Denver Health provides healthcare to at-risk populations, including hundreds of millions of dollars in uncompensated healthcare to the uninsured.
To continue meeting its mission in the face of this increasingly challenging environment, Chief Executive Officer Patricia Gabow, MD, sought a way to derive maximum benefit from every aspect of the enterprise, to analyze and improve its processes, and to deliver quality and value to its patients.
In 2005, Denver Health chose the Toyota Production System’s “Lean” methodology as its process analysis and improvement toolset. Lean is a systematic approach to continuous improvement based on the car company’s manufacturing experiences and quality improvement efforts. It’s founded in a fundamental respect for people and the belief that continuous improvement involves the identification and elimination of waste that takes up time, resources and money.
Examples of waste include unused human talent, unnecessary waiting, inventory, transportation, defects and processing. The theory behind Lean in healthcare is that eliminating unnecessary and non-value-added activities means that patients, who ultimately determine value, can receive the best possible care through sound processes.
In addition, staff members can deliver patient care and services in an effective and efficient manner, all while respecting their talents and efforts.
Consistent with Toyota’s Lean philosophies, Denver Health officials believe waste is disrespectful to society because it squanders resources, is disrespectful to workers because it asks them to perform non-value added work, and is disrespectful to patients because it asks them to endure processes with no value.
Guided by the Lean pillars of respect for people and continuous improvement, Denver Health has become a national leader in applying Lean to healthcare. From the beginning of its transformation until now, Denver Health has derived nearly $135 million in financial benefit and was the first healthcare organization to receive the Shingo Prize for Operational Excellence.
Going Lean at Denver Health
The Lean toolbox is stocked with numerous tools, including the strategic level value stream analysis (VSA) and the ground level “just do it” immediate change mechanism.
The major vehicle for improvement at Denver Health is the rapid improvement event (RIE), which is a weeklong event with a multidisciplinary team of seven to nine people. The team members, who are leaders and front-line staff members who know the ins and outs of the process, are led by a Lean facilitator to first identify wastes and opportunities and then to come up with solutions and improved process flows. They map the current state, an ideal state and gaps between the two. They then conduct rapid experiments with the proposed new process, create new standard workflow and implement the new process at the end of the week.
In 2005, two representatives from the paramedic division’s leadership team were among the first class of students to learn Lean methodologies at Denver Health. The fact that Lean’s cultural and technical philosophy is founded in respect for people was a good fit for the necessary cultural change the division would undergo. Since then, nine members of the leadership team have been trained in Lean.
The early Lean projects in the paramedic division were low-hanging fruit for the new team. Although the efforts may seem rudimentary for an EMS agency, they exposed opportunity, and the benefits were profound.
Some of these projects included adopting the medical priority dispatch system as the standard work for call screening, mapping the call cycle for a 9-1-1 EMS call to identify each interval of time and associated processes for potential improvement, a comprehensive overview of personnel scheduling and staffing to meet hourly demand and a review of the posting plan using historic call data from the computer-aided dispatch system. These efforts resulted in a financial benefit of nearly $400,000 in reduced overtime the first year, without compromising response performance.
The effort toward affecting cultural change began with a renewed focus on the patient. This has been woven into the fabric of the Division and can be heard as a common theme in discussions about processes among all division members.
This focus began with adopting the mentality of “quality at the source,” one of the fundamental tenets of Lean. This is the belief that the person doing the work has the best view of the quality and the opportunities for process improvement in real time. For the Division, this focus began with engaging employees by soliciting process improvement suggestions and providing them improved quality assurance/quality improvement feedback.
Moving from the status quo and toward continuous improvement also included performance boards, improved supervision and real-time performance feedback—a system for documenting and providing objective performance feedback for annual reviews and obtaining baseline information to share with employees on such measures as trauma scene times, hospital turnaround times and intubation success rates.
Early efforts showed improvements in multiple areas and taught the paramedic division about itself. These early efforts demonstrated that even small improvement projects with small corresponding monetary benefits were valuable. They improved morale and led to global organizational improvement and culture change.
Going to ‘Gemba’
The business axiom of “you can’t manage or improve what you don’t measure” has proved to be accurate in the paramedic division’s experience. Although it’s fortunate that much of what EMS does is documented and often time stamped, looking at reports isn’t adequate to affect meaningful process improvement and culture change. It’s critical to go to “gemba” (where the real work in Lean happens).
To do this, EMS leaders should get out of the office. Interacting with personnel in the field and watching with an inquisitive and critical eye is invaluable. Talking to the people doing the work, in the place they’re doing it, provides a perspective that doesn’t come from reports or spreadsheets.
