Psych Services Array Strategic Lean Improvement:  Jail Health Services/Department of Adult and Juvenile Detention

What would it take to achieve breakthrough improvements in timeliness, clinical care, operational efficiencies, and patient safety in serving the mental health needs of the King County inmate population? That is exactly the question executive sponsors from DAJD and JHS grappled with in May 2012, when the Psych Service kicked off a 12 month process and system level redesign.

The two departments held a Lean event together. They didn't just talk; they seized the opportunity to remove old layers of redundant policies and wasteful procedures. The achievement involves jail inmates with psychiatric needs who require in-patient treatment. 20% of 34,000 annual jail bookings were of individuals with serious mental illness, and 41% had substance abuse or dependency issues. Their care and security is provided by the Corrections staff - whose job is securing "inmates" - and by Public Health staff - whose job is treating "patients."

Redesigns had largely been unsuccessful over the last decade due to regulatory, external, and legal requirements. Employee workflows still included waste, inefficiency, and areas of ineffectiveness. The staff was not feeling respected, and the system was not stabilizing. Customer behavior, in this case the inmate population, was not influencing problem solving. And change was a struggle when it affected other departments. The Lean approach was successful because it was grounded in two foundational pillars: respect for people and the knowledge they hold, and continuous process improvement.  Lean encouraged the staff to "fail forward," in other words, to be innovative, to problem solve, to test and repeat. 

The team enthusiastically embraced this philosophy. The best example was talking to the inmates about their needs and point of view. How much more customer centric can you get? They reached out to all participants and established an atmosphere of trust by relying on "data not dictum." They broke down and examined all the steps of the "booking process" and identified opportunities for improvement. The outcome has been transformational. Corrections and jail health staff are working more closely together than ever in teams - providing better safety and better care - for a net savings of $2 million.

It was a courageous move to take a huge part of the management staff off of their jobs for weeklong Lean training, and then follow through despite lots of nay-sayers. The results were phenomenal and beyond industry practice. It is the first such use of Lean in the country and it could become a national model. And there are additional applications for this methodology that the management team (Dr. Ben and Dr. Mike) are thinking about.

Self-Insured Workers’ Compensation Light Duty Program

The established evidence indicates the best way to reduce costs is to have an effective light duty return to work program. Early return to work benefits both the employees and the employer. But how can an organization like Transit have an effective program where almost all the jobs are physical and there are not nearly enough administrative light duty jobs available? King County has an innovative approach where they place injured workers throughout the organization.

A New Approach to Combating Workers Comp Fraud

Willful misrepresentation is when a person obtains payments or other benefits in an amount greater than that to which the person otherwise would be entitled, by making conscious or deliberate false statements, misrepresentations, omissions or concealment of any material fact with the specific intent of obtaining, continuing or increasing benefits.
RCW 51.32.240(5) – Payments induced by willful misrepresentation

The workers’ compensation law changed a few years ago in order to control workers compensation claim abuse. The new law replaced civil fraud with “willful misrepresentation”. King County is the leader in this state building these cases. The Civil Division of the King County Prosecutors Office has developed an approach to successfully prove these cases that any self-insured employer can use.

Re-tooling Public Employee Health Care Coverage To Improve Wellness and Control Costs

King County has enjoyed great success with their employee health promotion and wellness program resulting in $46M in health care cost savings and demonstrably improved employee health. Employees and the County now pay less for better health care because they enrolled in wellness programs, and took more responsibility for prevention. However, there are clear limits on the power of healthier employees to constrain health care cost growth—the real cost driver is waste in the health care delivery system. King County is actively working with other employers through the Health Alliance to develop actionable information on quality and total cost per episode of care to help providers improve their services and allow purchasers to design plans that encourage employees to select higher value care.

Healthcare costs were going up by 13.5% a year necessitating layoffs and program cuts. And a sizeable share of that was due to high rates of lifestyle related chronic disease. Through restructuring the employee incentive system, King County has experienced dramatically positive results. 2,000 people have lost 24 tons of weight, over 800 people have quit smoking, more people are using quality healthcare, and public services have been protected from further cuts.

Strong justification for this initiative was found by incorporating three values from the County's strategic plan: financial stewardship, quality workforce, and employee wellness. New requirements have allowed the County to enforce tighter controls over what they will and will not reimburse health providers, including unnecessary care, inefficient care, medical errors, or avoidable complications. Instead, cost, quality, and patient experience will be primary factors.

Transforming IT from Dysfunctional Isolation to Successful Business Partnerships

Through product based budgeting King County was able to reduce cost, increase service, and improve quality. It took a customer centric approach by conducting one on one conversations to better define necessary services. Thoughtful planning also enabled better judgement about capital expenses in IT, resulting in substantial savings. King County IT Services was selected to receive a national award for Excellence in State and Local IT for this work.

Energy Conservation and Renewable Energy Production

King County has established aggressive commitments to reduce its facility and vehicle energy use, and production/use of renewable energy.  The effort is demonstrating significant progress, resulting from comprehensive actions across county operations. Russell Harper of NexTec had this to say, "I thought the Conservation discussion around transit and appropriate metrics and products showed an organization thinking seriously about what they are doing and why. Any process like this is a journey, and clearly the County has started on it." The County was very interested in the financial modeling tools used by some firms in the private sector to make better judgements about long term environmental investments, particularly in new technologies. It would be beneficial to bring private and public sector energy and sustainability managers together to perform a deeper dive.

Storm Water Permit Compliance Program for Property Managers

The county’s storm water permit requires the county to ensure properties it owns and operates do not generate pollutants. The storm water property inspection program has resulted in more effective management of the overall portfolio of county-owned properties.  Besides being a better neighbor to adjacent private property owners, the interests of county taxpayers are being protected, the environment including both terrestrial and aquatic habitat are protected, and compliance with federal law is achieved.

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