The model cell

The hard work of transforming an organization is developing the model cell.

It is the critical first step in a lean journey because the model cell becomes your organization's introduction to lean thinking. With this cell, you tell everyone, "This is what good looks like for our organization."

The model cell is a testing center where people can experiment with ideas, embrace failure as a path for learning, and put new concepts into action. It will also be the demonstration exhibit – the results of your finest efforts that you will then use to sell lean healthcare ideas and spread these new methods to the rest of your organization.

Creating this cell is exciting but scary because it involves taking some risk. To help you keep the wheels on the track, I have identified five guidelines to follow that will also help to define the model-cell concept.

1. The model cell must be focused on a business problem that is important to the organization. The team should be able to clearly state the business case for this work. For example, if there is a department delivering regular harm to patients that's a perfect place to start. A crowded ED is another good place. When there is agreement on the business case, the team is better focused.

2. The model cell runs an inch wide and a mile deep. This means the scope of the redesign must be limited, usually to one unit or clinic. And knowledge of lean thinking, problem-solving practices, the management system, and tools must be sunk deep into the people within the project scope.

3. The redesign results in a new care system that is based on standard work. Standard work refers to the best known way of doing the work today. It also means all the team members follow the standard work. They have the power to change it using plan-do-study-act cycles as the work progresses.

4. Tie the model cell work to True North, the key organizational performance indicators. If your safety goals are to eliminate patient falls, for instance, this should be reflected in the scope of work for the model cell. If you haven't established the handful of key metrics that drive the organization, do that first. Everyone should get accustomed to coordinating improvement work with the organization's handful of key metrics. True North, therefore, is not 55 indicators. At the Children's Hospital of Eastern Ontario leaders have established five. One of them is the number of days children wait for tests and consults. Their goal is to reduce 50,000 days of waiting over the next two years.

5. This work must involve senior leadership. If the CEO and COO are not joining the team on at least one of the model cell's project redesign weeks, or if the work is not championed by a member of the executive leadership, you need to stop and reassess. This is difficult work that requires real change from the organization and your people. This demands that the people at the top change as well.

Let's turn to the work done at Palo Alto Medical Foundation where Mike Conroy M.D. led the transformation of the outpatient care process.

Cross-functional teams – including doctors, assistants, nurses, patients, and administrative staff – began redesigning the workflow and offices in late 2011. Specifically, they wanted to know if they could simultaneously improve service to their patients – measured by better outcomes – cut waiting time, and create better work flow in order to take some of the pressure off of their often overworked staff.

Working with the doctors, the teams took some radical actions. They removed all individual physician offices in favor of a central seating area for medical staff where every doctor sits beside or across from a medical assistant in order to aid the flow of communication.

Every morning there is a quick huddle with the core team of physicians and assistants to talk about the day ahead, review staffing issues, and highlight problematic cases. Using this time to collectively anticipate problems has reduced the amount of firefighting the staff must do during the day.

Incoming phone-call traffic was also completely reimagined and designed, eventually enabling clinic staff to resolve 50% of new questions or requests on first contact, as opposed to the previous rate of near-zero resolution on first contact. New systems also dramatically improved patients' access to same-day appointments.

Newly designed processes helped physicians complete all note taking and close patient files while still in the exam room with the patient. Physicians agreed that their documentation was better in this new process, since they did not have to remember the details of many appointments over a busy day.

Within a few months doctors were going home on time, their work completed. The daily accumulation of tasks in their in-baskets was cut in half. All this was accomplished without hiring new employees and while the clinic was steadily gaining new patients.

Once the model cell is established the next step is to spread the work. This is where we bring James Hereford to the discussion. James is the COO at Stanford Healthcare. Prior to that he was the COO at Palo Alto Medical Foundation (PAMF) and prior to that he was the Senior VP at Group Health in Seattle. At Group Health James learned an important lesson about model cell spread. In his words, "The problem was that we did a tell-and-sell. We went into each clinic and described the model cell and all the benefits they would be getting, and I think the natural human reaction to that is resistance" (Toussaint, 2015). His team heard a lot of reasons why the new processes would not work in the clinic. "We're different," people said or "my patients are different." He realized, "The real problem was that we didn't ask, we told." Subsequently his strategy with model cell development both at PAMF and now Stanford Healthcare has been "adopt or adapt." In other words, the spread clinics got to choose whether to simply adopt the new standards or modify them. The design team produced two-minute videos of each module of the redesign. Many clinics changed some of the standards but the framework of what was working in the model cell clinic was maintained. The model cell was spread to all 30 plus clinics (over 1000 physicians) in less than 15 months. In 2014 PAMF was rated by Consumer Reports as one of the top clinics in the Bay area for quality and service.

It's not possible to successfully implement the model cell without core support teams. These include a central improvement office capable of teaching scientific problem-solving. An HR process that is focused on developing people to identify and see waste. An IT system that delivers real time data for improvement and a finance team that acts as financial improvement staff rather than budget cops.

In my new book Management on the Mend: The Healthcare Executive Guide to System Transformation, I detail each administrative function and its importance. The leadership and management changes that are the underpinning of the journey to create operational excellence are covered in this book. There is no prescription for the operational excellence journey but there is a framework which has emerged from the learning journeys of many executives. I am confident this framework can help most everyone succeed on this difficult but rewarding journey.

 John Toussaint, MD, is CEO of the ThedaCare Center for Healthcare Value and one of the foremost figures in the adoption of lean principles in healthcare. Under his leadership, the Center has launched several peer-to-peer learning networks, developed in-depth workshops and advanced the idea of healthcare value through delivery reform, transparency and payment reform. He is a featured speaker, contributor to peer-reviewed and consumer publications, and author of three groundbreaking books: On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry; Potent Medicine: The Collaborative Cure for Healthcare; and Management on the Mend: The Healthcare Executive Guide to System Transformation.

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