PICTURE OF HEALTH

Industrial Engineer, Feb 2008 by Gabow, Patricia A, Albert, Richard, Kaufman, Linda, Wilson, Michael, Eisert, Sheri

Denver Health uses 5S to deliver quality, safety, efficiency

CONCERNS CONTINUE TO GROW WITH REGARD TO American health care in terms of quality, safety, and cost. The public demands that health care institutions address these issues, but there are no simple solutions. As health care leaders consider approaches that would help solve these problems, it seems prudent to examine other industries that have addressed similar problems and use the approaches and tools that have allowed them to achieve success.

Denver Health, a large academic "safety net" institution, provides health care to 25 percent of all Denver residents. It has adopted lean principles and tools to promote efficiency, quality, and safety. Through the application of 58, middle management orchestrated projects tailored to individual offices and nursing stations to the entire laboratory and financial services departments.

Outcomes included space reclaimed to the extent that changes implemented in just two areas were equivalent to $312,000 of capital costs, improvements in efficiency in terms of both turnaround time in the laboratory department and time to locate equipment in respiratory therapy, and the facilitation of better patient care overall.

Denver Health (DH) operates on a budget of $442 million and employs 4,300 people, including 160 physicians. It is an academic institution with a formal affiliation with the University of Colorado School of Medicine. DH trains 2,400 health professional students each year, including 230 interns and residents. DH's components include an acute care hospital with a level I trauma center, the 911 emergency medical response for both Denver and a neighboring city, eight neighborhood community health centers, 11 school-based clinics, the public health department, a correctional care service, an HMO, and a call center that includes a regional poison and drug center. This integrated system serves approximately 140,000 patients and provided $278 million in care to the uninsured in 2005 - an amount representing 42 percent of its total charges.

This burden of unsponsored care and the drive to maintain excellence in quality and safety spurred our search for robust approaches to address the issues of cost, efficiency, quality, and safety.

Two years ago, with a grant from the Agency for Healthcare Research and Quality, we searched for the appropriate change agent and assembled a comprehensive plan punctuated by lean essentials in a health system.

Benefits of healthy training

In order to use lean in our organization, we launched a graded educational effort through a combination of reading the literature and classroom training provided by a consultant group. The entire executive team, all physician leaders, and 130 middle managers were training in the basic principles of lean. Of that group, 22 individuals, including two physician directors of service, service line administrators, middle managers, and department directors, were chosen to be trained extensively. The extensive training program included more than 100 hours of classroom and hands-on training in lean principles and tools. An industrial engineer was hired to further facilitate observations and training.

After this initial training, lean transformation was begun using one of the simplest, most intuitive and foundational of the lean tools, 58, to establish a self-ordering, self-regulating environment of sustainable change.

To launch this effort, two hours of additional training on the 5S approach was provided to all middle managers. Every middle manager was then asked to submit a 58 project to the CEO and to complete this project within two months, providing metrics of the results. The metrics ranged from as simple as before and after photos to collecting quantitative measures of trash removed, square feet of space reclaimed, furniture reclaimed, or time spent to obtain equipment. Metrics were assessed according to the quantitative scoring system used in 58, which rates multiple components in each domain from zero, or the complete absence of a 58 component, to five, which reflects the complete achievement of a 58 component.

Teams from all divisions of DH were involved in this effort. The projects ranged from individuals using 58 to organize their own offices to the effort of an entire department involving more than 100 individuals and two floors of an office building. The majority of projects involved multiple individuals. Three projects in different components of the system are described in detail below to emphasize the broad utility of this lean tool in health care institutions.

Project 1: Patient financial services

Patient financial services are DH's back office billing function, with primary activities in bill coding, billing, and collections, including both legal actions and handling of customer service calls. This division has 103 employees and occupies two floors, encompassing approximately 17,000 square feet. The patient financial services director was one of the extensively trained individuals who then trained the managers and supervisors in the department in an overview of 58 followed by discussion of its value principles. The actual project was detailed in a departmental flyer and meeting. A scoring method was reviewed, and a day was scheduled for the project.