Lean At Denver Health: Saving Lives, Saving Money, Saving Jobs

Phil Goodman Director Lean Systems Improvement

What is LEAN? • LEAN can be defined as a systematic approach of continuous improvement, based on the Toyota Production System (TPS) of LEAN principles and LEAN tools, used for the identification and elimination of waste.

Lean Pillars of Transformation

Continuous Improvement

Respect for People

Transformation

Lean Deployment at Denver Health • Process Transformational Plan of Care Value Streams Rapid Improvement Events • Black Belts • Application in healthcare settings • Results

Selecting Value Streams: The Matrix Revenue Cycle

OB

Case Mgmt

Laboratory

Med/Surg

Imaging

ED Pt Flow

Equip Mgmt

Pt Reg./Sched.

Med Records

Pt. Transport

Wound Care

OR

Pharmacy

One Year Enterprise Goals

Cath Lab

CORE Processes

Weight Rank RxWRank RxWRank RxWRank RxWRank RxWRank RxWRank RxWRank RxWRank RxWRank RxWRank RxWRank RxWRank RxWRank RxWRank RxW

Financial: Improve Net Revenue 10% Delivery (Timeliness) Reduce Lead Time 50% VOC: 90th Percentile Pt Satisfaction Growth/Access : Increase Unduplicated Quality: Reduce Nosomial Infections

Total

5

5 25 5 25 5 25 5 25 2 10 4 20 5 25 3 15 5 25 4 20 5 25 5 25 5 25 5 25 5 25

4

4 16 4 16 4 16 4 16 3 12 2 8 3 12 5 20 5 20 4 16 4 16 4 16 2 8 4 16 4 16

3

5 15 4 12 5 15 3 3 3 9 1 3 5 15 2 6 5 15 4 12 5 15 3 9 2 6 4 12 3 9

2

2 4 2 4 4 8 1 2 1 2 1 2 3 6 2 4 5 10 4 8 2 4 2 4 4 8 2 4 2 4

1

1 1 3 3 5 5 5 5 1 1 1 1 1 1 1 1 3 3 3 3 5 5 2 2 2 2 3 3 1 1

61

60

69

51

34

34

59

46

73

59

65

56

49

60

55

Selecting Value Streams Transformation Plan of Care (TPOC)

Value Stream Analysis (VSA)

Value Stream Analysis (VSA)

Value Stream Analysis (VSA)

Value Stream Analysis (VSA)

Value Stream Analysis (VSA)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Rapid Improvement Event (RIE)

Enterprise Transformation Alignment System Metrics Value Stream Metrics RIE Metrics

Enterprise LEAN Alignment “Constancy of Purpose” Quality

Delivery (Access)

Productivity

Financial

Human Development

Nosocomial Infections

ED Divert

Visits per Session

Expense per D/C or Encounter

Employee Engagement

OB

ED/ AUC

Spec Clinic

Rev Cycle

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

BHS

RMP DC

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

HR

OR

CP

Med D/C

CHS

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

RIE

MC

Rx

RN

2012 Value Streams Value Stream

Executive Sponsor

Value Stream

Executive Sponsor

Emergency Department

Phil Mehler MD, CMO

Pharmacy

Rick Dart, MD Director, RMPDC

Human Resources (HR)

Gregg Rossman, Chief HR

Behavioral Health

Stephanie Thomas Chief Operating Officer

Managed Care MC

LeAnn Donovan, Director, MC

OB/Gyn

Chris Carey, MD Chief OB/Gyn

Nursing

Kathy Boyle, CNO

Ambulatory Care

Paul Melinkovich, MD Chief Ambulatory Care

Perioperative Svcs

Kathy Boyle, CNO

Revenue Cycle

Peg Burnette, Chief Financial Officer

Clinical Processes

Tom MacKenzie,MD Director Pt Safety and Quality

Medical Discharge

Rick Albert Chief of Medicine

Rapid Improvement Event (RIE) Simpler –Using LEAN Tools in Focused Manner Day 1 Mon

• • •

Examine a process/function or area Identify areas of waste, non-value added steps Identify metrics

Day 2 Tues

• •

Develop new process, standard work and communication to eliminate identified waste and increase value Design rapid experiments

Day 3 Weds

• • •

Implement the new processes, standard work Monitor production board and communicate standards Observe new process and any change in metrics

Day 4 Thurs

• •

Adjust and fine tune new standard work Put visual controls in place

Day 5 Friday

• •

Celebrate! Report out to executive staff 10 minute team reports

Lean Deployment at Denver Health • Process Transformational Plan of Care Value Streams Rapid Improvement Events • Application in healthcare settings • Blackbelts • Results

Pediatric Access RIE Team Let’s just say that there’s a certain level of bonding that occurs in RIEs

Examples of RIEs Clinical Rapid Improvement Event

Non-Clinical Rapid Improvement Event

Venous Thromboembolism Prophylaxis Standardized use of Low Molecular Weight Heparin (LMWH), Unfractionated Heparin (UFH), and Sequential Compression Devices (SCD)

Managing Facility Charge Denials By putting rules in Med Assets, putting standard work into place for denials management and communicating with registration, UM and Contracts Management about denials that can be prevented on the front end, we believe we can reduce outstanding denials by 15%, or $225,000

Oct 2011 Baseline: 5.7% Target ( 15%): 4.9% June, 2012 Denials: 3.3%

Lean Deployment at Denver Health • Process Transformational Plan of Care Value Streams Rapid Improvement Events • Black Belts • Application in healthcare settings • Results

Denver Health Lean Academy/ Black Belt Training Lean Tools to “Diagnose” Waste

Lean Tools to “Treat Waste”

Process Mapping

Standard Work

Time Observations

Poke Yoke (Mistake Proofing)

Level Loading Diagram

Kanban (Pull Systems)

Spaghetti Diagram

6S (Sort, Set, Shine, Standardize, Sustain, Safety)

Communication (Handoff) Circle

Andon (Stop the Line)

Waste Walk

Visual Management

A3 Problem Solving

A3 Problem Solving

Black Belt Project Example: Common Canister

Inhalers for Asthma and COPD: Combivent, Albeterol, Atrovent, and Flovent

Pharmacy/Respiratory Therapy “Common Canister” Black Belt Project: Pre Lean: 6,624 canisters/year

Post Lean: 2,381 Canisters/year Savings in Acquisition Costs: $363,000! (75% Reduction)

Lean Deployment at Denver Health • Process Transformational Plan of Care Value Streams Rapid Improvement Events • Black Belts • Application in healthcare settings • Results

Pre-Hospital: Denver Health Paramedic Value Stream Paramedic Division Response Time Performance Pre and Post RIE

Response Time in Seconds, 911 Answer to Arrival at 90% Compliance

880

860

840

820

800

780

760

740

720

700 EMS

EMS

EMS

EMS

EMS

EMS

EMS

EMS

Operating Expense 2011-2012

Total Personnel, Operating Expenses and Revenue 2007-2012

Hospital Flow and Readmissions

Hospital Acquired Conditions

UHC Quality and Accountability Aggregate Score

Outpatient: Community Health Services Total CHS Patients 140000 120000

100000 80000

60000 40000

20000 0

2005

2006

2007

2008

2009

2010

2011

Total Patients 102710 101162 103826 108042 113003 117058 123614

Community Health Services

Improving Outpatient Quality

Improving Outpatient Quality

SUMMARY • • • •

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!