The Start of Your Lean Healthcare Journey

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The Start of Your Lean Healthcare Journey
2
Learning Objectives

• At the end of this module, you will be able to
• Recognize imperatives driving lean healthcare
• Express what is lean healthcare
• Explain the 6S tool
• Identify the fundamental principles of lean
  thinking
• Cite some examples and benefits of lean
  healthcare implementation
• Express that lean is a journey not a state

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Imperatives United States
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Six Aims for Improvement

• Health care should be
• Safe
• Effective
• Patient -centered
• Timely
• Efficient
• Equitable
• These aims are not new. Yet American health
  care fails far too often with respect to these
  aims, despite enormous cost and dedication and
  good efforts of millions of American healthcare
  workers

5
US Healthcare - A Value Crisis

• Lean Six Sigma can increase healthcare value
  delivery by
• Improving healthcare quality
• Decreasing healthcare costs
• It is one piece of a puzzle to solve the US
  healthcare crisis

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Lean Healthcare Enterprises
To achieve its full potential, lean needs to be
implemented at the enterprise level

• A lean enterprise is an integrated entity that
  efficiently creates value for its multiple
  stakeholders by employing lean principles and
  practices.
• Murman et al., Lean Enterprise Value, Palgrave,
  2002

Value Expected from the Enterprise
Value Contributed to the Enterprise
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Healthcare Enterprise

• The enterprise boundaries need to be identified
  Definition is contextual

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Healthcare is a Complex System of Enterprises
Within Enterprises
Regulator
Supplier
Payer
Patient
Insurer
Provider
Interest Groups
Hospital
Labs
Pharmacy
Labs
Pharmacy
Operating Rooms
Inpatient Units
Primary Care
EmergencyDepartment
Radiology
Source Jorge Fradinho Oliveira, MIT
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The Path To Lean Healthcare
1911 Taylor, Principles of Scientific
Management
1950 L. Gilbreth Management Engineering and
Nursing
1916 F. Gilbreth, Motion Study in Surgery
1999
2001
Healthcare
Manufacturing
1939 Shewert, Statistical Method from the
Viewpoint of Quality Control
1990 Womack, Jones Roos, The Machine That
Changed The World
1977 Sugimori, et al, Toyota Production System
Kanban Systems Materialization of Just-In-Time
Respect-for-Human System
1996 Womack Jones, Lean Thinking
1950 Eiji Toyoda visits Fords River Rouge
Complex
1982 Deming, Out of Crisis
1951 Juran, Quality Control Handbook
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Essence of Lean Thinking

• Work to understand what your customers value
• Remove waste to reduce lead time and improve
  first time quality
• Make problems visible
• Break down functional silos
• Eliminate root causes of problems
• Standardize work processes
• Create a culture of Continuous Improvement
• Own the process
• Make data driven decisions
• Use easily understandable metrics
• Track reults

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What Would You See in a Lean Healthcare Work
Environment?

• Work is performed in a standard way, designed and
  improved by those performing the job
• Medication delivery Order to administered
• All staff alert others to problems before an
  error occurs
• Incorrect medication arrives for patient
• Problems or errors are fixed immediately
• Correct medication attained and administered
• Team formed to find and fix the root cause of the
  problem so it never happens again
• Standard way is revised continuous improvement
• Employees are productive and happy

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What Lean Does Not Do

• Eliminate jobs it eliminates unproductive
  activities and redeploys people on productive
  ones
• Force people to work harder it creates
  sustainable standard work that is safe and less
  fatiguing
• Just speed up the pace of work it eliminates
  waste and paces output to meet demand
• Just apply to manufacturing processes it
  applies to all process involving patients,
  materials, services
• Focus on disconnected improvement activities it
  is a systems way of thinking about every process,
  every person, and every patient

