The Role of Leadership in System
Transformation
November 2012
Leading Lean
• Overview of Denver Health
• Why is healthcare transformation needed?
• Transformation Journey
• Why Lean
• Implementing Lean
• Outcomes
• Lessons learned
2
Non
medical
Detox
Correctional
Care
Denver
Health
Medical
Center
911
Family
Health
Centers
Regional
Poison
Center &
Nurseline
Denver
Health
Medical Plan
School-
based
Health
Centers
Rocky Mtn
Center for
Medical
Response to
Terrorism Public Health
Rky Mtn
Regional
Trauma Ctr
Employed Physicians
HIT
3
4
Denver Health Patients
Denver Health cares for approximately 176,000 individual patients – almost one third of Denver County’s population
37% of Denver’s babies are born at Denver Health
40% of Denver children use Denver Health
70% of patients are ethnic minorities
75% of patients are below 185% FPL
42% of the patients are uninsured
Leading Lean
6
Quality of Care
Overall mortality is one of the lowest among academic health centers
Immunizations – 90% of one year olds fully immunized
Hypertension – 70% controlled
Leading Lean
Leading Lean
• If we are doing so well, why consider system transformation?
– American health care has serious problems in:
• Access
• Cost
• Quality/Safety
– The cost of health care contributes significantly to the deficit, impacts America’s ability to invest at home and be competitive abroad.
7
Scores: Dimensions of a High Performance Health
System 75
70
67
52
69
67
73
71
57
53
71
65
70
75
55
53
69
64
0 100
Healthy Lives
Quality
Access
Efficiency
Equity
OVERALL SCORE
2006 revised
2008 revised
2011
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 8
* Note: Includes indicator(s) not available in earlier years.
*
*
Leading Lean
Change in American healthcare will require new American models
New American healthcare models will require transformation at individual system levels
System transformations require institutional leadership that focuses on and delivers change
9
Leading Lean
• The Role of Leadership – Defining the journey
• Create the vision • Define the path
– Implementing the journey • Teach the path • Create structure – Build the road • Walk the path
– Commitment to outcome • Measure performance • Provide feedback • Create transparency
10
Leading Lean
• Role of Leadership – Define the Path
• Literature review • External steering committee • Site visits • Employee focus groups • Patient focus groups • Detailed examination of processes • Chose the path
11
©
Right
Person
Right
Environment
Patient and
Family
Right
Process
Right Reward
IT
Right
Service
Right
Communication
Leading Lean
14
Waste is disrespectful of humanity because it squanders scarce resources
Waste is disrespectful of individuals because it
asks them to do work with no value Past President Toyota
Waste is disrespectful to patients by asking them to endure processes with no value
Leading Lean
Transformation
Con
tin
uou
s
Imp
rovem
ent
Res
pec
t fo
r
Peo
ple
Lean Pillars of Transformation
15
• Role of Leadership – Implementing the Journey
– Teach the Path • Executive Staff and Directors of Service (Chairs) – 4
hours Lean 101
• Mid-Managers – 2 hours overview
• 2 hours first Lean tool (5S)
16 Gabow, 2012
Leading Lean
Leading Lean
• Role of Leadership – Implementing the Journey – Teach the Path
• All mid managers do 5S project
• Report with metrics to CEO
• Provide a rapid Lean results applicable to clinical and support areas—fun/useful
• Large number of employees involved
• Immediate results
• Begins spread of Lean
• Is foundational
17 Gabow, 2012
18
Unit 1, Basement, Bedroom, Plumbing (BEFORE)
Frank Ortega 4/19/06
Leading Lean
19
Unit 1, Basement, Bedroom, Plumbing (AFTER)
Frank Ortega 5/2/06
Leading Lean
Engineering 5S Project Results
20
Engineering Expense Trend
Supply Expense
2004 1,034,631
2005 1,155,500
2006 869,734
2007 707,223
2008 714,993
2009 711,505
2010 906,285
2011 811,329
6 yr avg savings per yr is $526,196
Lean Deployment at
Denver Health
DH Black Belts (BBs):
• 250 Black Belts
• 48 hours lean training
• Day to day lean
• Bi-Monthly reports
• BBs embedded throughout clinical and non-clinical areas
Rapid Improvement Events (RIEs)
• 16 Value Streams
• 8 RIE’s/yr/vs
