lean at denver health: saving lives, saving money, saving jobs phil goodman director, lean systems...
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Lean at Denver Health:Saving Lives, Saving Money,
Saving JobsPhil Goodman
Director, Lean Systems ImprovementDenver Health
Denver, Colorado
Lean At Denver Health:Saving Lives, Saving Money, Saving Jobs
• Denver Health • Lean Principles and Tools• Application of Lean Results– Pre-Hospital– Inpatient – Outpatient– Public Health
• Financial Impact
Non Non medical medical DetoxDetox
Non Non medical medical DetoxDetox
Correctional Correctional CareCare
Correctional Correctional CareCare
Denver Denver Health Health
Medical Medical CenterCenter
Denver Denver Health Health
Medical Medical CenterCenter
911911911911
Family Family Health Health CentersCenters
Family Family Health Health CentersCenters
Regional Regional Poison Poison
Center & Center & NurselineNurseline
Regional Regional Poison Poison
Center & Center & NurselineNurseline
Denver Denver Health Health
Medical PlanMedical Plan
Denver Denver Health Health
Medical PlanMedical Plan
School-School-based based Health Health CentersCenters
School-School-based based Health Health CentersCenters
Rocky Mtn Rocky Mtn Center for Center for
Medical Medical Response to Response to TerrorismTerrorism
Rocky Mtn Rocky Mtn Center for Center for
Medical Medical Response to Response to TerrorismTerrorism Public HealthPublic HealthPublic HealthPublic Health
Rky Mtn Rky Mtn Regional Regional
Trauma CtrTrauma Ctr
Rky Mtn Rky Mtn Regional Regional
Trauma CtrTrauma Ctr
Employed PhysiciansEmployed Physicians
HITHIT
3
Improve Patient Safety and Quality of Care
Improve Patient Access
Reduce Cost
The Holy Grail of Process Improvement in Health Care
Is it possible to drive all three goals simultaneously?
Hint: Try eliminating waste, and see what happens!
What Waste?
• Underutilized Human Talent• Waiting• Inventory• Transportation• Defects• Motion• Overproduction• Processing
Lean ToolsLean Tools to Identify Waste:• Process Mapping• Time Observations• Takt Time• Spaghetti Diagram• Communication Circle• Waste Walk• Voice of the Customer• Root Cause Analysis
Lean Tools to Eliminate Waste:• 6S• Standard Work• Poke Yoke• Heijunka• A3 Thinking• Visual Management• Quick Change• Kanban
Framework for Using Lean Tools in a Focused Manner:
Value Stream Analysis 2P/3P
Rapid Improvement Event Vertical Value Stream Analysis
Pillars of Lean TransformationPillars of Lean Transformation
Con
tin
uou
s Im
pro
vem
ent
Res
pec
t fo
r P
eop
le
Principles of LeanPrinciples of Lean
• The customer defines value• Deliver value to the customer on demand and
without waste• Standardize to solve and improve• Transformational learning requires a deep
personal experience• Mutual respect and shared responsibility
enable higher performance
Pre-Hospital:Denver Health Paramedic Value Stream
Paramedic Division Response Time Performance Pre and Post RIE
700
720
740
760
780
800
820
840
860
880
EMS EMS EMS EMS EMS EMS EMS EMS
<48 48 49 50 51 52 53 1
Weeks of 2008-2009
Re
sp
on
se
Tim
e i
n S
ec
on
ds
, 9
11
An
sw
er
to A
rriv
al
at
90
%
Co
mp
lia
nc
e
RIE Conducted This Week
Pre-Hospital:Denver Health
Paramedic Value Stream
Total Personnel, Operating Expenses and Revenue 2007-2012
Note Revenue >Operating Expense 2010-2012
Improving Inpatient Safety and Quality of Care
Improving Inpatient Safety and Quality of Care
Improving Inpatient Safety and Quality of care
Hospital Flow and Readmissions
Improving Inpatient Safety and Quality of Care
UHC Quality and AccountabilityAggregate Score - 2011
Improving Inpatient Safety and Quality of Care
Improving Inpatient Safety and Quality of Care
Community Health Services
2005 2006 2007 2008 2009 2010 2011
Total Patients 102710 101162 103826 108042 113003 117058 123614
0
20000
40000
60000
80000
100000
120000
140000
Total CHS Patients
Improving Patient Access
Community Health Services
Improving Efficiency
Improving Outpatient Safety and Quality of Care
Community Health Services
Improving Outpatient Safety and Quality of Care
Community Health Services
Improving Outpatient Safety and Quality of Care
What About Applying Lean in Public Health?
How Can Lean Help?
• Identify and eliminate waste• Develop and Implement Standard Work: The currently best known, least waste way of getting the work done Developed by the people who actually do the work Not optional
Standard Work Wedge
STANDARD WORK
Performance
Time
Performance
Time© Simpler Consulting, L.P. 1996-2012 All Rights Reserved.
