Doug Woolley, MD, FRCS(C)
Missoula, Montana
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A Surgeon's Story
Dr. D.L. Woolley September 05
Welcome, I am Dr. Doug Woolley, an orthopaedic surgeon from Missoula, Montana. Since 1993 I have become passionate about improving the patient care process in Total Joint Reconstruction (TJR).
Thank you for taking the time to hear my story. I hope to demonstrate over the next few minutes that by fully applying the Lean Healthcare West© program, developed by Cindy Jimmerson of Lean Healthcare West, you can reduce waste and increase value in TJR. Simultaneously, you can also decrease the frustration in your practice and develop the mutual trust and respect that can make you and your hospital a winning team.
My initial interest for improving the TJR care pathway was inspired in 1993 by Dr. Ken Bramlett’s presentation on process improvement. His results were impressive as his LOS (length of stay) was 3-4 days, when mine was 5-6 days and nationally it was 8-12 days. After his talk it became clear to me that LOS was not a meaningless statistic; rather it represented the best index for quality of care!
Thus began a fascination with the evolution of short stay TJR. I was stimulated to explore different techniques to decrease LOS and improve care. From 1993 - 1999, I was able to decrease the LOS to between 3 and 3.3 days, but my frustration index had reached its limit. I believed our administration was wasting precious resources as they were content with the improvements in LOS and were unwilling to support and participate in further change. I have titled this form of waste as “Obstruction.” We had good people but poor systems. One example is it took 12 hours to do 4 TJRs. I was now convinced that poor results came from poor systems and not because of poor patients nor poor doctors.
Accordingly I moved my practice to Community Medical Center in 1999. With the necessary administrative participation, we initiated a program based on my pre-medical experience of customer service, team building and the elimination of waste to improve the flow and value in TJR. The results were immediate and showed a dramatic improvement in LOS, worker satisfaction and patient outcomes. At that time I was unaware of how close we were modeling the Toyota Production System’s(TPS) ideals and rules.
When my friend Cindy Jimmerson introduced me to the Lean Healthcare West© program and TPS in 2002, I was intrigued to learn the principles of our program that I had attributed to my intuition and experience, were already well described Toyota fundamentals. Besides Toyota’s over 50 year record of success, TPS had been validated many times by other manufacturers over the last 20 years. As we worked together on process improvements in our program, I saw the power of the essential tools of Value Stream Maps (VSM) and A-3 problem solving upon which the Lean Healthcare West© program is based. I realized, here was a simple way to get the workers to be the architects of their own environment. It is an easily taught method that all of us can use to rapidly solve our problems. If you are willing to become a student again and have your team be educated and trained in the Lean Healthcare West© program, I am convinced they can obtain or surpass the following results.
Starting in 1999, my first 250 consecutive TJR patient’s average LOS decreased to 2 days. Compare that to my old hospital average LOS of 3.2 days, the Mountain Region average of >3.5 days and the National average of >4 days. This was a definite improvement.
Additionally, 96% or better went directly home without any formal home health, PT or nursing care. Compared to stats at 50% nationally and 60% in the Mountain Region, you can start to see a significant trend for early recovery and real savings.
This trend continued; by 2 months 65% of hips and 76% of knees were walking unassisted. At 3 months 100% of patients were free of walking aids. At 3 months the average ROM for knees was 115 ° , with 92% obtaining at least 110 ° . There were no manipulations under anaesthesia performed on any of the 143 knees in this study!
Patient benefits included:
-95% claimed their care was the best, or better than average when compared to previous admissions.
-Only 2% required OP PT after 6 weeks.
-Only 2% required blood while in the hospital.
The financial benefits for the hospital revealed average charges and costs per case decreased $4,274 and $2,287 respectively. Profits were up $1,837. The volume increased 700% in 5 years. The staff’s quality of care and satisfaction increased as did the value to the patient. This resulted in increased pride in their work and staff retention. Community Medical Center received 2 awards in 2001 for their improved care. The first from USA Today and the Rochester Institute of Technology as a finalist in the Quality Cup, Healthcare Division. The second from JACHO; 1 of 2 given nationally for significant care improvement.
The increase in efficiency with a 2-day LOS and 40% increase in volume of TJR coupled to improved my financial bottom line and decreased the time for patients waiting for surgery. This allowed me to take more time off, which led to a happier MD, family and staff
In conclusion, by modeling the ideals and rules of the TPS, I saw a significant decrease in LOS. This is the best index of quality of care and financially benefits everyone concerned in TJR. This has been validated by my new partner adopting these principles in 2002 and achieving similar results . I am convinced once these principles become part of the personality of an orthopedic surgeon, his or her hospital and its staff, this process can be used as a template to improve all the systems and service lines in a hospital.
If you are feeling frustrated on a daily basis by the competitive, antagonistic and sometimes selfish demands of the various players in the current state of Healthcare Baseball, by using the Lean Healthcare West© program all of us can become an effective change agent. There is a crisis in healthcare looming larger everyday. We are all part of the problem and to be successful we will all have to be part of the solution. We can all be winners if we cooperate to increase value and meet the needs of the patient.
I believe by coming together in the future state of Healthcare Baseball, we can eliminate these competitive, non-productive demands and form a team with the following shared goals.
1) All the players want to provide the best possible care for our patients.
2) It does not have to cost more to do it better; but actually can cost significantly less.
3) By making our efforts patient-centric, all the players will satisfy their mutual needs.
I am convinced with the right attitude and system everyone can reach their potential and become the “A TEAM”. To quote Hannibal Smith; “I love it when a plan comes together!” If you are open to achieving similar results to mine and would like to consider the use of the Lean Healthcare West© program, I would love to get you started on your journey.