1. Lean and You Part 1 September 15, 2016
Special thanks to Marti Beltz, PhD, former NQC consultant and current Lean consultant, for contributing her expertise and many content slides to this presentation.

2. Learning Objectives Describe Lean methodology and history
Introduce basic Lean principles and tools
Identify improvement projects conductive to using Lean methodology
List key factors for successful project implementation
Describe key conditions for organizational implementation

3. What is Lean
The National Institute of Standards and technology defines Lean as: “ A systematic approach to identifying and elimination waste through continuous improvement ; flowing the product at the pull of the customer in pursuit of perfection.”

4. Thought Leaders
“all work is a process, and all processes can be designed measured and improved” – Phillip Crosby “94% of the problems are due to the system; 6% are due to the worker.” -W. Edwards Deming
A great quote from one of the “fathers of quality”.

5. Some History Henry Ford was a forefather of Lean practices
Lean also incorporates some of the principles of quality improvement as put forward by Juran and Deming
The Toyota Production System built upon the work of Ford through the foresight of K. Toyoda, T. Ohno, et. al.
The Toyota Production System was meant to react quickly and efficiently to the changes in customer demand

6. Toyota Production System
“ The ability to eliminate waste is developed by giving up the belief that there is ‘no other way’ to perform a given task. It is useless to say, ‘It has to be done that way,’ or ‘This can’t be helped!’ At Toyota, we have found that there is always another way.” “We get brilliant results from average people managing and improving brilliant processes. Our competitors get mediocre results from brilliant people managing around broken processes. When they get in trouble, they try to hire even more brilliant people. We're going to win.”
There are a number of versions of the history of Lean. Many start with the biggest contribution, Toyota’s in Japan, and some credit Henry Ford’s assembly line as an early Lean influence. Lean is known by several names and although its origins are in manufacturing; the methodology and tools are easily adaptable to service industries.

7. Five Lean Principles Specify the value desired by the customer
Identify the value stream for each product providing that value and challenge all of the wasted steps (generally nine out of ten) currently necessary to provide it
Make the product flow continuously through the remaining value-added steps
Introduce pull between all steps where continuous flow is possible
Manage toward perfection so that the number of steps and the amount of time and information needed to serve the customer continually falls
The Machine That Changed the World (1990) by James P. Womack, Daniel Roos, and Daniel T. Jones 

8. Lean 101
A process improvement methodology to achieve: the elimination of waste; increase speed via “flow”; reduction of costs; increased value for the customer; increased profits; increased quality and safety; increased flexibility for reacting to change
Projects focus on achieving outcomes: faster with fewer steps; with fewer resources; less expensively; less waste; less wait; and increased value
Advantages include: being intuitive; just-do-it; easily taught; quick results; appeals to the data-shy
Challenges include: some counterintuitive concepts; can be erroneously associated with increasing work demand and/or downsizing; does not directly target elimination of defects; necessity for culture change for best effect

9. Lean’s Relationship to Other Improvement Methods
Six Sigma : Six Sigma’s focus is on eliminating defects and using statistical process control of variation. Lean focuses on the elimination of waste. Lean cannot bring a process under statistical control. Six Sigma alone cannot dramatically improve process speed or reduce invested capital. Both enable the reduction of the cost of complexity. Lean tools can be used in each phase of Define, Measure, Analyze, Improve, and Control.
PDSA: Lean tools can be used in each phase of Plan, Do, Study, Act.
Baldrige: Lean tools can be an important part any organization’s process for improvement.

10. Definitions of Value and Non-value Added
Non-value-added – Those activities that do not transform or shape the product or services and do not add to the customer value
Business-value-added – Activities that are required by law or regulation
Customer-value-added – An activity the transforms or shapes material or information in order to provide a service to the customer. These are things
The goal is to eliminate all non-value added steps. One way to consider what is “non-value added” is to ask yourself, “would the customer pay for that?”. In this photograph we see two clinicians looking for a patient’s chart that is misfiled. Would a patient want to pay for the salaries of those two clinicians while they hunt? No, but they do. Another way to look at non-value added activities is to consider a patient’s wait. Is any kind of wait adding value to the patient? No, it is costing them time, potentially valuable treatment time if they are waiting to see a doctor or for test results.
Business-value-added process steps are inevitable and unavoidable pieces of the process that make it necessary for the work to get done. Billing a patient’s insurance is an example. Would the patient want to pay for the time it takes for a coder to submit charges to an insurance carrier? No, but does that step fulfill a business step that helps the patient and the organization interact effectively? Yes. Scrutinize these steps. They are often full of redundancy and therefore creep into the category of non-value-added. Customer-value added processes are steps that get the customer what they ultimately want; the reason they are interacting with you. In the case of health care, they are only the steps that can be directly associated with getting them well.

11. Methodology Value Stream Mapping Metrics: Kaizen
Value Stream Mapping: Comparing Current to Ideal to Future. Symbols. Power of the picture.
Metrics:
Cycle Time, Takt Time, Percent Load, Process Cycle Efficiency, Little’s Law, First Pass Yield, Up-Time, Total Productive Maintenance, Change Over Time, Touch Time
Kaizen: Dedicated resources applied to small bites.

