This document outlines a value stream improvement project to reduce adverse outcomes for patients undergoing coronary artery bypass graft surgery. The initial state showed high rates of atrial fibrillation and prolonged ventilation in 2007, resulting in financial losses. The target state aims to lower complication rates and increase contribution margin by December 2008. Teams were formed comprising staff from relevant departments. Rapid experiments included developing care teams, mapping the value stream, and establishing daily huddles. Insights noted successes in breaking down silos and engaging staff, while identifying needs to resolve staffing issues and better communicate goals to all involved.

1. O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms© 2007 ThedaCare All Rights Reserved
Title: CAD CABG Value Stream Revision: 2 Date: 9/12/08
2. Initial State:1. Reason for Action:
3. Target State:
4. Gap Analysis:
Team:RajChakravarthy,DebWisnet,ShawnChartier,
Dr.RobertFerrante,ChristieDreier,BobOlson,DanCollins

2. O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms© 2007 ThedaCare All Rights Reserved
5. Solution Approach: 6. Rapid Experiments:
8. Confirmed State:
7. Completion Plans:
Sponsor: Raj Chakravarthy Leader: Deb Wisnet
Facilitator: Shawn Chartier Sensei:
9. Insights:

3. O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms© 2007 ThedaCare All Rights Reserved
CAD (Coronary Artery Disease)
CABG (Coronary Artery Bypass Graft)
Value-Stream
 Site/Location: AMC
 Sponsor: Raj Chakravarthy
 Team Leader: Deb Wisnet
 Facilitator: Shawn Chartier
 Sensei: TBD
 Date: TBD

4. O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms© 2007 ThedaCare All Rights Reserved
CAD CABG Value-Stream
Team Members: Team Role:
 Raj Chakravarthy Sponsor
 Deb Wisnet Team Leader
 Shawn Chartier Facilitator
 Dr. Robert Ferrante Physician Lead
 Christie Dreier Process Owner
 Bob Olson Process Owner
 Dan Collins Process Owner

5. © 2007 ThedaCare All Rights Reserved
O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms
Reason for Action
 38% of isolated CABG patients experienced an adverse
outcome in 2007.
 Postoperative atrial fibrillation and prolonged ventilation were
the most common adverse outcomes experienced.
 CABG treatment resulted in a $1,355,000 contribution margin
but a ($723,000) net income in 2007.
Scope: CABG patients from day of surgery to discharge.
Note: Isolated CABG is a surgical procedure in which CABG is the only major cardiac
surgery performed.

6. © 2007 ThedaCare All Rights Reserved
O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms
Initial State
2007 Atrial
Fibrillation
Rate = 30%
($723,000)
Net Income
Loss
2007
Pronged
Ventilation
= 11%

7. © 2007 ThedaCare All Rights Reserved
O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms
Target State
Measure Initial
2007
Target
Dec 2008
Quality Post-op Atrial Fibrillation
Initial Ventilation < 6 Hrs
30%
27%
15%
54%
Business Contribution Margin per
Case
$6,831 $9,073
Employee
Engagement
% of OHS Care Team
Members Involved in Value-
Stream Improvements
(VS, RIE, Project, A4,
Team Leader/Core Team
Member)
0% 100%
Metrics: Data is for isolated CABG patients

8. O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms© 2007 ThedaCare All Rights Reserved
Gap Analysis
Value Stream Readiness:

9. O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms© 2007 ThedaCare All Rights Reserved
Solution Approach
OHS Care Team Development:

10. O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms© 2007 ThedaCare All Rights Reserved
Rapid Experiments
May 2008
 OHS Care Teams developed – Inpatient Surgery (pre-existing), ICU and 2 South
June 2008
 Value Stream Core Team expands to include OHS Care Team reps (meets biweekly)
 Project held with OHS Care Team members to map Value Stream, determine gaps
 Individual OHS Care Teams begin meeting weekly, begin identifying metrics
 Value Stream daily huddle begins with reps from each OHS Care Team and
support departments
July 2008
 Value Stream Core Team expands to include RT, Rehab and Pharmacy
 Individual OHS Care Team daily huddles begin (exception – Inpatient Surgery)
 OHS Care Teams each develop metrics and improvement boards
 Project held to determine Care Team leadership structure
August 2008
 Care Team leadership structure finalized
 OHS Care Teams continue improving metrics, working toward goals and completing
improvement projects
September 2008
 Care Team leadership structure implemented in ICU

11. O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms© 2007 ThedaCare All Rights Reserved
Confirmed State
Quality
Customer
Business
Employee
Engagement
Measure Initial
(2007)
Target Achieved
(Date)
Quality Post-op Atrial
Fibrillation
Initial Ventilation < 6
Hrs
30%
27%
15%
54%
Business Contribution Margin
per Case
$6,831 $9,073
Employee
Engagement
% of OHS Care Team
Members Involved in
Value-Stream
Improvements
(VS, RIE, Project, A4,
Team Leader/Core
Team Member)
0% 100%
Within 5% of Goal
Off goal >10%

12. O:ThedaCare Improvement SystemBlank FormsA3-A4 Forms© 2007 ThedaCare All Rights Reserved
Insights
What went well? What did not go well?
Actions
• OHS Care Team huddles
• OHS Value Stream huddle
• ICU team development (exceeding expectations)
• Silos breaking down – departments working together
• Engagement and pull among all teams (and support
depts.) increasing
• Daily continuous improvement “on steroids”
• Value stream metrics improving and/or meeting goals
• OR OHS Care Team – delay in progress - staffing
issues/summer vacations and leaves
• 2 South OHS Care Team – delay in progress – desire
direction and clear expectations
• Finding time with surgeons for improvement work –
very busy schedules and summer vacations
• Communication to non-OHS Care Team members
concerning changes and goals
• Every team is unique – must adapt to the separate needs of
each team as they develop
• OR OHS Care Team – resolve staffing issues, place
increased focus on team
• 2 South OHS Care Team - provide direction, expectations
and increase focus on team
• Develop effective communication plan that includes OHS
Care Team members AND non-members