1. The Journey to Continuous Improvement Going with the flow Synchronous Flow

2. Harvard Business Review “Medical treatment has made astonishing advances over the years. But the packaging and delivery of the treatment are often inefficient, ineffective and customer unfriendly.” HBR, 2007 “Systems designed for manufacturing are fully applicable to health care.” HBR, 2005 -2

3. Today’s Objectives What is Synchronous Flow? How does it work with Lean Healthcare Kaizen Blitz Events Synchronous Flow Timeline -3

4. Our mission is to excel at providing personalized, quality care; where people come first. Our vision is to be the provider of choice by creating a professional environment where: –patients want to receive care –clinicians want to practice medicine –employees want to work -4

5. We will accomplish this by: empowering our caregivers with education, technology, and personal and professional development, creating an environment which builds collaborative relationships among physicians, staff and patients, providing our communities with the educational resources and support to enable individuals to make informed decisions and play an active role in managing their own health, offering safe, personalized, high quality care. -5

6. A Synchronized System: What does it take? -6

7. Synchronous Management A management approach that views resources in a system as elements of an interdependent network all of which can be synchronized to a strategically selected control point in such a way as to optimize the performance of the entire system. Rooted in the concepts of Constraints Management. -7

8. The Synchronous approach A “Control Point” is selected, optimized and finitely scheduled at the desired Throughput amount All other functions strive to serve the Control Point Predetermined inventory “ Buffers” are strategically placed to protect the Control Point Buffers are proactively managed daily New Patient release is metered to control WIP and lead times. -8

9. Drum, Buffer, Rope Gate CP Exit Input Medical Service Demand Constraint Buffer Time Rope Process Flow RM Buffer Time Output Processes from the Gate to the Exit are divided into zones and managed continuously -9

10. Synchronous Flow Elements Relentless efforts to reduce all waste that is of no value to the patient experience –More time dedicated to patient care –From about 40% to at least 70% Work release – Input / Output model Standard work practices Productive capacity and Protective capacity Buffer Management logbook for each process Buffer Analysis systems for each process Focus Meeting script. -10

11. Process Failures Errors – incorrect execution of a task when everything needed is available Problems – Disruption of a worker’s ability to execute a prescribed task as planned –Clear, complete and timely information unavailable –Some tool or resource needed is unavailable –Something is present that is not necessary Synchronous Flow procedures differentiate and track each.

12. Problem Solving Level One Problem Solving –Worker compensates for the failure –The underlying cause is not addressed –Worker does not want to “make waves” –Can actually be counterproductive Level Two Problem Solving –Worker addresses the immediate issue –Actions taken to identify and address the core causes –Willingness to “make waves” is encouraged by management –Organizational improvement occurs

13. - 13 Improvement Requires Change Your existing system is designed to give you the results you’re currently getting. If you want different results, you must change the system! Your existing system is designed to give you the results you’re currently getting. If you want different results, you must change the system!

14. -14 Implementing Change “Improvement occurs only with change.”

15. -15 The Opportunity for Change Change Knowledge What is it? Head Desire Why should I? Heart Skill How do I? Hands

16. -16 The Synchronous Flow Focusing Steps Three necessary conditions Define the system State the purpose Decide how to measure it Five Focusing Steps 1. Identify the system’s Control Point (s) (Constraints) 2. Decide how to exploit the system’s Constraints (s) 3. Subordinate everything else to the above decisions 4. Elevate the system’s constraint 5. When a constraint is broken, return to step one. Do not allow inertia to become the system’s constraint.

17. A Constraint is... Anything that limits an organization’s higher performance relative to its goals Can be internal or external Can be a process, a policy or a paradigm. The Control Point is… The location within the scope of the system on which we choose to focus The point upon which operational measures are based. -17

18. A Bottleneck is... A temporary limitation caused by Murphy The effect is an intolerable situation Something that we want to defeat Something we respond to with urgency –Prioritized according to the relative threat to the Control Point. -18

19. Productive Capacity The capacity required to meet the overall demand Largely determined by the constraint of the system This is the Drum of the process. -19

20. Protective Capacity Additional capacity required on all resources to overcome... –Murphy (statistical fluctuations) –Resource contention Establishes an unbalanced system Generally available with existing resources. -20

21. A Closer Look The are anything that limits performance They’re not necessarily bad things Every system has at least one They determine your system’s capacity They are your system’s most valuable resources Choosing to manage them is better than chasing Murphy Focusing attention on them simplifies life. -21 Constraints

22. Buffer Management Purpose: to identify and record buffer problems and assign responsibility to fix them Meetings are held at least once per day at a designated time and place for a maximum of 15 minutes Everyone is on time and prepared Actions items and person responsible for each is communicated The essence of proactive management. -22

23. Remember! Common practices lead to balanced capacity Balanced capacity systems are unstable and under-productive Unbalanced capacity systems are stable, with increased velocity and predictability Constraints hold the key to focusing improvement activities. -23

