Dr. Patricia Gabow served as CEO of Denver Health, that city's safety net health system, for 20 years before retiring in 2012. In 2005, Denver Health became one of the first systems in the U.S. to embrace Lean, a management and quality-improvement approach based on the Toyota Production System. In 2011, Denver Health received the Shingo Bronze Medallion for Operational Excellence, becoming the first healthcare organization to win that award, given out by the Shingo Institute, a not-for-profit dedicated to promoting excellence in organizations. Now in “retirement,” Gabow, a nephrologist by training, serves on several advisory boards and commissions. She is writing a book about Lean management, expected to come out this year. Modern Healthcare reporter Steven Ross Johnson recently spoke with her about the challenges of organizational transformation in healthcare. The following is an edited excerpt.
Leaders' engagement key to process of eliminating waste, respecting patients
Modern Healthcare: What have you been doing since retiring from Denver Health?
Dr. Patricia Gabow: I continue to be on the Medicaid and CHIP Payment and Access Commission, which is very dear to my heart because Medicaid and the Children's Health Insurance Program are about serving the people whom I committed my life to serving. I joined the board of the Robert Wood Johnson Foundation, an organization that has helped produce major transformational efforts in healthcare. I joined the National Governors Association's Health Advisory Group. I'm still on the Institute of Medicine Roundtable on Science and Value-Driven Health Care. I'm also on the lecture circuit. And I'm writing my book.
MH: What inspired your decision to start using Lean at Denver Health?
Gabow: I've been in healthcare for more than 40 years, and it occurred to me over time that we were doing things very much the way we did them when I was an intern. The core processes hadn't changed, and I started to think that this was crazy. That kind of thinking is what got me moving down the path.
One of the first things we did was we put together an external advisory group that was largely made up of people not from healthcare—for example, the head of global health at Microsoft. We just started to brainstorm about what is “change.” Also, I did focus groups with all of our employees starting with housekeepers, and we asked two sets of questions: What things do you see happening to patients that you think shouldn't happen, and what keeps you from working efficiently? The focus groups were very informative and also gave a message to employees that we wanted to do something different and we wanted them to be part of it. Then we hired an industrial engineer who had never been in healthcare to come in and start mapping everything from the food service tray line to a nurse's bay. After about a year of this, we decided that there were a lot of things that weren't right, and we needed to fix them.
MH: Why did you pick Lean over other management approaches?
Gabow: We decided on Lean because it was a philosophy as well as a tool set, and everyone could understand it. The philosophy was built on respect for people and continuous improvement. What was brilliant about the philosophy is that it links disrespect to waste. Waste is disrespectful to our patients because it asks them to endure processes with no value. I think that when you're looking to transform American healthcare, it can't just be tools. The tools are great, but the fact that it was a philosophy that had at its core respect for people and continuous improvement and the removal of waste and linking these together in such a meaningful way seemed to me to be ideal. What you have with Lean is you have the leadership creating prioritization and alignment, and you have the front line solving the problems.
We need this transformation in all of healthcare. It just can't be something done by leadership. This requires all of us who work in this discipline to say, “How do we do this in the most respectful, least wasteful way to serve our patients?” We've talked a lot in healthcare lately about patient satisfaction, which I think is the more superficial view of patient engagement. Engagement is really at the core of Lean because everything is from the customer's perspective.
MH: What are some of the key components to running a successful Lean performance- improvement program within a healthcare setting?
Gabow: Lean is about transformation. Certainly it does improve quality and it does reduce cost. But the key component is that leadership must be involved. If leadership is not engaged, then forget it. Lean is so interesting because it requires the senior leaders to be heavily engaged, but it lets the front line solve the problem.
Secondly, a Lean program has to have a disciplined structure. Looking at Lean in other places, I see that people think they can do a rapid improvement event here and then three months later do one somewhere else. While every event will yield something, unless Lean is done in a very structured, disciplined way you won't get the robustness of the results that you can get.
Third, you have to use metrics and you have to have transparency with the metrics. Metrics that are kept to a few are not going to be transformative. Knowledge is power, and one of the things that Lean does is to say everybody should have the information so you have visual management everywhere, and people see what they need to see.
MH: What are some of the challenges?
Gabow: The challenge is the desire to really embrace Lean fully and not dabble. You need a teacher. Some people think they can send two people off to some course and learn Lean and that will be it. The biggest barrier is senior leadership actually wanting to do this completely. Front lines love Lean. It's the first time for many of them that they can be really engaged in problem-solving.
Rapid improvement events are one of the most powerful things in Lean because you take eight to 10 people, mostly front line, and you give them four-and-a-half days to solve a problem. This is so radically different from the committee way that we usually use to solve problems. In Lean done correctly, the leadership is setting the priorities by focusing on which value streams or areas of focus most align with the system's metrics, and out of those value streams come the rapid improvement event, where front-line workers solve the problem. This is a radical approach to problem solving.
MH: Do you find health systems are more willing to embrace a quality-improvement program like Lean?
Gabow:There is more of an understanding that we have serious problems with access, cost, quality and patient engagement. People are starting to realize that what we have is not sustainable. Not only is it not sustainable, it shouldn't be sustained, and it is not the system we want for America.
Follow Steven Ross Johnson on Twitter: @MHsjohnson
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