One of These Docs Is Doing Her Own Thing

And it’s working. Dr. Patricia Gabow’s remarkable turnaround of Denver Health has made it a national model for public hospitals. And it just may be a blueprint for health care in the United States.

One of the first Value Streams targeted, in June 2005, was surgery, and the first process to be addressed was the prevention of postoperative infections. One of the major causes of complications while a patient is in the hospital is infection. A patient comes into the hospital infection-free, gets an infection in the hospital, and gets sick or dies. This is not good—not good medicine or, considering the follow-up treatments and potential litigation, not good for business. And yet, in theory, these infections could so easily be prevented.

Hospital infections commonly occur during surgery, and one of the best ways to prevent them is to administer an antibiotic to the patient within one hour of the first surgical incision. For years, Denver Health had what was considered a high rate of surgical infections, which Gabow had been trying to fix. The hospital had so many committees on the topic, yet when it came to the percentage of time the drug was administered within that crucial one-hour period, the staff could never get above 70 percent.

So in the summer of 2005, one of the first RIE teams took on the nagging problem. The team included the medical director, the chief of infections, a nurse anesthetist, and two registered nurses. According to the RIE protocol, on Day 1, the group met in a conference room from 8 to 9:30 a.m., and discussed the existing process. Next, they went on a site visit, or a “waste walk,” meaning they studied the handling of a patient being transported to surgery. Finally, they reconvened in the conference room and mapped the existing process by sticking Post-it notes on a wall. Based on their observations during the waste walk, they marked each step that appeared to be unnecessary. A total of eight hours.

Day 2: The group met in the conference room and designed a new process. Eight hours. Day 3: The group returned to the site and orchestrated a few test runs of their redesigned process. At 4 p.m. the group gave the executive staff an update. Eight hours. Day 4: They refined and “standardized” the redesigned process. Day 5: Between 8 and 9 a.m., in the conference room, they gave a presentation to executive staff, including Gabow. Then, from 9 to 10 a.m. they trained employees on the new formally approved and standardized process. Two hours.

What that RIE team realized was that in the old, accepted way, the OR would call a nurse on the patient’s floor to notify them the patient was on deck for surgery and that the antibiotic ought to be administered. What would then frequently happen is the patient’s surgery would get delayed. Maybe another emergency took precedence. Or, the OR nurse would call too early. Or any number of glitches. Regardless, the simplest, most efficient process, as the RIE discovered, would be to have the anesthesiologist, not a nurse, administer the drug. After all, no matter what, that doctor is going to be with the patient one hour pre-op. The new process the RIE produced in a week, for a problem that had been occurring for years, improved the rate from 70 percent to almost 96 percent within a matter of months. Today, some five years later, the RIE-created process is still in place, only now with a 96 to 100 percent effective rate.

Between June 2005 and June 2010, 254 Rapid Improvement Events took place within Denver Health. Some 1,273 employees representing 220 departments participated. The Value Stream processes addressed included, oh, just about everything: physician billing, psych consults, address verification, physician credentialing, dialysis, cancer screenings, in-patient enrollment, and so on. All of which, thus far, has saved or otherwise benefitted Denver Health by at least $88 million.

Another noteworthy RIE impact: Gabow has also orchestrated a dramatic institutional expansion of Denver Health, and while the square footage has increased by more than 30 percent, its mechanical engineering supply costs—think light bulbs—have decreased from $1.2 million to $700,000. While the physical space has gotten bigger by one third, the costs to sustain and supply that expansion have gone down. And each of these RIEs, according to just about every measure of patient care, has dramatically improved Denver Health’s ratings. According to the University Health-System Consortium, which is a group of 112 medical centers and 256 affiliated hospitals—Denver Health’s peer group—Gabow’s shop has the “lowest observed mortality rate,” meaning, in short, Denver Health saves more lives. Considering the patient pool, this statistic is especially remarkable, and not just in hospital land.

That Shingo Prize that Gabow had talked about in that staff meeting is named after Shigeo Shingo. Regarded as an “engineering genius,” Shingo was one of the architects of the manufacturing policies that drive Toyota’s production system. And the prize in his name is a very big deal. It was established in 1988 “to be the standard of excellence to educate, assess and recognize organizations that achieve the highest level of world-class operational excellence around the globe.” The prize is administered by the Jon M. Huntsman School of Business at Utah State University, and is overseen by a board of governors that is a Who’s Who of CEOs. Gabow’s Denver Health was indeed the first heath-care provider to enter, and, almost as if she willed it so, was recognized earlier this year with a Bronze Shingo Prize.