The Idea of Being Lean Cost Control and More! Steve Peirce, CMQ/OE, CQPA, Six Sigma Black Belt Director, Process Improvement Alberta Health Services CHPCA Banff, Alberta, June 7 th and 8 th 2014

2 The Performance Improvement Toolbox TheoryofConstraints Six Sigma Lean Kaizen SPC QI +Thinking

3 PART I - LEAN THINKING

4 Profound Knowledge 6. Deming p.p. Ch 4

5 Continuous Improvement 1. Deming p.p

6 Lean Thinking The core idea is to maximize customer value while minimizing waste. Simply, lean means creating more value for customers with fewer resources. »Lean Enterprise Institute, –Guiding Principles Purpose Process People Source:

7 Lean Thinking Ford, Highland Park Michigan, 1913 End to end integrated production process Source: Toyoda Weaving, Toyota Motor Company, 1930s / 1940s Self monitoring machines (Jidoka) Just-in-time (Kanban) Womack / Jones, 1990’s Lean Thinking Value / Value Steam / Flow / Pull / Perfection

8 Lean Thinking - JIT Lean Thinking – JIT (Just-in-Time) –Response to variation –In Supply chains – parts are available: –at the time they are needed –in the right quantity –in the right condition. –In service systems – service providers are available: –At the time they are needed –Without undue delay (queuing) –With the right skills In response to a demand signal ( 看板 Kanban ) In response to demand

9 Lean Thinking - Jidoka Jidoka (Autonomation) –Automation with a human touch 4 Steps –Detect the abnormality (problem visibility) –Stop (learn how to wait). –Fix or correct the immediate condition. –Investigate the root cause and install a countermeasure. Source: 4. Nakance / Hall p 12 Kaizen, Rapid Improvement Event, Work Out PDSA

10 Value It must transform the product or service. The customer must be willing to “pay” for it. It must be done correctly the first time. Waste Mura or waste due to variation Muri or waste due to overburdening or stressing the people, equipment or system Muda also known as the “seven forms of waste” Source:

11 Overburdening (Muri) Theory of Constraints 4 Focusing steps 1.Identify the constraint usually a bottleneck 2.Exploit the constraint run the constrained step efficiently 3.Subordinate all other processes to above Re-balance the work 4.Elevate the constraint system / capacity changes

12 Variation / Unevenness (Mura) 1.Understanding Variation 2. Planning for Variation

13 Six Sigma and Variation Six Sigma – Improves results by finding and eliminating sources of defects and reducing variation Variation –“If I could reduce my message to management to just a few words, I’d say it all has to do with reducing variation.” Attributed to W Edwards Deming

14 Waste (Muda) OVERPRODUCTION WAITING DEFECTS PROCESS INEFFICIENCY TRANSPORTATION INVENTORY MOTION MISUSED TALENT Drawing too many samples, Extra tests Waiting for a doctor, procedure, bed, test result, or discharge Medication Errors, Wrong Patient, Wrong Procedures, missing information, redraws, poor clinical outcomes Multiple Bed Moves, Multiple tests, excessive paper work Moving samples, specimens, patients, or equipment No empowerment, unenlightened management, poor hiring practices, lack of training, scope of pracice Searching for patients, medication, charts, gathering supplies Patients waiting, inventory of supplies, out-of-date supplies, stock outs. Also… Safety Also… Safety Source: 12. Dean Page 29

15 Lean and Healthcare “Everyone is different, but they are different in very similar ways” Jason Meyers CEO Canadian Manufacturers and Exporters

16 PART II - IMPROVING

17 Product Families / Value Streams Product 1 Product 2 Product 3 Product 4 Step A Step D Step G Step H Step I Step J Step E Step F Step B Step C

18 Spaghetti Diagram Source:

19 Process Mapping Swimlane Charts (Cross Functional) Customer Department A Department B Department C Customer Step 1Step 2 Step 3 Step 4 Step 5 Step 6 Customer Shows: Relationship of the steps / interdepartmental handoffs Balance of work Unnecessary steps / reviews / approvals Process Scope

20 Value Stream Map 4. Rother and Shook p. 3 “Whenever there is a product for a customer, there is a value stream. The challenge lies in seeing it.” Learning to See, Lean Enterprise Institute

21 1.What are the steps? Value Stream Map Check In Exam Book Appt Demand = 50 patients / day Available Time = 450 Minutes

22 2. Where are the waits? Value Stream Map Check In Exam Book Appt 2 patients 10 minutes 4 patients 60 minutes 1 patient 10 minutes Demand = 50 patients / day Available Time = 450 Minutes 1 2

23 3. Understand the work content Value Stream Map Check In Exam Book Appt 2 patients 10 minutes 4 patients 42 minutes 1 patient 10 minutes PT = 5 Min PT = 12Min PT = 6 Min CT = 5 Min CT = 6 Min CT = 6 Min C/O = 1 Min C/O = 5 Min C/O = 3 Min U/T = 70% U/T = 100% U/T = 75% Demand = 50 patients / day Available Time = 450 Minutes

24 4. Understand the Flow Value Stream Map Check In Exam Book Appt 3 patients 15 minutes 4 patients 42 minutes 1 patient 10 minutes PT = 5 Min PT = 12 Min PT = 6 Min CT = 5 Min CT = 6 Min C/O = 1 Min C/O = 5 Min C/O = 3 Min U/T = 100% U/T = 75% 15 minutes PT = 5 Min 42 minutes PT = 12 Min 10 minutes PT = 6 Min PT = 23 Min LT = 90 Min VA Ratio = 25% Demand = 50 patients / day Available Time = 450 Minutes

25 Creating the Future State 8 Future State Questions 1.What is the takt time? 2.Will you build to a finished goods supermarket or directly to shipping? 3.Where can you use continuous flow? 4.Where will you use pull systems? 5.What single point will be the pacemaker where you will schedule work? 6.How will you level production mix at the pacemaker? 7.What increment of work will you release? 8.What improvements will be necessary?

26 Future State Map Step 1, Mark your future state ideas on your current state map 2. Build to shipping 3. Flow 4. Supermarket to exam room supplies 5. Pacemaker 6. Mix 7. Ptich 1. Takt = 9 Minutes

27 Future State Map 2. Build to shipping 3. Flow 4. Supermarket to exam room supplies 5. Pacemaker 6. Mix 7. Ptich Step 2 (Future State Q8, Document the improvements necessary) Reduce C/O time to 1 minutes Nurse to assist with patient / physicain change over Step 3 Calculate the new lead time Increase nurse uptime to 100% 1 Minute _________ 1. Takt = 9 Minutes 4 Minutes _________ 1 Minutes _________ 28 Minutes _________

28 Demand / Capacity / Queuing Demand Work / Time + Variation Capacity Work / Time + Variation Demand Variation Re-Work No Shows Server Variation Unused Capacity

29 Airplane Simulation - Round 2 Rules Do only your job Work as fast as you can Fold exactly per the instructions Inspector is responsible for Quality/Test All material movement by Material Handler Build, move, deliver in batches of 5 Shipper records shipments 10 minute round Factory layout cannot change Job descriptions cannot change Batch size cannot change

30 Rapid Improvement - Kaizen Kaizen ( 改善 ) / Kaikaku

31 Standard Work

32 Standard Work

33 Lean and Learning “Why not make the work easier and more interesting so that people do not have to sweat? The Toyota style is not to create results by working hard. It is a system that says there is no limit to people’s creativity. People don’t go to Toyota to ‘work’ they go there to ‘think’” - Taiichi Ohno Rother

34 Lean Healthcare Case Studies

35 References

36 Glossary

37 Glossary

38 Glossary