Making a Difference - National Network of Public Health Institutes

Report
Making a Difference: The Lean
Culture and Results at Denver
Public Health
Judith Shlay, MD, MSPH
Heather Weir, MPH, RD
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?
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
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
HIT
Employed Physicians
Rocky Mtn
Center for
Medical
Response to
Terrorism
911
Denver
Health
Medical
Center
Public Health
Regional
Poison
Center &
Nurseline
Schoolbased Health
Centers
Rky Mtn
Regional
Trauma Ctr
Family
Health
Centers
Correctional
Care
Denver
Cares
Denver
Health
Medical Plan
Legend:
Bright Green – Pt Revenue
Blue – City
Orange – DHMP
Lavender – Grants
Dark Red - RMPDC
Getting It Right…
Perfecting The Patient Experience
Right
People
Right
Process
Right
Communication
and Culture
Right
Environment
Right Reward
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
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
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
Strategic Planning
Strategic Planning Process
Organize
(Aug-Sept)
Assess
(Sept-Oct)
Facilitated
Planning
Session
Develop
Action
Plans
(Oct)
(Nov-Dec)
Implement
(starting
Jan 2014)
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
The Core Functions and Essential Services
Improve Health
Monitor Health
Develop Policies
Diagnose and
Investigate
Enforce Laws
CORE FUNCTIONS:
Assessment
Policy Development
Assurance
Link To / Provide
Care
Evaluate
Mobilize
Community
Partnerships
Develop and Apply PH Science
Epidemiology
Assure Competent Workforce
Quality
Inform, Empower,
Educate
Core Functions of Public Health
Implications for Quality
Priority Areas
Assessment
WORTHY
Improve Health
Policy
Development
WORK
Protect Health
Assurance
WELL-DONE
EmergencyPrepared
Elements of Public Health Quality
Worthy
Work
Well-Done
Important
Health Issues
High-Value
Interventions
Accountable
Performance
Prioritization
Evidence
Reviews
Performance
Measures
Continuous Quality Improvement
History of QI at DPH
2012
2012
2011
Customer Satisfaction
QI focus of Program
Director/Mgr meeting
February – Results Based
Accountability (RBA) training
at retreat
June- 2As+R QI project in
STD Clinic (NNPHI Grant)
November- ASI Grant to hire
QI Coordinator
2013 Progress
2013
2013
June – QI Plan finalized
2013
January – QI Coordinator
starts
February- Quality Committee
(QC) and Performance
Management Team start
meeting; onFocus software
1st used with DPH plan
March – QI Assessment
Survey
August – QC completed 1st
dept wide QI project
(customer satisfaction)
September – Started the
‘Oppy Award’; onFocus
expanded to Birth and Death
Records (1st pilot)
October – onFocus pilot with
the Infectious Disease Clinic
(2st pilot); Scorecard
development/improvement
November – 80% of
programs have started a QI
project (YTD: 4 completed/11
in progress); planning for
2014
Lean Work at Denver Public Health
The nuts and bolts
Performance Management Framework
DPH – Performance Management System
•Public Health Accreditation
Board (PHAB) standards
•Healthy People 2020
•National and State
benchmarks
•Program goals and targets to
set expectations
•Quarterly Reports
•BI Tool/Dashboards
•Visual Management Boards
•Website – internal/external
•onFocus
•Scorecards
Performance
Standards
Performance
Measurement
Reporting of
Progress
Quality
Improvement
Leadership & Culture
•Results Accountability
•Population Indicators
•Program Performance Measures
•Customer Satisfaction Surveys
•Strategic Planning –
metrics/achievement indicators
•QI Assessment (all-staff)
•Performance Management SelfAssessment
•Quality Committee
•Lean Events - RIEs, 6S
•Lean Black Belts
•QI projects
•PDSAs
•QI Plan
•QI training
onFocus (Performance Management Software)
• On Focus spreadsheet
Denver Public Health –
Process for Quality Improvement Projects
Start an A3
Identify what
you want to
improve or are
concerned about
Is there data
available?
