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Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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Page 1: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Lean at Denver Health:Saving Lives, Saving Money,

Saving JobsPhil Goodman

Director, Lean Systems ImprovementDenver Health

Denver, Colorado

Page 2: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver 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

Page 3: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 4: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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!

Page 5: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

What Waste?

• Underutilized Human Talent• Waiting• Inventory• Transportation• Defects• Motion• Overproduction• Processing

Page 6: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 7: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Pillars of Lean TransformationPillars of Lean Transformation

Con

tin

uou

s Im

pro

vem

ent

Res

pec

t fo

r P

eop

le

Page 8: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 9: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 10: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Pre-Hospital:Denver Health

Paramedic Value Stream

Total Personnel, Operating Expenses and Revenue 2007-2012

Note Revenue >Operating Expense 2010-2012

Page 11: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Improving Inpatient Safety and Quality of Care

Page 12: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Improving Inpatient Safety and Quality of Care

Page 13: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Improving Inpatient Safety and Quality of care

Page 14: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Hospital Flow and Readmissions

Improving Inpatient Safety and Quality of Care

Page 15: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

UHC Quality and AccountabilityAggregate Score - 2011

Improving Inpatient Safety and Quality of Care

Page 16: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Improving Inpatient Safety and Quality of Care

Page 17: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 18: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Community Health Services

Improving Efficiency

Page 19: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Improving Outpatient Safety and Quality of Care

Page 20: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Community Health Services

Improving Outpatient Safety and Quality of Care

Page 21: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Community Health Services

Improving Outpatient Safety and Quality of Care

Page 22: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

What About Applying Lean in Public Health?

Page 23: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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.

Page 24: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 25: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 26: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 27: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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.

Page 28: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

• 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

Page 29: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 30: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

Financial Impact: “Hard Green Dollars” from Denver Health’s Lean Initiative

Page 31: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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

Page 32: Lean at Denver Health: Saving Lives, Saving Money, Saving Jobs Phil Goodman Director, Lean Systems Improvement Denver Health Denver, Colorado

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!