1

Reducing Waste and Reducing Waste and Improving Health Care Improving Health Care Processes Through the Processes Through the

Application of LeanApplication of LeanSheri Eisert, PhDSheri Eisert, PhD

Associate ProfessorAssociate ProfessorUniversity of Colorado Health Sciences CenterUniversity of Colorado Health Sciences Center

Director of Health Services ResearchDirector of Health Services ResearchDenver HealthDenver Health

9/27/079/27/07AHRQ Annual Conference: Improving Health Care, Improving AHRQ Annual Conference: Improving Health Care, Improving

LivesLives

This project was supported by the Agency for Healthcare Research and This project was supported by the Agency for Healthcare Research and Quality under IDSRN Contract No. 290-00-0014,TO #11.Quality under IDSRN Contract No. 290-00-0014,TO #11.

2

Purpose of Lean Purpose of Lean ImplementationImplementation

Continued rise in health care costs and Continued rise in health care costs and uninsured.uninsured.

Reduction and uncertainty in health care Reduction and uncertainty in health care resources.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-Almost every health care process includes non-

value added activities.value added activities. Lean philosophy and tools can be readily Lean philosophy and tools can be readily

understood by all employees. understood by all employees.

Was driven by healthcare system leadership.Was driven by healthcare system leadership.

3

Scope of Lean Scope of Lean ImplementationImplementation

Place:Place: Denver Health, an Integrated Denver Health, an Integrated Safety Net Healthcare SystemSafety Net Healthcare System 1- 500 Bed Hospital1- 500 Bed Hospital 8 Community Health Centers8 Community Health Centers Over 4,000 EmployeesOver 4,000 Employees

Timeframe:Timeframe: June 2005: Pilot in ORJune 2005: Pilot in OR October 2005: 5 Systems AreasOctober 2005: 5 Systems Areas June 2007: 14 System AreasJune 2007: 14 System Areas

4

How Lean Implemented?How Lean Implemented? Executive StaffExecutive Staff assigned to system areas or assigned to system areas or

value streams.value streams. Lean FacilitatorsLean Facilitators assigned to value streams assigned to value streams

(3 FTE then 8 FTE).(3 FTE then 8 FTE). 50 mid managers50 mid managers and clinical personnel and clinical personnel

Lean trained as “Lean Belts”.Lean trained as “Lean Belts”. Projects identifiedProjects identified by mapping the flow of a by mapping the flow of a

value stream.value stream. Rapid Improvement Events (RIEs),Rapid Improvement Events (RIEs), where where

teams of 6-8 people map scope of process, teams of 6-8 people map scope of process, eliminate waste in process and pilot new eliminate waste in process and pilot new process during this week long event. process during this week long event.

5

How Impact of Lean How Impact of Lean Evaluated?Evaluated?

Three levels of metrics:Three levels of metrics:1. System1. System -readily available such as Net -readily available such as Net

Revenue, Employee Turnover, Medication Revenue, Employee Turnover, Medication Errors, Patient Satisfaction, Patient VolumeErrors, Patient Satisfaction, Patient Volume

2. Value Steam2. Value Steam -related to healthcare system -related to healthcare system area such as divert rate for the hospital, clinic area such as divert rate for the hospital, clinic visit cycle time for outpatient visit cycle time for outpatient

3. RIE3. RIE -specifically identified for a particular -specifically identified for a particular process such as reduced patient waiting time in process such as reduced patient waiting time in surgery clinic, decrease in the amount of time surgery clinic, decrease in the amount of time from patient discharge to bed cleaned and from patient discharge to bed cleaned and reduction in OR overtime.reduction in OR overtime.

6

Results of Lean Results of Lean Implementation: From Implementation: From

October 2005 –July 2007October 2005 –July 2007 94 RIEs implemented.94 RIEs implemented. 395 employees participated.395 employees participated. $8.1 million in reduced costs/increased $8.1 million in reduced costs/increased

revenue ($3.5m in 2006, $4.6m in revenue ($3.5m in 2006, $4.6m in 2007).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 minutesRecovery Time: 210 minutes to 134 minutes Antibiotic within 60 minutes of incision: Antibiotic within 60 minutes of incision:

80% to 90%80% to 90%

7

Business Case Business Case ConsiderationsConsiderations

Accounting for indirect implementation Accounting for indirect implementation costs such as the opportunity cost of costs such as the opportunity cost of employee time in RIEs, Executive staff employee time in RIEs, Executive staff time, data analysis.time, data analysis.

Controlling for outside market and Controlling for outside market and regulatory factors that may impact metrics.regulatory factors that may impact metrics.

Return may not be realized until a year into Return may not be realized until a year into implementation.implementation.

Reducing waste and improving quality of Reducing waste and improving quality of care.care.

8

Lessons LearnedLessons Learned Necessary to implement many projects for Necessary to implement many projects for

their to be a tipping point.their to be a tipping point. Identifying and defining metrics linked to Identifying and defining metrics linked to

process change is challenge for operational process change is challenge for operational staff.staff.

Important to establish infrastructure for Important to establish infrastructure for evaluation with system redesignevaluation with system redesign

Quantitative evaluation not rigorous research Quantitative evaluation not rigorous research –lack of controls and randomization.–lack of controls and randomization.

Physician participation a challenge.Physician participation a challenge. Lean tools needed to be adapted to the Lean tools needed to be adapted to the

healthcare environment.healthcare environment.

9

Knowledge TransferKnowledge Transfer Lean in Healthcare National conference Lean in Healthcare National conference

targeting safety-nets supported by AHRQ targeting safety-nets supported by AHRQ small conference grant (2005-06).small conference grant (2005-06).

Participation in Lean activities by Denver Participation in Lean activities by Denver City Government and Denver University. City Government and Denver University.

Site visits by Commonwealth Fund and Site visits by Commonwealth Fund and Singapore Government Officials.Singapore Government Officials.

Partnership with DH, consultant and Partnership with DH, consultant and NYCHHC.NYCHHC.

Presentations at IHI, NAPH and locally.Presentations at IHI, NAPH and locally. Publications in Publications in Industrial Engineer Industrial Engineer and and

Academic Medicine.Academic Medicine.

10

Next StepsNext Steps

Expand knowledge transfer to Expand knowledge transfer to Healthcare Lean Education Institute.Healthcare Lean Education Institute.

Continue implementing RIEs, while Continue implementing RIEs, while improving defining scope of process improving defining scope of process improvement and metrics.improvement and metrics.

Continue monitoring impact at the 3 Continue monitoring impact at the 3 levels.levels.

2 articles under peer-review and 2 articles under peer-review and national and regional presentations.national and regional presentations.