Last Sunday I discussed the sixth driver of burnout – Conflicting Values. Today’s posting is a vignette from our book, Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine, and discusses Denver Health’s Lean journey. As CEO of Denver Health, Dr. Patty Gabow engaged Simpler Consulting to coach her and her team through their Lean transformation. I know Patty personally. She is one of the most values-driven leaders I know, as you will learn in reading Denver Health’s story below.
Denver Health and its Lean Journey
Denver Health is a public, academic, integrated health system that serves 25 percent of the residents of Denver. The safety net hospital faced escalating financial stress as economic shifts increased the number of uninsured—who make up about one third of the organization’s patients—and decreased reimbursement.
In 2005, the organization began its Lean transformation journey, eventually reaping a range of positive outcomes. For example, the organization had the lowest risk-adjusted trauma mortality rate for level 1 trauma centers in the state in the 2007-2009 data period—with a mortality ratio 26 percent below that expected for a hospital with its case mix. The number of sentinel events decreased from 13 in 2008 to two in 2010. Between July 2006 and December 2010, the organization saved almost $67 million by removing waste and inefficiencies—three times the target of $20.9 million.
More recently, the organization used Lean tools to transform primary care clinics to the patient-centered medical home model, with all staff working at the top of their licenses. In less than three years, all clinics were certified at level 1 or 2 under the new NCQA certification. Deep involvement of leadership has been an essential element in the organization’s success.
Leadership Commitment to Mission and Equity
When introducing Lean to Denver Health staff in 2004, CEO Patricia A. Gabow, MD, emphasized the importance of the transformation to protecting the organization’s deeply held mission to maintaining access to high-quality care for everyone, regardless of ability to pay. At the annual CEO address she told them, “Denver Health is going to take the road less traveled. We have only three options when faced with increased uninsured patients and decreased revenues: cut services to the uninsured, increase revenues, or dramatically improve efficiency. We’re going to maintain our mission and select the third.”
She also prioritized equity. “Everyone was treated the same,” she told us in an interview, “I had the same vacation time as the housekeepers.” She acknowledged positive contributions to the organization by staff at every level. She relayed that at another annual, standing-room-only, CEO address she presented the CEO award to a member of the grounds crew who had exemplified dedication to improving the patient experience. He received a standing ovation from the staff and leaders. “Everyone found meaning in the work we were doing. Everyone’s work was appreciated,” she said. In fact, the Lean Black Belts, a cadre of about 250 staff members with training in Lean, were initially provided with small financial rewards for the savings they achieved. “They didn’t want it, because it decreased collaboration between units,” she told us.
Transparency and Fairness
Gabow also emphasized transparency and fairness, ensuring that leaders were as involved as frontline staff in improvement work. She found that being a physician herself proved advantageous when working with frontline physicians. “I could tell them what needed to be done and they could hear me. In turn, they couldn’t pull the wool over my eyes about what was possible or not possible. I could speak their language.”
According to Rick Dart, MD, PhD, director of the Rocky Mountain Poison and Drug Center and former chief business development officer at Denver Health, Gabow’s ability to speak directly to physicians changed their level of engagement in improvement. “Before the mid-1990’s physicians’ attitude was not ideal. Many had a chip on their shoulders, having come to Denver Health because of the mission to help the poor. They were basically saying, ‘I’ll do what I want. You’re lucky to have me here.’”
According to Paul Melinkovich, MD, president of the Colorado Medical Services Board and director of Community Health Services at Denver Health, Gabow and other leaders used several techniques to improve physician engagement in improvement. “It’s important for leaders to help physicians understand that Lean is not a top-down endeavor and to recognize that the primary goal is not to improve finances, though it may. Instead, they need to appeal to higher ideals, like quality, safety, and the patient experience. It’s also important to help physicians to be involved in a way that doesn’t reduce their take home pay and that doesn’t put more work on other clinicians.” Denver Health maintained a float pool to cover for staff and physicians who were working on RIEs, for example.
In the years since Gabow retired as CEO of Denver Health, the organization’s approach has shifted and has faced growing physician discontent and turnover. This change highlights the importance of the CEO and the board of directors collaborating on a succession plan that effectively sustains the Lean transformation.
Have you had either good or bad experiences with conflicting values in your organization? Feel free to share those by clicking on the “Comments” link above.