Making a Difference: The Lean Culture and Results at Denver

Public Health

Judith Shlay, MD, MSPHHeather Weir, MPH, RD

Questions for the group

• Who uses Lean currently?• Who has been using Lean for > 2

years?• Who is considering using Lean?• Who would like to know what Lean

is?• Who has ever heard of an A3?

Objectives

• Background of Denver Health and Denver Public Health

• Reason for Action• Where we’ve been• Recent progress in 2013 • Structure of QI at DPH• QI Projects

Denver Health Overview

• Large, urban, integrated, public safety-net institution which includes:– 911 medical response system– 525 bed acute care hospital with a Level 1 Trauma

Center – Denver Public Health department– 8 family health centers– 15 school-based clinics– 100 bed non-medical detoxification facility– call center (includes a regional poison center, drug and

nurse advice line) – correctional care and a center for the medical response

to terrorism, mass casualties and epidemics • Approximately 65% of patients <185% federal poverty level• >70% members of ethnic minorities• Substantial amount of uncompensated care

Denver Denver CaresCares

Denver Denver CaresCares

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 Health based Health

CentersCenters

School-School-based Health based 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

HITHIT

Denver Denver CaresCares

Denver Denver CaresCares

Public HealthPublic HealthPublic HealthPublic Health

Employed PhysiciansEmployed Physicians

Legend:Legend:Bright Green – Pt RevenueBright Green – Pt RevenueBlue – CityBlue – CityOrange – DHMPOrange – DHMPLavender – GrantsLavender – GrantsDark Red - RMPDCDark Red - RMPDC

RightPeople

Right Environment

Right Communication

and Culture

Right Process

Right Reward

Getting It Right…Perfecting The Patient Experience

Principles 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

What is a Lean Management System?

• Lean is 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 Thinking is the operation of a business from the patient/customer’s definition of value…not from the organization’s or its assets

• Lean Management System is the mechanism to develop, sustain, and improve processes over time

Current Denver Health Lean Management System Focus

• Lean Management System– Strategic Alignment– Standard Work– Visual Management– Continuous Improvement (Lean Tools)

• Root Cause Problem Solving (A3 deployment)

– Leadership Standard Work

Strategic Planning

Strategic Planning Process

DPH Overview

• Provides public health services for the City and County of Denver – Direct disease control services (e.g., tuberculosis, HIV,

STD clinics and immunizations) – Epidemiology and informatics – Preparedness– Vital records/vital statistics – Denver Prevention Training Center – STD/HIV/TB prevention activities– Immunization outreach– Health promotion division

• Tobacco control • Maternal child and youth health• Healthy eating and active living prevention activities• Injury prevention

The Core Functions and Essential Services

Monitor HealthMonitor Health

Diagnose and Investigate

Diagnose and Investigate

Inform, Empower,Educate

Inform, Empower,Educate

Mobilize CommunityPartnerships

Mobilize CommunityPartnerships

Develop PoliciesDevelop Policies

Enforce LawsEnforce Laws

Link To / ProvideCare

Link To / ProvideCare

Assessment

Dev

elop

and

App

ly P

H S

cien

ceD

evel

op a

nd A

pply

PH

Sci

ence

Assu

re C

ompe

tent

Wor

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ceAs

sure

Com

pete

nt W

orkf

orce

Eval

uate

Eval

uate

Policy Development

Assurance

Epidemiology

Improve Health

Quality

CORE FUNCTIONS:

Core Functions of Public HealthImplications for Quality

Assessment

PolicyDevelopment

Assurance

Priority Areas

WORK

WELL-DONE

WORTHY Improve Health

Protect Health

Emergency-Prepared

Elements of Public Health Quality

Worthy Work Well-Done

PrioritizationEvidence Reviews

Performance Measures

ImportantHealth Issues

High-ValueInterventions

AccountablePerformance

Continuous Quality Improvement

History of QI at DPH

2013 Progress

Lean Work at Denver Public Health

The nuts and bolts

Performance Management Framework

•Quality Committee•Lean Events - RIEs, 6S•Lean Black Belts•QI projects•PDSAs•QI Plan•QI training

