2013.
Resources Used and Skills Needed
- Staffing: Initially, some extra staff were needed to cover for clinicians given time off from their regular duties to participate in rapid improvement events and other projects. Once up and running, however, the new staffing model actually cost less than the traditional care model. The model required the system to hire additional licensed practical nurses (to allow RNs to function at their highest scope of practice) and pharmacists (to accommodate admission team and bedside conference duties). These increases have been offset by reductions in nursing salaries, improved clinical quality outcomes, and expedited progression of patient care.
- Costs: Upfront development costs have not been estimated; major cost categories include labor, physical redesign, and consulting fees.
ThedaCare funded the majority of program development internally.
Tools and Other ResourcesInformation on the Institute for Healthcare Improvement/Robert Wood Johnson Foundation Transforming Care at the Bedside initiative can be found online at http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/TCAB/Pages/default.aspx
The Transforming Care at the Bedside toolkit is available at
More information on Simpler can be found at www.simpler.com.
Getting Started with This Innovation
- Apply model to local environment: While it is imperative that those adopting this model use a process redesign methodology (e.g., Lean), the specifics of the ensuing redesign will vary significantly across organizations. In other words, though ThedaCare's inpatient model cannot be directly adopted by other health systems, the concepts can. Each organization should define its ideal state of care delivery, identifying what gaps/obstacles exist and then allowing frontline staff to redesign care and implement solutions that match its ultimate goals.
- Adopt new model incrementally: Do not "go live" with the model in all units at once. Rather, adopt it slowly, allowing adequate time for training on each unit prior to implementation. This approach allows "experienced" staff members to act as mentors to those on adopting units.
- Assign project manager: Assign one person to be the project manager, overseeing overall development and implementation of the model.
- Involve frontline staff and patients: Frontline staff and patients should drive the redesign by making suggestions and providing feedback throughout the process.
Sustaining This Innovation
- Monitor progress versus performance objectives: Set performance objectives for the new model, and monitor and share progress against them on an ongoing basis. This information will help stakeholders stay focused on improvement.
- Monitor financial implications: Under Medicare reimbursement mechanisms, hospitals may receive less than the full diagnosis-related group payment per case for those patients discharged to other care settings (e.g., rehabilitation units or nursing homes) rather than their homes. Because the Collaborative Care model often allows for more prompt discharge to these settings, ThedaCare estimates that it loses approximately $2,000 in revenue on some patients; nevertheless, the overall financial health of the health system has improved since implementation of the model.
Contact the InnovatorJamie Dunham, MS, RN
Vice President of Operations
Appleton Medical Center
1818 North Meade
Appleton, WI 54911
Innovator DisclosuresMs. Dunham has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesBielaszka-DuVernay C. Redesigning acute care processes in Wisconsin. Health Affairs. 2011;30(3):422-5. [PubMed]
1 Reed K, May R. HealthGrades Patient Safety in American Hospitals Study. March 2011. Available at: http://www.healthgrades.com/business/img/HealthGradesPatientSafetyInAmericanHospitalsStudy2011.pdf
Bielaszka-DuVernay C. Redesigning Acute Care Processes in Wisconsin. Health Affairs. 2011;30(3):422-5. [PubMed]
4 U.S. Patent 8,060,377.
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Original publication: October 10, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.