Overview of Lean Principles and Continuous Improvement Lean in Healthcare

What is Lean? Definition-”The endless transformation of waste into value from the customer’s perspective.” Definition-”The endless transformation of waste into value from the customer’s perspective.” IT is a System Thinking Concept. A little History A little History

The “4P” model Problem Solving (Continuous Improvement And Learning) Process (Eliminate Waste) People and Partners (Respect, Challenge, and Grow Them) Philosophy (Long-Term Thinking)

Impact of Lean in the Industry Direct Labor/productivity improved 45-75% Cost Reduced 25-55% Throughput/Flow Increased 60-90% Quality (Defects/Scrap) Reduced 50-90% Inventory Reduced 60-90% Space Reduced 35-50% Lead Time Reduced 50-90% Source: Virginia Mason Medical Center

Examples of Lean in Healthcare Adding greater “value-added” services Adding greater “value-added” services Same day office visits Same day office visits Next day outpatient surgery Next day outpatient surgery Next day mammogram Next day mammogram Quick & errorless billing Quick & errorless billing No wait emergency room No wait emergency room

TRADITIONAL CULTURE VS. LEAN CULTURE TRADITIONALLEAN Functional Silos Interdisciplinary teams Managers direct Managers teach/enable Benchmark to justify not improving; “just as good” Seek the ultimate performance, the absence of waste Blame people Root cause analysis Rewards: individual Rewards: group sharing Supplier is enemy Supplier is ally Guard Information Share information Volume lowers cost Removing waste lowers cost Internal focus Customer focus Expert driven Process driven

Examples of process improvement tools

A3 reporting

Clean it up, Make it Visual STRAIGHTEN SHINE STANDARDIZE SUSTAIN SORT

What is Waste in Healthcare?

Eliminating Waste Overproduction Overproduction Pills given out early Treatments done to balance staff Duplication of test

Eliminating Waste  Transportation Moving same patient, specimens, or supplies,workers

Eliminating Waste Motion Motion  Searching for patients,  needed meds,  right charts,  supplies

Eliminating Waste  Waiting for bed assignments ordischarge,or testing results

Eliminating Waste  Processing  Retesting  More paperwork  Duplicate procedures

Eliminating Waste Inventory Inventory Linen (laundry)  Pharmacy stock  Supplies  Specimens waiting for analysis

Eliminating Waste  Defects  Medication error  Wrong procedure  Wrong patient  Missing information

The Toyota Way 14 Management Principles to LEAN Development Process to LEAN Development Process

LEAN Development Process 1. Establish the vision for the future  Focus the organization on the PATIENTS  Align Performance Measurements  Set high expectations for success and low tolerance for failure Method:  Establish a core team of implementers  Focused training, reading, and benchmarking  Standardized, systematic, methodical approach  Clearly define objectives and time table  Create success through pilots and spread

Mission Statement Develop the ability: To recognize and identify waste To have the courage to call it waste To have the desire to eliminate it Eliminate the waste Understand that waste simply Raises costs Produces no corresponding benefit Threatens all of our jobs You get what you expect and you deserve what you tolerate.

LEAN Development Process 2. Develop your objectives  Look at your key processes or VALUE STREAMS  Patient Journey (ER  Radiology  Clinic  OR  Billing)  Charge capture (Clinical Service  Billing Insurance)  Operating Room flow (Scheduling, consent, pre-op visit, prep,….)  These support your “ Products ” which might be  Office visit  Inpatient stay  Visit to the ED  How do your Internal and External Customers define Value

LEAN Development Process 3. Selection of Team Members Characteristics: Technology curiosity Common sense Inner confidence (create structure, Win allegiance, instinctive reactions) Cross Functional Team: Manager/Supervisor from the area Operators from area Functional departments (HR, Lab, Pharmacy, Admitting, Surgery, Materials Management,etc.)

RESOURCE MATRIX NAMETITLE SKILL 1 SKILL 2 SKILL 3 SKILL 4 Larry Moe Curly

LEAN Development Process 4. Initiate Team Training: Read required literature Attend team and leadership training, lean overview Tools: Standardized analysis and simulation tools Video cameras, TVs, and VCR’s Computers, Printer, and Projector Facilities: Lean War Room located in the operational area Office area appropriately furnished and supplied

Resource and Innovation Center

LEAN Development Process 5. Select Pilot Area Selection Criteria: Contributes to key competitive strengths of business Innovation has a good chance of success Significantly tests the innovation Solutions are transferable to other areas Baseline the current process Do an initial walkthrough

Baseline Analysis 1. # patients transferred from ED to inpatient bed within 1 hour of decision to admit 2. Time to third next available appt 3. # tests/day or # tests/week Keep it simple - look at 25 patients/wk collected over some time period including weekends and at night

LEAN Development Process 6. Activity of Product Videotape: selected products Analyze videotape and segregate: travel time and distance storage time and type inspection time non-value added processing time value added processing time Map the flow of the product:

Process Charts Process: Emergency room admission Subject: Ankle injury patient Beginning: Enter emergency room Ending: Leave hospital Step no. Time (min) Distance (ft) Summary Number of steps Activity Time (min) Distance (ft) Step description Insert Step Append Step Remove Step 1XEnter emergency room, approach patient window 2XSit down and fill out patient history 3XNurse escorts patient to ER triage room 4XNurse inspects injury 5XReturn to waiting room 6XWait for available bed 7XGo to ER bed 8XWait for doctor 9XDoctor inspects injury and questions patient 10XNurse takes patient to radiology 11XTechnician x-rays patient 12XReturn to bed in ER 13XWait for doctor to return 14XDoctor provides diagnosis and advice 15XReturn to emergency entrance area 16XCheck out 17XWalk to pharmacy 18XPick up prescription 19XLeave the building Transport Operation523— Inspect28— Store——— Delay38—

LEAN Development Process 7. Group Technology Analysis Process sequence Process sequence Pre- Post data collection Pre- Post data collection Identify number of possibilities and combinations Identify number of possibilities and combinations Identify commonality within each product family Identify commonality within each product family Plan analysis phase Plan analysis phase

A3 reporting

LEAN Development Process 8. Line/Cell vision Product flow Product flow Operator activity Operator activity Flexibility Flexibility Zero defect production Zero defect production

Group Technology Machine 1 Machine 2 Machine 3 Machine 4 Machine 5 Materials in Finished goods out One Worker, Multiple Machines

LEAN Development Process 9. Activity of Operator  Map work pattern Videotape Analyze what is value added, required waste, and pure waste Point to Point diagram representing movement of operator in work area  Time studies analysis  Document new process

Point to Point

LEAN Development Process 10. Develop Standard Work Define job steps, standard times, and material location within each order of process Define takt time Establish Line Balance

LEAN Development Process 11. Improve Line flexibility  Videotape – selected setups and operators  Document improvement suggestions related to – preparation, organization  “Milk runs”  Document new process

LEAN Development Process 12. Design and approve Line Layout Design Considerations Design Considerations Steps to approve new Layout Steps to approve new Layout

LEAN Development Process 13. Performance Measurements  ID standard work, source quality control  Monitor performance and Post results  ID ‘hit list’ and resolve identified problems on a 90 day cycle  Monitor changes on 30/60/90 days cycle

LEAN Development Process 14. Develop a business case  Compare base conditions with projected lean conditions (benchmark or audit)  Output rates  Floor space  Inventory  Labor  Document cost of implementation  Present findings to senior management  Include all stakeholders and decision makers  Let the facts speak loudly