•Quarterly Reports•BI Tool/Dashboards•Visual Management Boards•Website – internal/external•onFocus•Scorecards

•Results Accountability•Population Indicators •Program Performance Measures•Customer Satisfaction Surveys•Strategic Planning – metrics/achievement indicators

•QI Assessment (all-staff)•Performance Management Self-Assessment

•Public Health Accreditation Board (PHAB) standards

•Healthy People 2020•National and State benchmarks

•Program goals and targets to set expectations Performance

StandardsPerformance

Measurement

Quality Improvement

Reporting of Progress

Leadership & Culture

DPH – Performance Management System

onFocus (Performance Management Software)

• On Focus spreadsheet

Denver Public Health – Process for Quality Improvement Projects

*All forms, resources, and the QI Project Tracking list are available on the Pulse/Intranet (DPH subsite) -

DPH Performance Management site (QI Project folder)

Ask for help!Contact Heather Weir, QI Coordinator (x23582)

and your Quality Committee representative when starting a QI project

• Why are we doing this?• What is the burning platform?• What is the chief complaint?

• What are the attributes of the Initial State (qualitative and quantitative)?

• Use visuals.

• What are the attributes of the Target State (qualitative and quantitative)?

• Use visuals.• Have metrics that are defined

and achievable.

• What holds us back from the Target State?

• What are the root causes of these road blocks?

• What is the hypothesis to address the root cause (If/Then statements)?

• Does solution approach link well with root causes?

• Expect the Solution Approach to not be perfect – test them!

• Are Rapid Experiments achieving desired results?

• Action Plan – who, what, when• Check that Completion Plan is

on track at follow-up meetings

• Are Confirmed State metrics in place and do they validate the target state?

• Do insights show key lessons learned and identify future opportunities?

QI Projects

Rapid Improvement Event (RIE) – Vaccine Inventory Management

Reason for Action:• adhere to federal/state laws• improving/creating standard work• outgrown current Vaccine Registry

(Vaxtrax)• inefficient use of resources

Initial State Target State

Results

Results

• The number of private vaccine orders decreased to one time a month

• Decreased the time for the nurse ordering• Used par levels to determine how many vaccines to order

Results

• 100% charts were reviewed • 30% errors in September to 10% in April• Errors found primarily in not indicating which program they are

from (Travel, 317 funded, Tdap cocooning)

Return on Investment

STD Clinic – Ask, Advise, Refer (2As+R)

Root cause analysis

Barriers Potential Solutions

Competing priorities/Tobacco is not STI-related

Education

Staff time Streamlined, standardized work process

Patient receptivity Education and training

No system to document tobacco use and referrals

Create a standard work processChange the EMR

Perceived lack of cessation resources Education

No incentive for clinic staff buy-in Education: Cessation savesMonetary incentives for staffPotentially able to bill

STD Clinic – Ask, Advise, Refer (2As+R)

The current state and the ideal state

STD Clinic – Ask, Advise, Refer (2As+R)Rapid Experiments

October 24 November 1 November 15 December 1

Paper Pilot in the Clinic

Clarified questions, re-training & provided additional resources

Attend clinic huddles weekly to reinforce, encourage

Amended the EMR

STD Clinic – Ask, Advise, Refer (2As+R)Results

Flu Vaccines - in all DPH clinics

Shared Drive Clean Up Projects

• Reason for action: – reduce time in finding files– ensure critical files are

accessible/backed up– correct permissions on folders

Birth and Death Records – Phone Orders

• New process• Process mapping

– staff identified 14 areas of improvement

Birth and Death Records – Phone Orders

Contact Information

Judith Shlay, MD, MSPH605 Bannock St., MC 2600Denver, CO 80220(303) 602-3714judith.shlay@dhha.org

Heather Weir, MPH, RD605 Bannock St., MC 2600Denver, CO 80220(303) 602-3582heather.weir@dhha.org