1. Healthcare Operations Management
Daniel B. McLaughlin
Julie M. Hays

2. 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.

3. 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.

4. Types of Waste (Muda) Overproduction Waiting Transportation Inventory
Motion
Overprocessing
Defects
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5. 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.

6. 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
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7. Value Stream Mapping
Diagram created with eVSM software from GumshoeKI, Inc., a Microsoft Visio add-on.
Copyright 2008 Health Administration Press. All rights reserved.

8. 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.

9. 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.

10. Throughput Time
Time for an item to complete the entire process, which includes:
Waiting time
Transport time
Actual processing time
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11. 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.

12. 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 = = 70 minutes.
Copyright 2008 Health Administration Press. All rights reserved.

13. 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.

14. 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.

15. Spaghetti Diagram
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16. 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.

17. 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 "Going Lean in Healthcare." Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Online information available at:
Copyright 2008 Health Administration Press. All rights reserved.

18. 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
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19. 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.

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

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

22. 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.

23. 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
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24. 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.

25. 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.

26. 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.

27. 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.