• What Lean Can Mean to Your Organization—If It’s Done Right

    A conversation with Patricia Gabow, MD Nov 02, 2015

    Patricia Gabow, MD, former CEO of Denver Health, knows from firsthand experience how the Lean approach to change management can transform an organization.

    Patricia Gabow, MD, former CEO of Denver HealthIf you want to talk Lean, you can't do better than to talk to Patricia Gabow, MD. Under her leadership from 1992 to 2012, Denver Health was one of the earliest and most successful healthcare adopters of Lean, the Toyota Production System of improvement. The organization's track record earned Gabow election to the Association for Manufacturing Excellence Hall of Fame—undoubtedly the only nephrologist so honored.

    She has won a slew of other major awards, as well—among them, the Health Quality Award from the National Committee for Quality Assurance and the Dr. Nathan Davis Award for Outstanding Public Service from the American Medical Association—for her work in leading Denver Health's evolution from a department of the city government to an independent governmental entity that is a national model.

    Retired from Denver Health, Gabow is currently a trustee of the Robert Wood Johnson Foundation, a member of the National Academy of Medicine's Leadership Consortium for Value & Science-Driven Health Care and of the National Governors Association Health Advisory Board, and a MACPAC (Medicaid and CHIP Payment and Access Commission) commissioner.

    What makes Lean a good fit in health care?

    I'm always embarrassed that Lean is the product of an automobile company when it should have come out of health care. The core philosophy of Lean is that transformation is built on two pillars: respect for people and continuous improvement. And while it focuses on removing waste from the perspective of the customer— in the case of health care, our patients and their families—the respect for people also means respect for the workforce. Many people who work in health care today feel unempowered, and Lean is both empowering and democratizing: It relies on the people who actually do the work to solve the problem.

    In addition, many of the tools use a problem-solving approach that's not all that different than research, which makes physicians comfortable with it. One of the standard tools is called an A3, a term coined from the name of the size of the paper used by Toyota to solve a problem. When completed, it resembles a research abstract in that it's very precise and very concise. It includes boxes for the reason for action, the current state and the target state, the gap analysis, the solution approach, etc. In general, the tools of Lean are powerful but exquisitely simple and intuitive. If you map the steps walked in doing a task and it ends up looking like a plate of spaghetti (i.e., a spaghetti diagram), you don't need a college degree to understand that there has to be a better way.

    What makes Lean more effective than other improvement approaches used in health care today?

    Two of the most common problem-solving strategies we use are consultants and committees, and Lean is dramatically different from both.

    Consultants typically come in and interview people about the issue, use external benchmarking data to compare performance levels with those of other organizations, and generate a solution, often involving staffing. External benchmarking is often useful, but it is incomplete, so whenever someone said they were in the top 1 percent or 5 percent of whatever in the region or the country, I'd say, "Great, you're now the smartest one in the dumb row" (a saying from my rural upbringing). There is so much waste in health care that measuring yourself against someone else who has a lot of waste doesn't get to the core of the issue.

    In Lean, by comparison, you never decide what the problem is by interviewing people about how a process works. You go in and observe the work being done, which is the only way to really understand it.

    And what about committees?

    They are generally made up of leaders rather than frontline workers, and—because there's a belief, especially in academic medicine, that every stakeholder should be at the table—you may have 20 people. And although we know when a committee starts, we often don't know when it ends. Committees take a long time and often don't come out with a clear deliverable; even when they do, it usually has to go up the chain of command, so there are many chances for a veto.

    With a rapid improvement event (RIE), which is a standard Lean tool, you pull together eight to 10 people, most of them frontline workers and not all from the area in question. You put them in a room for four days and at the end of Thursday afternoon, they've not only decided what change is necessary to get rid of waste, they've implemented it. All three words are important in an RIE: It's rapid, it results in improvement, and it's a self-contained event.

    How does the organization decide what problems to work on?

    Healthcare processes are so complicated that you have to use a disciplined structure that comes from the top: You're transforming your system to be something wonderful, not just randomly solving problems with "drive-by" RIEs.

    First you need to identify your institution's ultimate goal—your "true north." Your true north has to be noble, it has to be important, and it has to be a stretch, because you want people to be engaged and you want them to believe it's worth their time. Also, to tell people that they can achieve something that's a stretch is a vote of confidence. A true north is not, "We want to make more money."

    Next you need to identify the metrics that will tell you if you're getting there, and then you need to determine which areas of the enterprise will do the most to drive those metrics. Those are the value streams you organize around.