Are there
standards to
compare your
data to?
Complete steps
4-9 of the A3
Use the Word or
PPt template*
Develop a
concise Reason
for Action and
why change is
needed
(Complete step 1
of the A3)
Decide on a
Project Leader
and get buyin/sponsorship
from
management
4. Gap Analysis
Assemble the
project team
May be a larger
group (involve
those who do
and are affected
by the work)
*All forms, resources, and the QI Project Tracking list are
available on the Pulse/Intranet (DPH subsite) DPH Performance Management site (QI Project folder)
List the QI
Project on the
DPH QI Project
Tracking list*
Complete steps
2-3 of the A3
5. Solution
Approach
2. Initial State
3. Target State
6. Rapid
Experiments (use
the PDSA form*)
Project team
activity
7. Completion
Plans
Update project
information on
the DPH QI
Project Tracking
list*
8. Confirmed
State
9. Insight
Ask for help!
Contact Heather Weir, QI Coordinator (x23582)
and your Quality Committee representative
when starting a QI project
•
•
•
Why are we doing this?
What is the burning platform?
What is the chief complaint?
•
•
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.
•
•
•
•
•
•
•
•
What holds us back from the
Target State?
What are the root causes of
these road blocks?
•
•
Action Plan – who, what,
Check that Completion Pla
on track at follow-up mee
What is the hypothesis to
address the root cause (If/Then
statements)?
Does solution approach link
well with root causes?
•
Are Confirmed State metr
place and do they validate
target state?
Expect the Solution Approach
to not be perfect – test them!
Are Rapid Experiments
achieving desired results?
•
Do insights show key lesso
learned and identify futur
opportunities?
QI Projects
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
Initial State
Target State
Results
Results
Private Vaccine Orders - # of orders per month
7
6
5
4
2012
3
2
2013
2013 (projected)
1
0
• 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
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)
Return on Investment
STD Clinic – Ask, Advise, Refer (2As+R)
Root cause analysis
Barriers
Potential Solutions
Competing priorities/Tobacco is not
STI-related
Education
Staff time
Streamlined, standardized work process
Patient receptivity
Education and training
No system to document tobacco use
and referrals
Create a standard work process
Change the EMR
Perceived lack of cessation resources
Education
No incentive for clinic staff buy-in
Education: Cessation saves
Monetary incentives for staff
Potentially able to bill
STD Clinic – Ask, Advise, Refer (2As+R)
The current state and the ideal state
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
STD Clinic – Ask, Advise, Refer (2As+R)
Results
Flu Vaccines - in all DPH clinics
DPH Clinic Influenza Vaccinations: 2013
1000
100.0%
900
90.0%
800
80.0%
700
70.0%
600
60.0%
500
50.0%
Total Vaccinations 2013
% Total Patients Vaccinated 2013
400
40.0%
300
30.0%
200
20.0%
100
10.0%
0
0.0%
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
% Total Patients Vaccinated 2012
Shared Drive Clean Up Projects
• Reason for action:
– reduce time in finding files
– ensure critical files are accessible/backed up
– correct permissions on folders
GB
500
92.2%
400
96.7%
98.6%
99.6%
99.9%
100.0%
90.0%
80.0%
76.3%
70.0%
300.1922
300
60.0%
GB
58.3%
50.0%
40.0%
200
30.0%
92.94685
100
82.2
20.0%
22.99746
10.0%
9.828532
4.95
1.944415
0.274047
G:Users
I:Apps
G:StrategicArea
G:Common
0
0.0%
I:Users
G:Apps
E:
I:User1
Birth and Death Records – Phone Orders
• New process
• Process mapping
– staff identified 14
areas of improvement
Birth and Death Records – Phone Orders
Contact Information
Judith Shlay, MD, MSPH
605 Bannock St., MC 2600
Denver, CO 80220
(303) 602-3714
[email protected]
Heather Weir, MPH, RD
605 Bannock St., MC 2600
Denver, CO 80220
(303) 602-3582
[email protected]

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