• RIEs coordinated by 9 Lean Facilitators
• 7-9 members per team
• >400 RIEs
21
2012 Value Streams
First Floor (ED,DECC,
AUCC)
RMPDC – Drug and Product
Safety
Nursing Clinical Process
Managed Care Revenue Cycle
Specialty Clinic OB/GYN
Human Resources RMPDC – Patient Access
Perioperative Services Pharmacy
Behavioral Health Services CHS (x16 RIEs)
Medicine Discharge Education
Leading Lean
Application of Lean to Quality
Diabetes Chronic Care Management
Reducing inpatient laboratory send-out tests
Clinical Guideline 6S Project
Reducing Medical Readmissions
Improved Cancer Screening
Anticoagulation Clinical Quality Project
–VTE Prophylaxis
–Outpatient Anticoagulation Services Redesign
Leading Lean
24
• Role of Leadership—Implementing the Journey
• Walk the Path —Role of the Executive Staff
• Create steering committee for VS
• Meet with steering committee to establish RIEs in VS for year
• Attend preplanning—picking team, metrics
• Attend RIE sign out—Monday–Thursday-redirection/remove barriers
• Attend Friday report out
• Participate in two RIE’s per year
Gabow, 2012
Leading Lean
• Role of Leadership – Commitment to Outcome
• Measure Performance
– Define metrics/target all levels
– Metric reporting CEO
• Provide feedback
• Create transparency
25
26
• Define metrics
– Black Belt target -- $30,000
– Value Stream target
• Financial
• Quality
• Human Development
Leading Lean
Financial Benefit Per Black Belt Trend
Value Stream 2012 Financial
Target
Quality Target
Pharmacy $1,200,000 Outpatient
Satisfaction
Managed Care $2,300,000 CMS Safety
Monitoring
Community Health
Services
$1,000,000 Visits to Medical
Home
Revenue Cycle $6,000,000 Aggregate Clean
Registration Score
28
Leading Lean
Wall with Value Streams
30
$133,474,232
$42,265,651
$-
$20,000,000
$40,000,000
$60,000,000
$80,000,000
$100,000,000
$120,000,000
$140,000,000
$160,000,000Jul-0
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2
RIE + Blackbelt Financial Benefit Trend Cumulative Through July 31, 2012
RIE Total Savings Black Belt Savings
31
$175,739,883
$-
$20,000,000
$40,000,000
$60,000,000
$80,000,000
$100,000,000
$120,000,000
$140,000,000
$160,000,000
$180,000,000
$200,000,000Jul-0
6A
ug-0
6S
ep-0
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ct-
06
No
v-0
6D
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6Jan-0
7F
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-07
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7Jun-0
7Jul-0
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7Jan-0
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2
RIE + Blackbelt Combined Total Financial Benefit Trend Cumulative Through July 31, 2012
Breast Cancer Screening
Colorectal Cancer Screening
Post Operative DVT
Overall Inpatient Mortality Index
36
247
PEOPLE
WALKED
OUT
ALIVE
Leading Lean
37
I have participated in an RIE 44%
I see the benefits of the LEAN process in driving Right Process at DH.
69%
I understand the LEAN philosophy and how it reduces waste in our organization.
83%
Impact of Lean on Culture Employee Survey– 85% response
2012
Leading Lean
• Engagement
• Pride
• Focus on Success
• Communication
• Career Planning
• Talent Selection
• Quality
• Investment
• Trust and Listening
• Relationship
• Patient Centricity
38
Relationship Between RIE participants and
Dimension of Culture 2012
RIE participants were statistically (<0.01) higher in all
Dimensions
Dimensions
• Transformation Lessons Learned – Transformation requires integrated components – no silver
bullet
– A clear process is necessary for transformation
– The process needs to be applicable to all places where work is done
– Leadership from top is needed to create transformation
– Cultural transformation requires entire workforce engagement
– Need a pace that produces transformation
– Patience and steadfastness are needed
39
Leading Lean
Operating Principles of
Change and Improvement
40
Lean Lessons Learned • Organizational 5S a good start
• Black Belts are an asset
• Project approach not optimal path
• Structure is important
• RIE’s require power transfer
• Handling push back
• Sensei are valuable
RaThank you to Denver Health teams Lean Department Department of Quality and Safety Staff