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Transcript of Lean at Denver Health - · PDF fileLean at Denver Health Phil Goodman, MS, HSA, RRT Senior...
Lean at Denver HealthPhil Goodman, MS, HSA, RRTSenior Lean FacilitatorDenver Health Medical CenterDenver, Colorado
© 2007 Denver Health Medical Center
Lean at Denver Health
Outlinen Why Leann Implementing Leann Using tools—examplesn Sustaining Improvements
RightPeople
Right Environment
Right Communication
and Culture
Right Process
Right Reward
Getting It RightGetting It RightIT
©
Lean at Denver Health
n Why did we choose Lean?q A philosophy, set of principles and a tool
setq Philosophy fits for health careq Tool set is intuitiveq Meaningful employee engagementq Initial rapid resultsq Power to change culture
Lean at Denver Health
n Implementation-Trainingn Fall 2004-June 2005
q “Black Belts” – 50 Physician Directors/Nursing Directors/Service Line Administrators/Mid-Managers
q Extensive Lean Trainingq Key “day to day” implementersq Launched Organization-Wide 5S Campaign
Lean at Denver HealthLean at Denver Health
n Respiratory TherapyScavenger hunt 20 pieces of equipment by 20
therapistsTime to find 14.4 minutes to 8.7 minutesNumber of steps 762 +185 to 465 +123Pieces of equipment not found: 45 to 1 Financial impact ~ $10,000/yrClinical impact
Lean at Denver Health
n Lean-5SEngineering Departmentq 21 number of sites for inventory before q 19 number of sites for inventory afterq Materials Managementn $ cost before – 2004 $1,034,631; 2005 –
$1,155,500n $ cost after – Actual 2006 savings $869,766
(24.7% reduction expense over prior year)
Lean at Denver Health
n Utility of starting with 5Sq Easy/Intuitiveq Applicable to clinical areas and support
functionsq Creates safetyq Improves moraleq Large number of employees engagedq Immediate resultsq Basis for other Lean toolsq Begins spread of culture of Leann A must now for space requests and moves
Lean at Denver Health
n Role of Black Beltsq Originally two projects/year (pre RIE approach)q Now – way of doing business; monthly reports
from every BB to CEOq Some impressive ongoing efforts
Lean at Denver Health
n Examples Black Belt Use of Leanq Emergency Departmentn Standardized roomsn Mapping work flow-regained space
q Paramedicsn Mapping change over- create vehicle stocking
techq Legal n Transform paper process to electronic
Lean at Denver Health
n Outcome of Black Beltsq Imbedding lean in cultureq Dollar savings $701,337
Lean at Denver HealthImplementation
n June 2005-Presentn Rapid Improvement Event n Simpler
n Radically different problem solvingq Intense self-reflectionq Highly focused, outcome directed
n 5 Strategic Value Streamsq Accessq Outpatientq Inpatientq Operating Roomq Billing
Lean at Denver HealthLean at Denver Health
Lean at Denver Health
n RIE Teamq Facilitator – Coaches in use of Lean; owns
pre and follow-up dataq Team Leader – Manages one day to day
processq Process owner – In the focused area;
responsible for sustaining changeq New eyes – Someone from non RIE areaq No more than 1/3 new RIE team members
Lean at Denver Health
n RIE level Metricsq Easily measurableq Financial metricq Quality metricq Employee metric
n Production board on siten Ongoing measurement
Rapid Improvement Event Week:Rapid Improvement Event Week:•• Monday (8 hrs) 8 amMonday (8 hrs) 8 am--9:30 am training 9:30 am training ––mapping mapping process; waste walkprocess; waste walk•• Tuesday (8 hrs)Tuesday (8 hrs)––design new processdesign new process••Wednesday (8 hrs) Wednesday (8 hrs) -- pilot new processpilot new process••Monday Monday ––Wednesday Wednesday ––four pm report out tofour pm report out to
