1. 1 Reducing Waste and Improving Health Care Processes Through the Application of Lean Sheri Eisert, PhD Associate Professor University of Colorado Health Sciences Center Director of Health Services Research Denver Health 9/27/07 AHRQ Annual Conference: Improving Health Care, Improving Lives This project was supported by the Agency for Healthcare Research and Quality under IDSRN Contract No. 290-00-0014,TO #11.

2. 2 Purpose of Lean Implementation Continued rise in health care costs and uninsured. Continued rise in health care costs and uninsured. Reduction and uncertainty in health care resources. Reduction and uncertainty in health care resources. Workforce shortages. Workforce shortages. Need to improve patient safety/quality. Need to improve patient safety/quality. Silos of care and communication. Silos of care and communication. Almost every health care process includes non-value added activities. Almost every health care process includes non-value added activities. Lean philosophy and tools can be readily understood by all employees. Lean philosophy and tools can be readily understood by all employees. Was driven by healthcare system leadership.

3. 3 Scope of Lean Implementation Place: Denver Health, an Integrated Safety Net Healthcare System Place: Denver Health, an Integrated Safety Net Healthcare System 1- 500 Bed Hospital 1- 500 Bed Hospital 8 Community Health Centers 8 Community Health Centers Over 4,000 Employees Over 4,000 Employees Timeframe: Timeframe: June 2005: Pilot in OR June 2005: Pilot in OR October 2005: 5 Systems Areas October 2005: 5 Systems Areas June 2007: 14 System Areas June 2007: 14 System Areas

4. 4 How Lean Implemented? Executive Staff assigned to system areas or value streams. Executive Staff assigned to system areas or value streams. Lean Facilitators assigned to value streams (3 FTE then 8 FTE). Lean Facilitators assigned to value streams (3 FTE then 8 FTE). 50 mid managers and clinical personnel Lean trained as “Lean Belts”. 50 mid managers and clinical personnel Lean trained as “Lean Belts”. Projects identified by mapping the flow of a value stream. Projects identified by mapping the flow of a value stream. Rapid Improvement Events (RIEs), where teams of 6-8 people map scope of process, eliminate waste in process and pilot new process during this week long event. Rapid Improvement Events (RIEs), where teams of 6-8 people map scope of process, eliminate waste in process and pilot new process during this week long event.

5. 5 How Impact of Lean Evaluated? Three levels of metrics: 1. System -readily available such as Net Revenue, Employee Turnover, Medication Errors, Patient Satisfaction, Patient Volume 2. Value Steam -related to healthcare system area such as divert rate for the hospital, clinic visit cycle time for outpatient 3. RIE -specifically identified for a particular process such as reduced patient waiting time in surgery clinic, decrease in the amount of time from patient discharge to bed cleaned and reduction in OR overtime.

6. 6 Results of Lean Implementation: From October 2005 –July 2007 94 RIEs implemented. 94 RIEs implemented. 395 employees participated. 395 employees participated. $8.1 million in reduced costs/increased revenue ($3.5m in 2006, $4.6m in 2007). $8.1 million in reduced costs/increased revenue ($3.5m in 2006, $4.6m in 2007). Examples of improved quality of care: Examples of improved quality of care: Diabetic Foot Exams: 14% to 24% Diabetic Foot Exams: 14% to 24% Recovery Time: 210 minutes to 134 minutes Recovery Time: 210 minutes to 134 minutes Antibiotic within 60 minutes of incision: 80% to 90% Antibiotic within 60 minutes of incision: 80% to 90%

7. 7 Business Case Considerations Accounting for indirect implementation costs such as the opportunity cost of employee time in RIEs, Executive staff time, data analysis. Accounting for indirect implementation costs such as the opportunity cost of employee time in RIEs, Executive staff time, data analysis. Controlling for outside market and regulatory factors that may impact metrics. Controlling for outside market and regulatory factors that may impact metrics. Return may not be realized until a year into implementation. Return may not be realized until a year into implementation. Reducing waste and improving quality of care. Reducing waste and improving quality of care.

8. 8 Lessons Learned Necessary to implement many projects for their to be a tipping point. Necessary to implement many projects for their to be a tipping point. Identifying and defining metrics linked to process change is challenge for operational staff. Identifying and defining metrics linked to process change is challenge for operational staff. Important to establish infrastructure for evaluation with system redesign Important to establish infrastructure for evaluation with system redesign Quantitative evaluation not rigorous research –lack of controls and randomization. Quantitative evaluation not rigorous research –lack of controls and randomization. Physician participation a challenge. Physician participation a challenge. Lean tools needed to be adapted to the healthcare environment. Lean tools needed to be adapted to the healthcare environment.

9. 9 Knowledge Transfer Lean in Healthcare National conference targeting safety-nets supported by AHRQ small conference grant (2005-06). Lean in Healthcare National conference targeting safety-nets supported by AHRQ small conference grant (2005-06). Participation in Lean activities by Denver City Government and Denver University. Participation in Lean activities by Denver City Government and Denver University. Site visits by Commonwealth Fund and Singapore Government Officials. Site visits by Commonwealth Fund and Singapore Government Officials. Partnership with DH, consultant and NYCHHC. Partnership with DH, consultant and NYCHHC. Presentations at IHI, NAPH and locally. Presentations at IHI, NAPH and locally. Publications in Industrial Engineer and Academic Medicine. Publications in Industrial Engineer and Academic Medicine.

10. 10 Next Steps Expand knowledge transfer to Healthcare Lean Education Institute. Expand knowledge transfer to Healthcare Lean Education Institute. Continue implementing RIEs, while improving defining scope of process improvement and metrics. Continue implementing RIEs, while improving defining scope of process improvement and metrics. Continue monitoring impact at the 3 levels. Continue monitoring impact at the 3 levels. 2 articles under peer-review and national and regional presentations. 2 articles under peer-review and national and regional presentations.