Value Stream Mapping in Public Health
Client Arrives
RegistrationCT=37min
Class CT= 45 min
Access Client
History ICT= 8 min
Access Client History II
CT= 21 min
Client SpecimenCT= 4min
Lab WorkCT=6 min
Physical Exam CT= 19min
Post Council CT= 14 min
Client Checkout CT=
3 min
ABC County Health DeptGeneral ClinicCurrent State
December 6, 2012
25 MinsWait
20 MinWait 22 Min 12 Mins 28 Mins15 Mins
Sing inPaperwork
Create ChartComplete Self Hx
Obtain chartComplete lab
formsReview
immunizationsInfo
Produce lab specimen
Can’t move Forward
w/o lab test
Blood Tests x3UA x 2
Client ExitsDocumentation
Access needDispense meds
Clin F/U
PaymentSurvey
Actual Value Stream Map = Wait
= Kaizen Opportunity
Adapted from: Nat’l Network of Public Health Institute’s Public Health Performance Toolkithttp://nnphi.org/tools/public-health-performance-improvement-toolkit
Application of Lean in Public Health to Improve Services to Clients
ETOH Screening Current State Process in STD Clinic and Community Health Services at DH
PREVENTING ALCOHOL-EXPOSED PREGNANCIES IN UNDERSERVED WOMEN ATTENDING A SAFETY-NET INPATIENT/OUTPATIENT HEALTHCARE SYSTEM
P Gillen,1 K Peterson2
1University of Colorado-Denver, Anschutz Medical Campus, 2Denver Public Health, Denver, USA
• Reason for Action: Poor coordination of FASD prevention and treatment services within Denver Health
• Initial Condition: Relevant work being done in silos of departments
• Target Condition: Integration of services to provide best care efficiently, utilizing existing resources well
• Gap Analysis: Silos across multiple
departments with poor coordination of services/referrals
• Solution Approach: Including methods gained from Practice Collaborative training and forum with other sites
•Rapid Experiments: DPH took leadership in creating a collaborative at DH, with technical assistance provided by CityMatCH. Two half-day planning sessions utilizing LEAN methods identified the current siloed state of prevention efforts and care at DH, analyzed the gaps, and developed solutions. DPH clinic data were used to assess the prevalence of high-risk alcohol use in reproductive age women, defined as 4 or more drinks on one occasion or 8 or more in a week, and their rates of effective contraception.
• Completion Plans:Arrange trainings with clinics to
coincide with the new EMR in Jan, 2013
• Confirmed State: 16% of women attending the DPH clinic were both drinking at high-risk levels and not using effective contraception (816/4976)
ObGyn
• Pre-natal Care• High-risk
Deliveries• Contraceptive
Care
Family Practice
• Pre-natal Care• Low-risk Deliveries• Kids’ Care• Adult Care• Contraceptive Care
Pediatrics
• Kids’ Care• Child Advocacy• Contraceptive
Care
Outpatient Behavioral Health Services
Substance Abuse Treatment ServicesOther Mental Health Care
Denver Public HealthMaternal Child Health ProgramSTD-CHOICES Demonstration ProjectContraceptive CareData Analysis Expertise
Larger CommunityCOFASFASD EducationLegislative PolicyOther Health Care SystemsEt ceteraCityMatCH Practice Collaborative to Reduce the Risk of Alcohol-Exposed Pregnancy
Applying Lean to Business Processes at Denver Public Health
• Implemented standardized billing for Public Health Services which traditionally has not been done. Examples include: Billing for certain lab tests ordered out of the TB clinic; A collaboration between the TB clinic and DU to test
their foreign born students for TB which resulted in a small profit for the clinic;
Created standard work for billing of insured walk-in patients in our STD clinic;
Billing third party payor sources for immunizations given in our Immunization Clinic and during immunization outreaches
including outreaches occurring in Denver Public Schools.
• Automated ways of pulling and sharing data: Retrieving STD lab data from the main lab to be
automatically loaded into our STD Electronic Medical Record.
Before this was created the results (18k per year!) had to be manually entered by clerical staff.
Applying Lean to Business Processes at Denver Public Health
Applying Lean at Colorado Dept of Public Health
• Created standard work to eliminate redundancies (re-work) in: Licensing of Health Facilities Background checks and CEUs required for
certification of EMS professionals
• Implemented “andon” (red flags) to prevent actual issuance of inappropriate license
Source: Nancy McDonald, BS, RN: Director for Medical Facilities and Emergency Medical Services Division at Colorado Department of Public Health and Environment (and former Assistant Director of Lean Systems Improvement, Denver Health
Financial Impact: “Hard Green Dollars” from Denver Health’s Lean Initiative
SummarySummary• Lean is a philosophy and tool set that fits for healthcare• Eliminating waste improves quality of care• Lean tools are intuitive• Frontline staff must be respected because they understand
where the waste exists and how best to eliminate it• Lean has the power to change culture because it truly
empowers employees to break down silos, rapidly implement change and own the process!
March, 2011: DH first Healthcare Organization recipient of Shingo Prize
for Operational Excellence
855-888-LEAN
Judith Shlay MD, Denver Public HealthKaren L. Peterson MD, Denver Public Health
Dean McEwen, Data Applications Supervisor, Denver Public HealthAndrew Yale, Administrative Director, Denver Public Health
Nancy McDonald, Director for Medical Facilities and Emergency Medical Services Division at Colorado Department of Public Health
and Environment
Acknowledgements and Thank Yous!