Skinny is good for management, too

Lean practices can work well in healthcare

When the National Committee for Quality Assurance (NCQA) named Patricia Gabow, MD, CEO of the Denver Health and Hospital Authority, one of the winners of its National Quality Awards, it didn't shock the people she works with. She has been pushing Denver Health from success to success for years with her pioneering use of Lean management techniques more often associated with industry than healthcare.

Her Lean journey started several years ago when she was talking with some of her colleagues about how, in the 40 years since her internship, not a whole lot had changed in the way things were done. "That can't be right," she says. "We hadn't really stepped back to look at what we do."

After getting a grant from the Agency for Healthcare Research and Quality, Gabow put together an external advisory group to look at systems and processes. Rather than gather people from only like organizations around the table, though, she chose participants such as the head of global health for Microsoft, someone from the FedEx center for supply chain management, the head of labor for Ritz-Carlton, and the Institute for Healthcare Improvement's Don Berwick, MD. They looked at operations for companies like Dell and FedEx, and health systems in countries like Sweden. "One of my docs said of all the craziest ideas I had, this was the stupidest, because patients aren't packages." After the trip to the FedEx operation, though, he came to Gabow again, pining about how nice it would be to know as much about patients as FedEx knew about its packages.

She led focus groups with patients in Spanish and English, with every level of staff from housekeeping through the C-suite, with insured and uninsured patients. She asked them what they saw that was wrong with the patient experience. An industrial engineer was hired to map everything from the food service tray line to the 24-hour shift of a trauma resident. The latter showed more than 8.5 miles of walking, which, while great for health, uncovered a lot of inefficiency. "Every diagram he brought me was so inefficient," Gabow says.

One of the things they realized after a year of study was that many things needed to be addressed. One of them was finding the right processes. "Lean appealed to me as having a toolset that was intuitive, that can involve the whole workforce in a meaningful way."

By 2006 the journey had begun. Gabow says that the Lean philosophy is built on respect for people and continuous improvement. Waste is disrespectful, whether it is of resources or of the time and labor of employees. While work with no meaning is what a company like Toyota would define as waste, in a hospital setting, Gabow says it is process with no value. If it isn't doing something good for the patients, it doesn't have value. So when a diagram of movements in the OR comes to her attention and looks more like a plate of spaghetti than anything else, Gabow knows there is something to fix. "That's not something anyone would design."

Rapid improvement events

One of the outcomes of Lean has been a series of rapid improvement events, where eight to 10 people work for a single week on a single problem. There have been around 400 of them so far, with more than 2,000 employees involved. People who have never gotten up in front of an audience confidently talk to executives about their event, Gabow says. It is incredibly empowering for staff at all levels. According to Denver Health staff surveys, 78% report they understand how Lean helps to improve things.

While initially Gabow thought she'd use her 25 handpicked Black Belts to run the rapid improvement events, she quickly realized "these amazing people have day jobs." So there are now eight full-time facilitators to run the events. And while she started out thinking they could do Lean project by project, "I realized that at that rate I'd be dead before there was transformation." They needed to embed them in the system. So she created some 16 areas of focus, and over the course of six years, there have been at least $158 million in benefits. Gabow says a third of that amount is in hard cash savings — they have the lowest supply costs in the University Health System Consortium (UHC) and the lowest antibiotic costs, too; a third is increased productivity, which allowed some 30,000 more clinic visits, which translates into more revenue; and a third came from the ability to enroll more people into Medicaid and CHIP.

Gabow knows that some people believe if you lower cost, it must come at the expense of quality. "My response is to ask them to explain how waste improves quality," she says. "There isn't anything about a bad process that makes quality better." Then she points at the Denver Health standings for quality or mortality in the UHC. "The graph of that looks the same as the financial benefit graph. We have gotten better every year."

As for some specific projects on which Lean was used, Gabow points to developing registries.

The system mapped a process of antibiotic use for surgical patients that led to the antibiotics being given by the anesthesiologists rather than by a nurse on the unit.

They have used Lean to attack deep vein thrombosis (DVT). "It can add days to hospitalization and lead to increased mortality. Everyone had their own horse to champion. But Lean is about standardizing work. We got six or eight physicians together to work on this. We found that the anticoagulation service was using the highest-cost drug, often inappropriately. We lowered costs and lowered DVT."

Part of Lean's value, she says, is its demand for transparency. "You have to have visual management. So for vent-associated pneumonia, all our patients, families, and visitors can see our protocols. The same with OB patients or for catheter-associated urinary tract infections. If you bury the information, you don't get transformation."

The costs of Lean are quickly made up. The participants on the rapid improvement event teams are not backfilled except for nurses. It's viewed as an additional activity for all other participants.

Lean training for Black Belts is spread out over the course of six or seven weeks, a couple of days at a time. Not everyone gets training, either. Gabow says she wants a third of the rapid improvement events teams to be new to Lean. Why? If you train people in skills they won't use for a few months, they have forgotten it. Better they learn it as it is needed. And nothing is so difficult to learn that it detracts from the potential improvement.

The only exception to limited training was a module for a visual management tool, a two-hour course for all mid-level managers. Every one of them was asked to do a so-called 5S project — Sort, Set in Order, Shine, Standardize, Sustain. That spread the method quickly throughout the organization, and Gabow still gets comments from people that they have "5S'd their basement."

There was little pushback — partly, Gabow says, because the physicians are employees. And they are academics, which means they naturally love data. "This is a mode of research for them," she says. "They publish this stuff."

For more information on this topic, contact:

  • Patricia Gabow, MD, CEO, Denver Health and Hospital Authority, Denver, CO. Telephone: 303-436-6000.