Executive staffExecutive staff••Thursday (8 hrs)Thursday (8 hrs)–– create standard workcreate standard work••Friday 8 amFriday 8 am--9 am9 am-- all team report out to all team report out to Executive Staff and CEOExecutive Staff and CEO•• 9 am9 am--10 am Training10 am Training
Lean at Denver HealthLean at Denver Health
Access Value Stream: Inpatient Enrollment RIE Team
Peg Burnette Executive SponsorCarol Lovseth EnrollmentChristine Lassiter Patient AccountingJoe Masi Office of IntegrityNancy Holtzmaster Information SvcsRichard Castro Community HealthCesar Rodriguez EnrollmentLuz Collins Community HealthRafael Gomez-Gaitan AdmissionsVera Stelter FacilitatorSara Richardson Facilitator
Lean at Denver Health RIE Case Studies
Lean at Denver Health RIE Case Studies
Inpatient Enrollment RIE Inpatient Enrollment RIE
n AIM : Reduce inpatient Self-Pay charges and increase Enrollment
n SCOPE : Inpatients arrive without proof of insurance/program (trigger) presenting in an unscheduled admission (done)
Lean at Denver HealthIn Patient Enrollment RIE
Communication Plan/Follow Up
n Track how process is working with Enrollment Specialists
n Train OP registration staff, Billing and Customer Service departments of upcoming changes
n Track and graph data for metrics, using a 12-month rolling average, and distribute it to RIE team and Enrollment Specialists (Production Board)
Lean at Denver HealthIn Patient Enrollment RIE Results
Self Pay Charges90 Day Rolling Average
$-
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
$1,600,000
$1,800,000
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06
Target: $1,074,99030% Reduction
MemorandumTo: Carol Lovseth
From: Team Award Committee:-Peg Burnette, Phil Mehler, M.D., Kay Daugherty, Mike O’Malley
Date: 1/29/2007Re: Team Incentive Plan Project SubmissionCongratulations! The Team Award Committee has approved your Team Award project submission “Inpatient Enrollment RIE”! The committee has also verified that you have achieved the targeted metrics as outlined in your project submission! Payout per teammember will be $500 (before deduction of taxes) and will appear on the February 13th, 2007 paycheck! This is the maximum award amount under the Team Award policy! Please note that if you are a CSA employee, payout will appear at the end of the calendar year in which the payout was made. Please contact a Committee member if you have any questions.
CONFIDENTIALRightPeople
Right Process
Right Communication
and Culture
Right Environment
Right Reward
Lean at Denver HealthGetting It Right:Putting the Pieces Together
Lean at Denver Health
n Financial outcome of access value stream -- $638,817
Lean at Denver HealthRIE Case Study: Value Stream: Patient Billing Financial CounselingRIE January, 2006 (1st Pass)August, 2006 (2nd Pass)
Lean at Denver Health Financial Counseling RIERIE Team:
Executive Sponsor: Peg Burnette (CFO)Team Leader: Cheryl StephensonFacilitator: Amit KarkhanisTeam Members:Rafael Gomez-Gaitan (Process Owner)Carol LovsethLuis PicardoBettina SchneiderTom McCloskeyNancy KlockNancy McDonald
Lean at Denver Health Financial Counseling RIE
Aim: Expand financial counseling processes established in Jan’06 RIE
Scope: Insured, Self-Pay and CHS InpatientsWhen patient is contacted by financial counselor (trigger) to payments are received or account goes to collections (done)
Lean at Denver HealthFinancial Counseling RIEMetrics
Measurement Baseline Target
n Collections $10,108 $75,472(Oct-Dec’06)
n No. of payment 1 per day 4 per dayagreements per counselor
Lean at Denver HealthFinancial Counseling RIEProblem Identification• No standardized referral process• Excess human capacity due to limited scope
