Making a Difference: The Lean Culture and Results at Denver Public Health Judith Shlay, MD, MSPH

1. Making a Difference: The Lean Culture and Results at Denver Public Health Judith Shlay, MD, MSPH Heather Weir, MPH, RD

2. 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?

3. 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

4. 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

5. HIT Employed Physicians Denver Health Medical Center Rky Mtn Regional Trauma Ctr Rocky Mtn Center for Medical Response to Terrorism 911 Public Health Public Health Regional Poison Center & Nurseline Family Health Centers Denver Health Medical Plan School-based Health Centers Correctional Care Denver Cares Denver Cares Legend: Bright Green – Pt Revenue Blue – City Orange – DHMP Lavender – Grants Dark Red - RMPDC

6. Getting It Right… Perfecting The Patient Experience Right People Right Process Right Communication and Culture Right Environment Right Reward

7. 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

8. 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

9. 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

11. Strategic Planning

12. Strategic Planning Process

13. 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

14. The Core Functions and Essential Services Improve Health Quality Inform, Empower, Educate Mobilize Community Partnerships Epidemiology Monitor Health Develop Policies Evaluate Develop and Apply PH Science Assure Competent Workforce Diagnose and Investigate Enforce Laws CORE FUNCTIONS: Assessment Link To / Provide Care Policy Development Assurance

15. Core Functions of Public HealthImplications for Quality Priority Areas Assessment Improve Health WORTHY Protect Health Policy Development WORK Assurance Emergency- Prepared WELL-DONE

16. Elements of Public Health Quality Worthy Work Well-Done Important Health Issues High-Value Interventions Accountable Performance Evidence Reviews Performance Measures Prioritization Continuous Quality Improvement

17. History of QI at DPH

18. 2013 Progress

19. Lean Work at Denver Public Health The nuts and bolts

20. Performance Management Framework

21. DPH – Performance Management System Performance Standards Performance Measurement • Public Health Accreditation Board (PHAB) standards • Healthy People 2020 • National and State benchmarks • Program goals and targets to set expectations • Results Accountability • Population Indicators • Program Performance Measures • Customer Satisfaction Surveys • Strategic Planning – metrics/achievement indicators • QI Assessment (all-staff) • Performance Management Self-Assessment Reporting of Progress Quality Improvement • Quarterly Reports • BI Tool/Dashboards • Visual Management Boards • Website – internal/external • onFocus • Scorecards • Quality Committee • Lean Events - RIEs, 6S • Lean Black Belts • QI projects • PDSAs • QI Plan • QI training Leadership & Culture

22. onFocus (Performance Management Software) • On Focus spreadsheet

24. Denver Public Health – Process for Quality Improvement Projects Ask for help! Contact Heather Weir, QI Coordinator (x23582) and your Quality Committee representative when starting a QI project *All forms, resources, and the QI Project Tracking list are available on the Pulse/Intranet (DPH subsite) - DPH Performance Management site (QI Project folder)

25. Why are we doing this? • What is the burning platform? • What is the chief complaint? • What holds us back from the Target State? • What are the root causes of these road blocks? • 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? • What is the hypothesis to address the root cause (If/Then statements)? • Does solution approach link well with root causes? • 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. • Expect the Solution Approach to not be perfect – test them! • Are Rapid Experiments achieving desired results? • Do insights show key lessons learned and identify future opportunities?

26. QI Projects

27. 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

28. Initial State Target State

29. Results

30. 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

31. 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)

32. Return on Investment

33. STD Clinic – Ask, Advise, Refer (2As+R) Root cause analysis

34. STD Clinic – Ask, Advise, Refer (2As+R) The current state and the ideal state

35. 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

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

37. Flu Vaccines - in all DPH clinics

38. Shared Drive Clean Up Projects • Reason for action: • reduce time in finding files • ensure critical files are accessible/backed up • correct permissions on folders

39. Birth and Death Records – Phone Orders • New process • Process mapping • staff identified 14 areas of improvement

40. Birth and Death Records – Phone Orders

41. Questions?

42. Contact Information Judith Shlay, MD, MSPH 605 Bannock St., MC 2600 Denver, CO 80220 (303) 602-3714 judith.shlay@dhha.org Heather Weir, MPH, RD 605 Bannock St., MC 2600 Denver, CO 80220 (303) 602-3582 heather.weir@dhha.org