It seems that some whining is inherent to EMS. However, it’s important for leaders to listen because much of what might be considered whining is an opportunity coming from those who perform the job. Complaints may expose opportunities to make relatively easy changes to improve processes and morale.
Process mapping is an incredibly useful tool. Being able to visually display a process in detail leads to many “light bulb” moments and the inevitable question, “Why do we do that?” One of the resultant cultural shifts from Lean has been a tendency to embrace change as normal, rather than resisting it. From the line level to the chief’s office, everyone is looking to improve everything, and employees share improvement ideas freely. This has helped the paramedic division break down some of the pervasive mentality: “We do it that way because we always have.”
For more on that mentality, read the February Leadership Sector column at jems.com/journal.
Standard work is another Lean pillar that has proved to be invaluable.
Developing a consistent, standardized approach to a process has multiple benefits. Not only does it provide clear direction and a sense of confidence for people, but it also helps with managing the expectations of everyone involved. Having re-invented the wheel many times with multiple processes, the paramedic division is now focused on writing things down and developing flow charts and job action checklists.
This has grown the agency’s confidence in continuity of operations.
Previously, extended leaves, retirements, promotions or job changes meant a loss of institutional knowledge and the need to reinvent the wheel. Now each leadership team member has developed a standard work document outlining their functional area’s daily, weekly and monthly deliverables with step-by-step guidelines for accomplishing them. If someone is on extended leave, another team member can keep core functions intact by following the standard work.
Gaining Institutional Support
The executive staff at Denver Health recognized the improvements in the paramedic division and named it one of the system’s 14 value streams in 2007. This began with the annual cycle of identifying and obtaining baseline core metrics, VSA and resultant strategic initiatives, rapid improvement events and projects for the year.
Once the division was officially identified as a value stream, a new level of institutional support became available to its leadership team.
A Lean facilitator with a background in Lean and strong understanding of the tools was assigned to the division 20 hours per week. The role of the facilitator was to provide technical expertise and to serve as a set of outside eyes on all Lean activities.
Additionally, a value stream steering committee was developed to provide oversight of the Lean activities within the division and to monitor clinical, operational and financial metrics on a monthly basis. This committee included the hospital’s chief operating officer, director of emergency medicine, and the division’s medical director, chief paramedic and assistant chief of operations
With the full value stream structure in place, the paramedic division widened the focus of Lean activities to almost every aspect of the organization. High-level metrics based on such overall division goals as financial viability, response-time compliance and clinical outcome measures were prioritized.
Over a two-year period, rapid improvement events were planned and executed. These RIEs addressed a standardized posting plan for paramedic dispatchers, the rollout of two major pieces of software (including a new electronic patient care report system for field providers), an analysis of crew scheduling aimed at improving efficiency and employee satisfaction and refinements of vehicle readiness procedures. They also included recruitment, hiring and orientation of new employees.
Other projects over this time period included vehicle operations and safety, community outreach, document management and security, and the development of a business plan for the Denver Health Paramedic Division EMS Education Department. Lean projects that have been identified for the future will address healthcare reform, disaster preparedness and ambulance crashes.
The paramedic division has incorporated Lean into all aspects of its operation, including the clinical realm. These methods have resulted in improved performance and quality, as well as more than $5 million in savings and additional revenue since 2006. Lean tools have allowed the paramedic division to continue to optimize its EMS services to the citizens of and visitors to the city and county of Denver. They’ve also positioned the division to weather the difficult economic times facing systems across the country—with improved quality of care and without a reduction in staff or services.
Lean’s focus on quality at the source and on respect for people has led to line-level participation in almost all Lean activities. In fact, line employees have initiated many of the process improvement efforts. The courage to critically analyze every process is well worth the effort. RIEs offer an opportunity for leadership and line representatives to analyze a process together, to develop an improved process, to conduct rapid experiments on the new process and to implement the new process within one business week.
Although these events are ambitious, they’ve been fruitful and led to measurable improvements in performance and quality. Incorporating Lean has been synergistic with the cultural transformation the organization has undertaken since 2005, culminating in improved morale, improved employee engagement and improved work life for employees of the paramedic division—but most importantly, improved care for patients. JEMS
James Robinson, BS, EMT-P, is operations chief of Denver Health EMS. He can be reached at James.Robinson@dhha.org.
Jessica Vastola, BSISE, is assistant director, Lean Systems Improvement, for Denver Health EMS.
Scott Bookman, MPA, EMT-P, is a chief paramedic for Denver Health EMS.
This article originally appeared in March 2012 JEMS as “Doing More with Less: Applying Lean methodology to EMS.”