Denver Health, a comprehensive and integrated medical system that is Colorado's largest health care safety-net provider, has a national reputation as a high-performance organization. Members of The Commonwealth Fund Commission on a High Performance Health System observed Denver Health during a site visit in March 2006, to assess its operation and determine whether it might serve as a model for other public and private health care systems around the country. The Commission concluded that Denver Health is indeed a "learning laboratory." It has succeeded at providing coordinated care to the community, promoting a culture of continuous quality improvement, adopting new technology and incorporating it into everyday practice, taking risks and making mid-course corrections, and providing leadership and support—and accepting accountability—both at the top and throughout the organization. Moreover, it has accomplished these objectives and others in straightforward ways that could be adapted elsewhere.
This report documents a case study of Denver Health?a comprehensive and integrated health care system that serves approximately 25 percent of all Denver residents. This organization is the largest health care safety-net provider in Colorado and its major Medicaid provider. It also has a national reputation as a "high-performance" model for developing a sustainable public health care system. In order to witness some of its operations firsthand, members of The Commonwealth Fund Commission on a High Performance Health System visited Denver Health in March 2006.
Streamlining Operations and Eliminating Waste
In 2003, Denver Health embarked on an effort to transform itself and create a culture of deliberate improvement. As a result, the organization adopted specific new processes and tools. For example, it systematically applied the principles of "lean manufacturing" based on Toyota's approach to streamlining its operations and eliminating waste. To develop appropriate in-house expertise, Denver Health invested in the training of 50 staff members in these industrial techniques adapted to health care settings. As a result, five strategic "value streams"—access, inpatient flow, outpatient flow, operating room flow, and billing—were selected as targets for the initial redesign efforts.
Denver Health then initiated a series of week-long "Rapid-Improvement Events," five of which were conducted each month to improve individual processes within each value stream. The "operating room flow" team, for example, significantly increased the number of patients who received antibiotics within the appropriate time frame before surgery—one hour, as recommended by national guidelines—from 80 percent at baseline to 96 percent in July 2006. Another Denver Health team strongly influenced the design of a new Medical Intensive Care Unit, making it more patient- and family-centered.
The Right Technology, the Right PeopleDenver Health has also focused on building its infrastructure for high performance in two important areas?information technology (IT) and workforce.
The organization's investment in health-oriented IT, which has totaled $275 million since 1997, has enabled the establishment of a centralized data warehouse that integrates both clinical and financial data and allows for standardized reporting. A single imaged electronic-record format is used across the entire system so that a patient's information can be retrieved in "real time" by any of his or her providers.
To ensure that it has a capable workforce, Denver Health has restructured its hiring practices to recruit and retain the "right people." It implemented a four-part strategy that includes a talent bank, an interview tool that measures "talent intensities," training for key leaders regarding selection, and an employee-engagement survey. It has also demonstrated a strong commitment to the training of health professionals—on average, about 3,000 per year—such as physicians, nurses, pharmacists, and emergency medical technicians.
Four Exemplary Operations
Denver Health's major redesign of its organization, still ongoing, is manifested in multiple strategic initiatives targeted at particular facilities and services, several of which Commission members observed during their on-site visits.
The Westside Family Health Center is a clinic aimed at providing high-quality, culturally sensitive, patient-centered care to the uninsured and low-income populations. Its accomplishments include instituting an "open access" scheduling system that has reduced no-show rates by half, instituting group visits to promote patient self-care, and (together with other Denver Community Health clinics) more than doubling the percentage of young children who are up to date on immunizations.
Denver Health's medical critical care group is a multi-professional team that cares for critically ill patients in an intensive care unit using standardized protocols supported by information technology. The group conducts national and international collaborative clinical and translational research and has been recognized as a top performer by the University HealthSystem Consortium.
The Rocky Mountain Poison and Drug Center (RMPDC) encompasses three call centers—the Rocky Mountain Poison Center, the Rocky Mountain Drug Consultation Center, and the Denver Health NurseLine. The RMPDC also has a dedicated research arm and a medical toxicology consultation service, including a training program for physicians.
Medicaid Choice, Denver Health's Medicaid plan, serves as a business case of how a high-performing safety-net health system can successfully compete in the marketplace. For example, an average inpatient charge per stay at Denver Health for Medicaid patients is one-third lower than at other metro Denver hospitals, even as numerous measures of treatment efficacy score higher.
These and other components of the Denver Health system are briefly described in Appendices 1 and 2.
Lessons from Denver Health
While there are many factors contributing to the overall high quality of care that Denver Health provides to its patients, the Commission highlights the following attributes that other health systems might consider replicating:
- Denver Health is an integrated system, endowed with appropriate tools.
- An infrastructure exists to provide coordinated care to the community.
- There is a commitment to adopting new technology and incorporating it into everyday practice.
- Denver Health promotes a culture of improvement, peopled by dedicated staff.
- The decisions are data-driven and feedback loops allow for continuous quality improvement.
- There is willingness among the leadership to take risks and make mid-course corrections.
- Innovation at Denver Health has strong support at the top.
- Leaders at Denver Health clearly communicate their vision that high-quality care derives from a high-quality system. The leadership and staff are bound by a common mission that reflects this vision.
- The leadership has adopted a market-based strategy with a clearly defined target population. Their approach, which requires strict accountability, aligns incentives to encourage the systems approach.
The authors—along with the Commission on a High Performance Health System—hope that this health system's best practices, and the lessons learned from the significant barriers it has overcome, will constitute a "learning laboratory"—a potential model—from which other institutions and the nation may benefit.
R. Nuzum, D. McCarthy, A. Gauthier, and C. Beck, Denver Health: A High-Performance Public Health Care System, The Commonwealth Fund, July 2007