Healthcare Operations Management Daniel B. McLaughlin Julie M. Hays

Chapter 9. The Lean Enterprise Definition of Lean Types of waste Kaizen Value stream mapping Tools Takt time, throughput time, five Ss, spaghetti diagrams, kaizen events, standardized work, jidoka, andon, kanban, SMED, flow and pull, heijunka, advanced access Lean Sigma Copyright 2008 Health Administration Press. All rights reserved.

What Is Lean? Elimination of waste Philosophy Methodology Tools Toyota Production System (TPS) Philosophy Produce only what is needed, when it is needed, with no waste Methodology Determination of value added in the process Tools Five Ss, kaizen event, standardized work, etc. Copyright 2008 Health Administration Press. All rights reserved.

Types of Waste (Muda) Overproduction Waiting Transportation Inventory Motion Overprocessing Defects Copyright 2008 Health Administration Press. All rights reserved.

Kaizen Philosophy Employee-led continuous improvement Five steps Specify value Map and improve the value stream Flow Pull Perfection Even if it isn’t broken, it can be improved. Copyright 2008 Health Administration Press. All rights reserved.

Value Stream Mapping Process map of the value stream Includes information processing and transformational processing Value-added steps: “Would the customer be willing to pay for this activity?” Non-value-added steps Necessary Unnecessary Copyright 2008 Health Administration Press. All rights reserved.

Value Stream Mapping Diagram created with eVSM software from GumshoeKI, Inc., a Microsoft Visio add-on. Copyright 2008 Health Administration Press. All rights reserved.

Tools Takt time Throughput time Five Ss Spaghetti diagram Kaizen blitz or event Jidoka Andon Standardized work Kanban Single minute exchange of die (SMED) Flow Pull Heijunka Copyright 2008 Health Administration Press. All rights reserved.

Takt Time The speed with which customers must be served to satisfy demand for the service. Cycle time is the time to accomplish a task in the system. System cycle time is equal to the longest task cycle time in the system—the rate at which customers or products exit the system, or “drip time.” Copyright 2008 Health Administration Press. All rights reserved.

Throughput Time Time for an item to complete the entire process, which includes: Waiting time Transport time Actual processing time Copyright 2008 Health Administration Press. All rights reserved.

Riverview Clinic Cycle, Throughput, and Takt Time Diagram created with eVSM software from GumshoeKI, Inc., a Microsoft Visio add-on. Copyright 2008 Health Administration Press. All rights reserved.

Riverview Clinic Cycle, Throughput, and Takt Time Patient check-in cycle time = 3 minutes. System cycle time = cycle time for longest task = physician exam and consultation = 20 minutes. Throughput time = 3 + 15 + 2 + 15 + 5 + 10 + 20 = 70 minutes. Copyright 2008 Health Administration Press. All rights reserved.

Riverview Clinic Value-Added Time Valued-added tasks: Nurse preliminary exam Physician exam and consultation Non-value-added steps, necessary: Patient check-in Value-added time = 5 minutes (nurse preliminary exam) + 20 minutes (physician exam and consultation) = 25 minutes. Percentage value-added time = 25 minutes/70 minutes = 35 percent. Copyright 2008 Health Administration Press. All rights reserved.

Five Ss Seiri (Sort)—Separate necessary from unnecessary items, including tools, parts, materials, and paperwork, and remove the unnecessary items. Seiton (Straighten)—Arrange the necessary items neatly, providing visual cues to where items should be placed. Seiso (Sweep)—Clean the work area. Seiketsu (Standardize)—Standardize the first three Ss so that cleanliness is maintained. Shitsuke (Sustain)—Ensure that the first four Ss continue to be performed on a regular basis. Copyright 2008 Health Administration Press. All rights reserved.

Spaghetti Diagram Copyright 2008 Health Administration Press. All rights reserved.

Kaizen Blitz or Event Determine and define the objectives Determine the current state of the process Determine the requirements of the process Create a plan for implementation Implement the improvements Check the effectiveness of the improvements Document and standardize the improved process Continue the cycle Copyright 2008 Health Administration Press. All rights reserved.

Results of 175 Rapid Process Improvement Weeks at Virginia Mason Medical Center Source: Womack, J. P., A. P. Byrne, O. J. Fiume, G. S. Kaplan, and J.Toussaint. 2005. "Going Lean in Healthcare." Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Online information available at: http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm. Copyright 2008 Health Administration Press. All rights reserved.

Standardized Work Written documentation of the way in which each step in a process should be performed Not a rigid system of compliance, but a means of communicating and codifying current best practices Massachusetts General Hospital care paths Copyright 2008 Health Administration Press. All rights reserved.

Jidoka and Andon Jidoka is the ability to stop the process in the event of a problem. Prevents defects from passing from one step in the system to the next Enables swift detection and correction of errors Andon is a visual or audible signaling device used to indicate there is a problem in the process. Copyright 2008 Health Administration Press. All rights reserved.

Kanban Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation. Copyright 2008 Health Administration Press. All rights reserved.

Kanban Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation. Copyright 2008 Health Administration Press. All rights reserved.

Single Minute Exchange of Die (SMED) Used to reduce changeover or setup time, which is the time needed between the completion of one procedure and the start of the next procedure Steps Separate internal activities from external activities Convert internal setup activities to external activities Streamline all setup activities Copyright 2008 Health Administration Press. All rights reserved.

Flow and Pull Continuous or single piece flow—move items (jobs, patients, products) through the steps of the process one at a time without interuptions or waiting. Pull or just-in-time (JIT)—products or services are not produced until the downstream customer demands them. Heijunka—“make flat and level”; eliminate variation in volume and variety of “production” Level patient demand Copyright 2008 Health Administration Press. All rights reserved.

Advanced Access Patients are unable to obtain timely primary care appointments. Advanced access scheduling reduces the time between scheduling an appointment for care and the actual appointment. The goal is swift, even patient flow through the system. Copyright 2008 Health Administration Press. All rights reserved.

Advanced Access Advantages Decreases no-show rates Improves patient satisfaction Improves staff satisfaction Increases revenue Higher patient volumes Increased staff and clinician productivity Promotes greater continuity of care Increased quality of care More positive outcomes for patients Copyright 2008 Health Administration Press. All rights reserved.

Advanced Access Implementation Advanced access challenges established practices and beliefs. Balance supply and demand: Obtain accurate estimates of supply and demand. Reduce or eliminate backlog. Minimize the variety of appointment types. May need to: Adjust demand profiles. Increase availability of bottleneck resources. Copyright 2008 Health Administration Press. All rights reserved.

Lean Sigma Lean and Six Sigma are focused on continuous improvement of the system. Lean Eliminate waste Achieve flow and pull Six Sigma Eliminate defects Reduce variation in processes Copyright 2008 Health Administration Press. All rights reserved.