of previous RIE• No consistent attempt to collect from
inpatient commercial insurance patients prior to discharge (learn from Willie)
• Cumbersome manual tracking of information• Limited communication between insurance
verifiers and financial counselors Willie Sutton
1901-1980
Lean at Denver HealthFinancial Counseling RIE
Elective Surgery Collections
$1,533 $1,170 $2,242$4,112 $3,944 $2,864 $3,085
$12,632
$26,033
$19,822
$-
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
Feb-06
Mar-06
Apr-06
May-06
Jun-06
Jul-06
Aug-06
Sep-06
Oct-06
Nov-06
Target
1st Pass2nd Pass
Lean at Denver Health
n Financial outcome billing value stream --$531,687
Lean at Denver HealthRIE Case Study: Clinic FlowWestside Peds/Teen HCP-Provider Flow Cell Team
q Paul Melinkovich, MD, Director of Community Health Services, Executive Sponsor,
q Mary O’Connor, MD, MPH, Clinic Team Leadq Tricia Mestas, RN Program Managerq Cherie Spinks, PAq Perla Garfio, HCPq Jenny McCoy, Lowry NPq Jeff McNally, IS Web Applications Supervisorq Vickie Leger, CHS Director of Nursing, Team
Leaderq Dana Ballai, Facilitatorq Amie Staudenmaier, Facilitator
Lean at Denver HealthWestside Peds ClinicRIE n Aim : To increase
provider & HCP productivity, decrease waiting and improve patient cycle time
n Scope: Time HCP calls patient (trigger) to the time patient leaves the room (done)
Lean at Denver HealthWestside Peds RIE Metrics
Users per FTE- improve by 5%UPFTE
Patients per Provider Session- improve by 20%PPS
Clinic Flow Time - Door to Door- improve by 10%Flow Time
Discipline Specific Quality Outcomes- improve by 5%
Clinic Outcome
Staff Satisfaction - improve by 5%Satisfaction
Value Stream Metrics
24 m45.6 mCycle time
>109.3Patients per provider session
TargetBaseline
RIE Metrics
Lean at Denver HealthWestside Peds RIE Spaghetti Diagram
n Pre n Post
Lean at Denver Health Westside Peds RIE Results
n Reduced cycle time by nearly 50% on first day of implementation
n Reduced movement/motion for HCP & Providern Created tight connections between HCP and
providern Used multiple/rapid PDSA to make adjustmentsn Addressed Value Statement & Business Case
created during Value Stream Mapping
Lean at Denver Health Westside RIE Follow Up
n Pilot teams will maintain daily control board and track cycle times
n Facilitators will observe and monitor pilot teams and make necessary adjustments during 3 weeks post RIE
n Attend monthly staff meeting to ensure changes are sustained
n Will strategically roll out new model to remaining Provider/HCP teams
Lean at Denver Health
n Financial outcome clinic value stream -- $457,006
n Medicine Service Line Administratorn Nurse Anesthetist (CRNA)n Facilitatorn Infection Control RNn ID Pharmacist n RNn Consultants:
q Chief of Infectious Disease, Medical Director, ITq Surgeons, Medical Director of Anesthesiologyq HIM/IS Regulatory Compliance Coordinator
Lean at Denver Health RIE Case Study: Value StreamValue Stream--ORORSurgical Site Infection (SSI) RIE Surgical Site Infection (SSI) RIE June, 2005June, 2005
n Changed point of administration of antibiotics from pre-op to anesthesiologist in the OR
n Documented standard work for application-process-timeliness
n Met with surgeons from each service to review process
Lean at Denver HealthSSI RIEInterventions
n Change process effective June 5, 2005n Communication letters sent to all personnel as
follow-up to face to face communication
Lean at Denver HealthSurgical Site Infection RIE Results
n Antibiotics within 1 hour of cut timepre target post
65-75% 100% 96%
Sustaining Results atDenver Health
Antibiotics Within 60 Minutes of Surgery
0%
20%
40%
60%
80%
100%
120%