12. Methodology Explained
Value stream mapping is used to map out a process and its associated time
Metrics are developed to measure the effect of your changes (sound familiar?). Also called key performance indicators
Kaizen is he heart of the improvement process. It is a multi day event where a team will discuss a process, map it and improvement s are made to a process. It improves a process by eliminating waste

13. Value Stream Mapping
Think of this as the flow of the entire process you want to improve
Helps to reduce waste, reduce process cycle times and visually point out areas for improvement
The process is a tool which should lead to an improved service
As an example, try the Peanut Butter and Jelly Game in the NQC Game Guide (pp. 43 – 47)

14. Value Stream Mapping

15. Future State map
To paraphrase an old Microsoft tag line, “Where do you want to go tomorrow?”
Looks at how you want things to work
It identifies improvements to the value stream that leads to improved delivery of services to the customer
Think of this as the transition map between the current value stream and the ideal value stream

16. Ideal State Mapping
This is where you want to eventually wind up; your ideal state that best serves the customer
This can help you organize your improvement priorities

17. Tools
Spaghetti Diagram
Check-list 5S
Kanban

18. Lean Tools The Spaghetti Diagram
Which one looks more efficient?

19. Lean Tools Checklists Help to reduce errors
Outline a process or a path to completion of a task
Enables even new employees to be more efficient
Popularized by Dr. Atul Gawande for use in healthcare

20. Lean Tools 5S Seiri (Sort) Seiton (Straighten) Seiso (Shine)
Seiketsu (Standardize)
Shitsuke (Sustain)
5S Explained…

21. Lean Tools Kanban (Japanese for signboard)
Helps to reduce a queue or backlog
Uses visual workflow representations
Supports a culture of continuous improvement; the data shown tracks flow, throughput and more

22. Culture Traditional Lean Function in silos Managers direct
Benchmark to justify not improving: "just as good“
Blame people
Supplier is enemy
Guard information
Volume lowers cost
Internal focus
Expert driven
Big projects; long term
Interdisciplinary teams
Managers teach/enable
Seek the ultimate performance: complete absence of waste
Root cause analysis of the process
Supplier is ally
Share information
Removing waste lowers cost
Customer focus
Process driven
Small projects; short term
Lean is not only an improvement methodology; fully exploited, it is a cultural shift that produces the greatest results.

23. Lean: Projects Faster Fewer steps Less expensively Less waste
Less wait
Increase quality
Increased value-added time, decrease non-value added time
These are the kinds of projects that lend themselves to a Lean methodology. If you are not seeing some of these words in your problem and goal statements, then your project may not be of the Lean variety.

24. How Do We Apply This in Our Work
Less expensively
Reduce the administrative overhead
Efficiencies in a process usually lead to cost reductions
Less waste
Too many level of administration (unnecessary redundancy)
Over ordering expendables
Less wait
Patient wait times to see prescribing practitioner
Subrecipients wait too long to receive contracts and put needed services in place

25. How Do We Apply This in Our Work
Increase quality
Is our patient literature written for the appropriate reading level of the patient
Do we base our funded services on current data
Increased value-added time, decrease non-value added time
Expanding clinic hours to accommodate patients that work at night
Decrease the number of meetings that focus on material irrelevant to your clients

26. How Do We Apply This in Our Work
Faster
Can you improve the rapidity of the patient visit to your clinic while maintaining the highest quality of care
Does your contracting process put necessarily services in place soon after you receive your NGA
Fewer steps
How many individuals does a potential client have to see at intake
How easy is it to get labs done

27. Success Factors in Lean Projects
Map the process from end-to-end, and from the perspective of the customer
Scope the improvements so they can be completed within one week
Measure … before, during, after, and later
Focus on the work, not on the workers
Bring in suppliers and objective observers to help “see” the process

28. Focus on the Customer: Critical to Quality Characteristics
CTQs (Critical to Quality) are the key measurable characteristics of a product or process whose performance standards or specification limits must be met in order to satisfy the customer. They align improvement or design efforts with customer requirements.
CTQ
NEED
DRIVERS
capacity for routine labs
timeliness
smaller batch size for transport
increase doctor satisfaction with lab service
One of the best ways to evaluate a process is to first understand what the customer is looking for at the end of the process.
computer order entry
convenience
remote access to results
standardized workforce training
accuracy
regular TPM on equipment

29. Waste: Muda Transportation Inventory Motion Waste Overproduction
Over processing
Defects or Delay
Skills/people
Delay: waiting for bed assignments, waiting for discharge, waiting for treatment, waiting for tests, waiting for supplies, waiting for approval/signatures, waiting for a caregiver
Defects anything that does no meet the customers specifications (i.e. an admission form with incorrect billing information, an x-ray that cannot be read correctly; a prescription that cannot be filled as written
Overproduction: creating more forms than you will need (they may become outdated or obsolete while being stored)
Waste: any
Non-utilized Talent: lack of thorough analysis of employee skill sets can lead to delays in promotions and/or not using an employee beyond their stated job description
Transportation: moving a patient from place to place when the product or process can be offered in closer proximity
Inventory: extra supplies (often times hoarded to prevent stock outs), extra laundry, extra equipment
Motion: walking around your desk to find get something that you need often
Ever processing: excessive paperwork, redundancy of forms

30. Success Factors Implementing Lean Organizationally
Enable the people who work in the process to improve the process
Engaging more people in continuous daily work improvement is often more valuable than a few people doing big projects
Leaders modeling the method will be a catalyst to culture change
Lean is not an fad, add-on work, or a panacea for all improvement opportunities; it is a mindset

31. If You’d Like to Learn More
Free Resources:
Books:
A Lean Guide To Transforming Healthcare
Lean Hospitals
Lean Six Sigma in Healthcare
The Machine That Changed the World