24. What is Lean? Delivering more Value with Less Investment The Toyota Production System (Deming and Ohno) Founded upon: –Customer focus –Respect for humanity –Prudent, systematic elimination of waste Expected outcomes: –Improved customer satisfaction –Improved employee satisfaction –Improved organizational performance -24

25. Lean Management Defined a systematic approach to identifying and eliminating waste through continuous improvement, by flowing the product at the pull of the customer, in pursuit of perfection. -25

26. Synchronizing the Lean Tools Kaizen Blitz Events - Continuous, incremental improvement of any activity to create more value with less waste A focused, team approach toward breaking the status quo by making immediate changes Applied continuously to exploit the selected control point. Prioritized to establish the necessary protective capacity. -26

27. Synchronizing the Lean Tools Value Stream Mapping - plotting all the activities necessary for a product family Identifies non-value-added activities Helps to identify the constraints and Control Point Developed to “define the system and its purpose” Used during “identify,” “exploit,” and “subordinate” to minimize waste and to prioritize Kaizen events. -27

28. Synchronizing the Lean Tools 5 S’s - A safe, clean, neat, arrangement of the workplace. Sort - eliminate the unnecessary Straighten - a place for everything and everything in its place Shine- Clean the workplace Standardize - Rules to maintain Systematize - Self discipline to sustain Prioritized during the “exploit” and “subordinate” steps to organize the workplace. -28

29. Synchronizing the Lean Tools Pull mentality - A system of operational behaviors from downstream to upstream activities Schedule for the Control Point is determined from market demand Release of Raw Materials is determined by consumption at the Control Point All other activities are Synchronized to Control Point via Drum, Buffer, Rope. -29

30. Characteristics of a Lean Enterprise High value-added - little waste Simplicity and visibility Process standardization Demand based flow Culture –Empowered teams –Open communication –Enforced accountability Continuous improvement mentality -30

31. -31 Lean Principles 1. Specify VALUE 2. Identify the VALUE STREAM 3. Make value-creating steps FLOW 4. Let patient flow PULL value 5. Pursue PERFECTION Lean Thinking, Womack & Jones

32. Lean Strategies and Tactics System mapping Organize for flow Total employee involvement Pull systems Quality systems Institutionalized improvement Standardized work Five S's Visual workplace Set up / changeover reduction Total productive maintenance Design out waste Measure the right things -32

33. Value Added vs. Non-Value Added Value added: An activity that directly serves the needs of the patient. Non-value added: any other activity Value Stream The specific series of activities required to provide a defined service for the customer -33

34. The Seven Types Of Wastes 1. Excess material movement 2. Unnecessary process 3. Unnecessary motion 4. Defects 5. Inventory 6. Delays 7. Over production -34

35. -35 Elements of Work Work content Work Waste At least 30% of skilled nursing time is spent doing non-clinical activities.

36. System Mapping Flowchart of value stream activity Understand the macro system Identify material stream flow, obstacles to flow, control systems, inventory locations Group knowledge, creativity -36

37. Functional Spaghetti Diagram -37 1 1 1 1 22 3 3 3 3 44 4 5 55

38. Kaizen Blitz Trained teams of people empowered to make immediate and tangible changes for improvement. The PCSAM model Problem / opportunity identified Core causes confirmed and documented Solution and plan of action developed Aggressive action applied to the solution in 3 to 5 days Measurements tracked to assure success No going from problem to solution in this approach. -38

39. The Kaizen Cycle -39 Problem Identification Core cause of the issue Solution and plan Action Measure results

40. Where to Begin Identify the system – value stream mapping Choose measures, set objectives Decide how to exploit the system –Flow layout, constraint positioning, inventory strategy, cells Pull system - synchronized flow Kaizen - waste elimination –Set-up reduction –Standardization –Workplace improvement/visual control -40

41. Conditions for Success Senior management understanding Visual and vocal leadership Clear and elevating goals Complimentary measurement system Guiding Coalition – Steering Committee Education and training Make clear - “What’s in it for me” -41

42. Implementation Timeline Educational session for key staff Selection and training of the Steering Committee Identification of Kaizen opportunities Selection and training of Kaizen Teams Development of the Synchronous Flow Model –Constraint and Control Point identification –Buffer Management –Productive / Protective Capacity Focus meeting process. -42

43. Process Improvement Communicate the basis of needed change to everyone in small group settings Select a Steering Committee to manage the process Select a key group of leaders to participate in the design and implementation of a new system for each identified target PCSAM development Kaizen Blitz to aggressively address each opportunity Synchronize all activities to support a single selected control point Make it visible for effective communication Practice Buffer Management for effective accountability Emphasize that continuous improvement means there is no finish line. -43

44. And remember… When you’re through changing, you’re through. Thank You ! -44

45. - 45 Did you know that 75% of all change initiatives fail? Change

46. The 8 Reasons for Failure Complacency Weak Leadership Lack of vision Lack of communication Stopping at obstacles Invisible progress Declaring victory too soon Neglecting to establish change in culture -46