May '0
5 (n=
12)
July
'05 (n
=26)
Augus
t '05 (
n=29
)
Sept '0
5 (n=
28)
Oct '05
(n=2
2)
Nov '0
5 (n=
22)
Dec '0
5 (n=
28)
Jan '
06 (n
=7)
Feb '
06 (n
=16)
March '
06 (n
=23)
April '0
6 (n=
20)
May '0
6 (n=
20)
June
'06 (
n=25
)
July
'06 (n
=27)
Augus
t '06 (
n=23
)
Sept '0
6 (n=
14)
Oct '06
(n=2
4)
Nov '0
6 (n=
22)
RIE WeekJune 3-6, 2005
Exec Staff Redefined Process Owner
n Facilitatorn Director of Anesthesiologyn Director of Perioperative Servicesn OR Charge Nursen Surgical Techniciann Two RN’sn Practice Administrator
Lean at Denver HealthOR Room Turnover RIETeam Composition
Lean at Denver HealthQuick Change RIEAugust, 2006
n Ophthalmology Room Turnover RIE Interventionsq Co-located equipment and medications (Point of Use)q Created and implemented standard work for ES
("Quick Turn")q Created and implemented standard work for SPD
for cataract casesq Modified schedules: Infected cases (cataracts) at
the end of the block q Using "wave schedule"
Lean at Denver Health OpthamologyRoom Turnover RIEMetricsMetrics
7.5812Room/ready minutes
785Case/day
posttargetpre
Backlog removedBacklog removed
Lean at Denver Health
-2%16,60916,947OR Hours
-1.0%$ 546 $ 551 Supplies per OR Hr
$979,424Total Impact
-0.9%$ 848 $ 856 OR Total Expense per OR Hour
2.5%$ 3,764 $ 3,673 OR Gross Charge per OR Hour
% ∆Jan-Dec 2006Jan-Dec 2005OR Financial Analysis
Lean at Denver Health
$14.09 $14.50 $12.61$10.27$9.58$8.92Total OR Expense
(million $$)
$546 $551 $468 $452 $434 $362 Supply Expensesper OR Hr
$848$856$741$689$676$566Total OR Expenseper OR Hour
$3,764 $3,673 $3,442 $3,365 $2,931 $2,469 Gross Charges per OR Hour
200620052004200320022001OR Financial
Trend
q Facilitatorq Director of Support Servicesq Asst Chief of Nursingq RNq Asst Manager Environmental Servicesq Admin Asst Admissionsq Financial Apps Supervisorq Nursing Supervisorq Transportation Supervisorq Program Managerq Project Manager
Lean at Denver HealthRIE Case Study:Hospital Flow Value StreamED to Patient In Assigned Bed RIE Team
1st Pass: November, 2005
2nd Pass: April, 2006
3rd Pass January, 2007
Lean at Denver HealthED to Patient In Assigned Bed RIE Aimn Decrease the time from
patient bed assignment to the patient’s arrival to the bed.
Scope:n Patients being admitted
to 3B, 4B, 6A, 9A from the ED
Lean at Denver HealthED to Patient In Assigned Bed RIE Metrics
Value Stream MetricsED Divert %Unutilized Bed Time (Bed Fallow Time)
RIE MetricsBaseline Pilot Target
Cycle Time:Bed Assigned to Patient in Bed 2.5 – 3 hrs 38-75 min* 1.5 hrs
Pilot studied already cleaned rooms- room cleaning takes 24-45 min
Lean at Denver HealthED to Patient In Assigned Bed RIE Interventions
n Active notification to ED of bed assignmentn Floor nurse “pulls” patient to floor by calling to
request report from ED nurse.n Clarified roles and responsibilities, created
standard workn Scripted communicationn Set clear expectations with timelines
Lean at Denver HealthED to Patient In Assigned Bed RIE Results
Bed Assigned -> Patient in BedPatients Admitted from the ED
0:000:280:571:261:552:242:523:21
Average 3B Average 4B Average 6A Average 9A
11-20-06 through 1-24-07
11-20 to 11-2811-29 to 12-612-7 to 12-1212-13 to 12-1812-22 to 12-2612-29 to 1-41-5 to 1-24
Goal:1:30
Lean at Denver HealthED to Patient In Assigned Bed RIE Follow Up
n Continue education to nursing staffn Seek feedback from nurse managers and all
staff involved in new processn Study financial impact of new processn Review standard work and make changes as
new technologies roll out
Lean at Denver HealthED to Patient In Assigned Bed RIE Standard Work
November RIE“You’ve Got Bed”
ED to Floor Patient Handoff4 Positive Changes!!!!!!
