Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement Ch. 3 Value and Waste Presented by Janea Spillers Mechanical Engineering Student ETM 528 Quality Engineering

Lean Lessons on Waste and Value Introduction Lean gives a framework to transition from “this is how we've always done it” to “this is how we should be doing it” Separating Motion from Value Evaluating the things we do vs. the things we do that help patients ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Waste Introduction What is Waste? Inefficiently delivered services; unnecessary services Problems and annoyances that constantly appear, interfering with our work and the best patient care Extra effort can usually be attributed to waste Lean Hospitals focus on reducing waste, not cost. More value for customers with fewer resources Lower costs and better performance across the board, without causing side effects or dysfunction Improving quality and patient safety leads to lower costs Focusing on "end result“ EX: Nurses typically only send 30% of their time on direct patient care. Nurse that runs around doing beyond her share is seen as the “hero” when Lean would look at that and say it is unnecessary ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Value Introduction What is Value? If waste is an activity that does not add value, then what is value? Value can be defined by asking "who is the customer" (STAKEHOLDER) Usually the customer is the patient… so spending more time with the patient will lead to better value Patient centered care Other Stakeholders: Patient's family Physicians, hospital employees Payers Each stakeholder defines value in a different way Nurse that runs around doing beyond her share is seen as the “hero” when Lean would look at that and say it is unnecessary ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Stakeholders Internal customer needs must be in alignment with the ultimate end customer, the patient. Ultimate End Customer The patient Internal Customer Also known as downstream recipient, other stakeholders within the hospital involved in patient care Risks on focusing on internal customer: Distract from the needs of the ultimate customer Too inwardly focused instead of patient focused ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Value in a Broad Sense Porter’s 3 levels of patient care Survival and the degree of recovery The time required to get back to normal activities Sustainability of said treatments Value is not just providing efficient, safe, effective care when it is needed… it is a system that: Helps KEEP them healthy Provides longer life with a higher quality of life ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

VA vs. NVA VA- value added NVA- non-value added Customer is willing to pay for the activity Activity must transform the product/service in some way Activity must be done correctly the first time NVA- non-value added Refers to waste ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

VA Rule 1. Willingness to Pay In healthcare, willingness to pay gets complicated, as patients often don't have a choice but to pay. How is value defined? Ask the patient Hospital employees can't assume all their activities are value- added: Waste: patient giving the same triage info to people 3 times, the second and third times are waste Value: giving education on how to reduce future falls at home to a patient Value: having x-rays reviewed Waste: waiting on busy radiologist to get your x-rays Compare with car buying ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

VA Rule 2. Transform product “Product" is usually the patient In Lean hospitals, it is better phrased as: “Activity must move patient closer to their ideal health" Value adding steps: Providing comfort for pain Stabilizing patient Diagnosis Treatment Education Anything maintaining health and quality of life Moving patient from room to room is NVA ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

VA Rule 3. Correct the First Time EX: wrong prescriptions given EX: preventable infections adding $15,000 to bill on average Would you pay more for a car that had been damaged and then re- fixed? …Of course not. “Never” events Certain companies are not paying for these types of errors or reworks ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Identifying and Describing Waste 8 types of waste: Defects Overproduction Transportation Waiting Inventory Motion Over-processing Human potential ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Types of Waste Defects Overproduction Anything not done right the first time, including things that lead to rework or work around Defect does not have to cause harm to be considered waste Overproduction Producing too much of a product or producing earlier than is needed 20-50% of lab tests are completely unnecessary However, a Lean thinker would make sure physicians are not being pressured into not ordering tests that could be helpful to the patient Ex: reducing unnecessary care In England, 1 in 7 hospital operations/medications are not necessary ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Types of Waste Transportation Waiting Excess movement of product through a system Improve flow Reconfigure hospital layouts Waiting Time when NVA activities are happening Patients are aware of this type of waste This can be fixed by fixing other forms of waste, such as better flow, etc. Employee waiting causes: Process defects Delays in upstream processes Uneven work loads Low patient volumes  ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Types of Waste Inventory Motion Excessive inventory is waste Improved inventory management can help Motion  Refers to those doing the work Hospitals should reduce amount of motion required by an employee to get a job done Unnecessary walking Time spent interacting with difficult computer software Nurses are the main ones that deal with this: Lean hospitals should consider pros and cons of decentralized stations and the potential effect on teamwork and other factors or results ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Types of Waste Overprocessing Talent Refers to doing something to a higher level of quality than required by the customer of doing unnecessary work Results from miscommunication in handoffs between people or departments Talent  Including ‘Talent’ in this list emphasizes the importance of people in the system, not always included in Lean literature Lean is not just about process or product, it's about managing, leading, developing, and inspiring people Employees are major drivers of patient satisfaction Higher skilled employees can sometimes do grunt work to be a team player, but too much is waste Include employees in improvement process-- they will feel more valued ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Conclusion it’s not always an easy answer… Trade-offs between types of waste Lean tells us to be creative and break away from the trade off: Does it have to be like that?? “What Lean says" is not always the most important Rather than having the "right" answer from Lean, part of the Lean mindset and process is to do our own analysis and consider our next steps. NVA activities are sometimes required Government regulations or inspections Need courage to take action and lead efforts to improve system and eliminate the waste ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Lean Lessons (pages 68 and 69) Value is added by the customer. Waste interferes with us doing our work. Not all activity is value. Waste tends to be driven by the system and the design in our process. Not all waste can be eliminated; some of it is required to make the system function. Just because we have to do something does not make it value. Quality is a primary goal of Lean, not just efficiency. Patients should not have to pay for defects or rework. The primary goal is not low inventory, but rather having enough inventory to efficiently do our work, without having too much. To drive problem solving and continuous improvement, focus on the process. Don’t argue too much over whether something is waste ow what type of waste it is. Focus on what you can and should improve, stop doing, or do more of. ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3

Citation Graban, Mark. “Value and Waste.” Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, 3rd ed., CRC Press, 2016, pp. 45–69. ETM 528 Spring 2018 Janea Spillers Lean Hospitals Ch 3