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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
kfor
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) [email protected]
Heather Weir, MPH, RD605 Bannock St., MC 2600Denver, CO 80220(303) [email protected]