Effective Monday, November 20,2006
ØED clerk receives a call from the floor charge nurse with bed assignmentØFloor nurse calls to get report from ED nurseØED Clerk verifies room ready (in Navicare) prior to transport ØED staff delivers admit paperwork to floor clerk before patient is taken to roomSee “Patient Flow Standard Work” for details
November RIE“You’ve Got Bed”
ED to Floor Patient Handoff4 Positive Changes!!!!!!
Effective Monday, November 20, 2006
ØFloor charge nurse contacts ED clerk with bed assignmentØFloor nurse calls to get report from ED nurseØAdmit paperwork delivered to floor clerk before patient is brought to roomØFloor clerk immediately notifies assigned staff of patient arrivalSee “Patient Flow Standard Work” for details
Lean at Denver Health
n Total financial benefit of Lean --$3,446,457 (18 months)
n Saved $191,470/month
Lean at Denver Health
n Rapid Improvement Eventsq Positivesq Focused effortsq Results orientedq Employee involvement and acceptanceq Interns/Residents involvement-unique
opportunityq Does save dollarsq Changes culture
Lean at Denver Health n Lesson learnedq Having sensei q Right Value Streamsq Decide RIE order and schedule in
advanceq Create right size RIE—pre work and
eventq Defined RIE process—pre work and eventq Team Composition—no more than 1/3
new; cliniciansq Establish and Monitor metrics/outcomesq Needed full-time facilitatorsq Reluctance to remove employeesq Sustaining results (F/U)q Have patience
n Monitoring metrics and outcomesq Executive staff member responsible for
each Value Stream (VS)q Facilitator responsible for each VSq Evaluation team-financial analyst, health
service research, senior facilitatorq Monthly review of metrics with CEOq Monthly review of process with Executive
Staffq Monthly meeting Executive Staff VS
sponsors and senseiq Monthly meeting CEO and sensei
Lean at Denver HealthHow To Sustain Process Improvements
Lean at Denver Health
•Lean Tools for Sustaining Improvements
q Standard Workq Executive Gemba Roundsq Visual Management: Production Boardsq Metricsq A3
Standardize and Solve to Improve and Sustainn Standard Work,
defined by the Rapid Improvement Team, “puts the hooks” in new process
PA
DC
STD WORK
Perform
ance
Time
PA
DC
PA
DC
STD WORK
Perform
ance
Time
Lean at Denver Health
Reprinted with permission from Simpler Consulting Inc
Sustaining Improvement Executive Gemba Rounds
n Review production boardsn Ask about standard workn Provide positive feedback!n Answer questions
Sustaining Improvement OR Production Control Board
Sustaining Improvements:MICU Production Control Board
Late Rounds (M&M Conference)
KM
EB
MH
Home IV, O2LW
TransportationPGComments
Discharge in next 24 hrs?Patient
Improve Std Work
Corrective Action
80/20 Problems
Rapid Improvement Target: Discharge Before Noon
Sustaining Improvements:Production Control Boards
Discharge Time
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
Tim
e Average
Goal
Date: 2/5/07 Date: 2/6/07 Date: 2/7/07
Lean at Denver HealthFinancial Counseling RIEControl Board
No. of Patient Contacts versus Payment Agreements Per Day
0
2
4
6
8
10
12
25 26 27 28 29
September
No. of payment agreementsper dayNo. of patient contacts perdayTarget for paymentagreements per day
A3: Telling the Story,Showing the Sustainment
1. Reason for Action2. Initial State3. Target State4. Gap Analysis5. Solution Approach6. Rapid Experiments7. Completion Plan8. Confirmed State9. Insights
Lean at Denver Health
731611I understand Lean philosophy and how it works in our organization and helps maintain our mission
622612I see benefits of the Lean philosophy in doing right processes at DH
591130I have been involved in the Lean Initiative like 5S or RIE
% Agree% Neutral% Disagree
Impact of Lean on CultureImpact of Lean on Culture
Lean at Denver Health
n Employee engagement score 4.48 (1-5) n Single best correlation to engagement was being
on RIE
Lean at Denver HealthConclusion
n Lean is a philosophy and tool set that is readily adaptable to health care
n Lean is an approach the health care work force will embrace
n Implementing Lean requires senior leadership, focus, training, structure and monitoring
n Preliminary data suggest two year effort to really get to Lean; long term commitment