    We had 15 value streams at Denver Health (e.g., revenue cycle, community health services, perioperative services)—each with an executive sponsor and a small steering committee, maybe four or five people, who started out by mapping the stream: At a 30,000-foot level, what does the flow of an orthopedic patient in the operating room (OR) look like, for example? Then they identified the major bottlenecks, the areas with the most waste, and picked out roughly eight of them to tackle in a year, each with the potential to generate at least $50,000 of financial benefit.

    What was Denver Health's true north, and what kind of results did you achieve?

    We wanted to be a model for the nation. My favorite quality metric is mortality because it kind of rolls up everything you're doing in one. For every year we were doing Lean, our observed-to-expected mortality was below 1 (which is the expected rate of death for a population of patients). In 2011, we had the

    lowest observed-to-expected mortality of all the academic health centers in the University HealthSystem Consortium. And we had a very vulnerable population: 70 percent minority, 30 percent non-English speakers, 40 percent uninsured prior to the Affordable Care Act.

    When we surveyed our employees about Lean in 2012, we had an 85 percent response rate, and 83 percent of respondents said they understood Lean and how it helped us maintain our mission. You can't get 83 percent of Americans to agree on the name of the country!

    What about your ROI?

    Our ROI on the Lean consultant—our teacher, or sensei—whom we hired to work with us was exceptional. We realized around $194 million of hard financial benefits between 2006 and 2012, divided about equally into hard savings, increased productivity, and improved revenue cycle management.

    A lot of healthcare organizations have tried Lean and not gotten such stellar results. Why do you think that is?

    The problem is that most of them are using it in a halfhearted way. It's a leadership-intensive approach—it's not something you can hand off to your quality improvement department and not be engaged in. We trained all our people from mid-managers up, including physician and nurse leaders, to be our Black Belts in Lean; their job was to get rid of waste in what they did every day. Almost every RIE team had a leader who was a Black Belt and also included one of seven trained facilitators from the Lean Systems Improvement Department.

    Each value stream steering committee met monthly to discuss the last three RIEs and plan the next three. As CEO, I met monthly with the executive staff Lean sponsors, the director of the Lean department, the facilitators, and our sensei to discuss any issues with past or upcoming RIEs. I also met monthly with the director of Lean and the associate CFO, who was responsible for assessing the financial benefit of the RIEs, and reviewed the Black Belts reports, which were provided first monthly, then quarterly.

    The other big problem is that organizations try to use just a few tools without understanding and embracing the core philosophy of respect and continuous improvement in the service of eliminating waste. A lot of healthcare leaders don't believe there really is that much waste in their organizations.

    Finally, so many people and organizations are making so much money off our dysfunctional system that there's sometimes little incentive to change.

    What are some of the other lessons you learned from Denver Health's experience?

    First of all, you need guidance on this journey—a sensei. And when you consider Lean consulting groups, you should look for teachers who have actually led a Lean transformation—not someone who went to three courses and has done two RIEs.

    Second, you need to set an aggressive pace. You see big organizations that have one or two value streams and are doing one or two RIEs every few months; as an organizational leader, you could be dead by the time you get where you're trying to go at that rate. On the flip side of that, you need patience. Healthcare systems are complex, and you have to learn the tools, you have to do enough events and have enough people involved to make progress. It took us probably seven or eight RIEs in our OR value stream before we really started to see change.

    Finally, you have to measure your results, have sound metrics, give feedback, and be transparent about what you're doing.

    It's not just our own experience that we learned from. There are other systems that have been very successful—Virginia Mason, Seattle Children's, Cincinnati Children's, New York Health and Hospitals. I've been around the track and seen a lot of different approaches to improvement. Lean is the only one I've seen that hits the bull's-eye on quality, cost, and employee engagement.

    Is there anything else you think organizational leaders need to know when considering Lean?

    I think many people don't understand how empowering it is to the workforce. Toyota said, "First we build people and then we build cars," and Lean is an investment in our employees. I'm not a "touchy-feely" sort of person, but the first time I saw a clerk stand up proudly to address a big group of people, including leadership, at a report-out from an RIE, it almost brought tears to my eyes.

    One thing we didn't realize before we started out was that Lean returns joy to the work, which is something a lot of people in health care don't feel anymore. I remember, after one of our very early RIEs, someone shared with me a comment they'd overheard a clerk making to some of her colleagues: "You've got to get on one of those rapid things!"

    Lauren Phillips is president of Phillips Medical Writers, Ltd., Bellingham, Wash., and a frequent contributor to Leadership.

    Interviewed for this article: Patricia A. Gabow, MD, senior adviser with Simpler Consulting, LP, and former CEO of Denver Health.

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