# Presentation: 514933

## 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.**

## Purpose of Lean Implementation

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

## Scope of Lean Implementation

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

## How Lean Implemented?

**Executive Staff** assigned to system areas or value streams.
**Lean Facilitators** assigned to value streams (3 FTE then 8 FTE).
**50 mid managers** and clinical personnel Lean trained as “Lean Belts”.
**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.

## 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.

## Results of Lean Implementation:  From October 2005 –July 2007

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

## Business Case Considerations

- 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.
- Return may not be realized until a year into implementation.
- Reducing waste and improving quality of care.

## Lessons Learned

- 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.
- Important to establish infrastructure for evaluation with system redesign
- Quantitative evaluation not rigorous research –lack of controls and randomization.
- Physician participation a challenge.
- Lean tools needed to be adapted to the healthcare environment.

## Knowledge Transfer

- 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.
- Site visits by Commonwealth Fund and Singapore Government Officials.
- Partnership with DH, consultant and NYCHHC.
- Presentations at IHI, NAPH and locally.
- Publications in *Industrial Engineer *and *Academic Medicine.*

## Next Steps

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