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Lean Six Sigma
Six Sigma was developed by Motorola in the 1980s
to systematically improve quality by elimination
of defects.
Six Sigma Lean
Objective Deliver value to customer Deliver value to customer
Theory Reduce variation Remove waste
Focus Problem focused Flow focused
Assumptions A problem exists Figures and numbers are valued System output improves if variation in all processes inputs is reduced Waste removal will improve business performance Many small improvements are better than system analysis
Lean Thinking applies Six Sigma methods once
waste has been identified or eliminated and value
added activities need improvement.
Adapted from Nave, Dave. How to Compare Six
Sigma, Lean, and the Theory of Constraints.
Quality Progress. March 2002
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Lean and TQM are Related
Traditional QI Programs focus on only improving
Value Added processes
Lean focuses on reducing or eliminating the
Non-Value Added processes
Lean combines the Problem Solving Models, Root
Cause Analysis Flow Charting from TQM with many
new systems, tools and analysis methods such as
Value Stream Mapping, 6S, Takt Time, 8 Wastes,
Kanban, Visual Control, Mistake Proofing, and
more.
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5S - A simple lean tool
6S

• Sort
• Safe
• Straighten
• Scrub
• Standardize
• Sustain

After
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6S Exercise - 1

• We will apply 6S to a workplace and measure the
  improvement in executing our job
• During each 20 second round, your job is to
  gather needed supplies
• The first page of your exercise represents our
  current workplace (dont turn the page over yet)
• The next slide is what you have to fetch
• Mark an X on each item you locate

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Round I Needs

• 5 syringes
• 5 bandaids
• 5 scissors
• 5 medication II
• Ready.Set..

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6S Exercise - 2

• The first S is Sort
• We have removed from the storage area unneeded
  items

• Sort
• Safe
• Straighten
• Scrub
• Standardize
• Sustain

Source Jefferson Healthcare, Port Townsend, WA
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Round 2 Needs

• 5 syringes
• 5 bandaids
• 5 scissors
• 5 medication III
• Ready Set

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6S Exercise - 3

• The second S is Safe
• Making the workplace safe for employees and
  patients

• Sort
• Safe
• Straighten
• Scrub
• Standardize
• Sustain

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Round 3 Needs

• 5 syringes
• 5 bandages
• 5 scissors
• 5 medication II
• Ready Set

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Mistake Proofing

• Mistake-proofing is the use of process or design
  features to prevent errors or the negative impact
  of errors
• Healthcare examples
• Wristbands
• Self blunting syringes
• Software data entry checks
• Alarm when Pt exits bed
• Daily Rx pill box
• Color, shape, size of pills
• Color coded gas connectors
• Anti scald devices
• Automatic wheel chair brake

Vacuum
Oxygen
Photos by Earll Murman
Square set pin
Round set pin
Ref Mistake-Proofing the Design of Health Care
Processes, Agency for Healthcare Research and
Quality, U.S. Department of Health and Human
Services. http//www.ahrq.gov/qual/mistakeproof/
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6S Exercise - 4

• The third S is Straighten or Set in Order or
  Store

• Sort
• Safe
• Straighten
• Scrub
• Standardize
• Sustain

• We have installed a rack system to help locate
  similar items

Source Mercy Hospital, Cedar Rapids, IA
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Round 4 Needs

• 5 syringes
• 5 rolls tape
• 5 tweezers
• 5 medication I
• 5 medication III
• Ready Set

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6S Exercise - 5

• The fourth S is Scrub or Shine or Sweep
• Cleanliness is important in healthcare workplaces

• Sort
• Safe
• Straighten
• Scrub
• Standardize
• Sustain

• Its tough to scrub a piece of paper, so well
  skip it this S

Source University of Michigan Health System, Ann
Arbor, MI
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6S Exercise - 6

• The fifth S is Standardize
• We have developed a standard way of storing
  things to make them easy to find.

• Sort
• Safe
• Straighten
• Scrub
• Standardize
• Sustain

Source Jefferson Healthcare, Port Townsend, WA
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Round 6 Needs

• 5 syringes
• 5 band aids
• 5 tweezers
• 5 rolls of tape
• 5 medication III
• 5 medication II
• Ready Set

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6S Exercise - 7

• The sixth S is Sustain
• This is your challenge Sustain your lean
  activities
• Often the hardest to achieve

• Sort
• Safe
• Straighten
• Scrub
• Standardize
• Sustain

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6S Standard Sheet
Sustain

• Example of part of a daily ED outside hallway
  checklist
• Initials at bottom

Source University of Michigan Health System, Ann
Arbor, MI
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Lean Thinking Fundamentals

• Specify value from the standpoint of the end
  customer (the patient)
• Identify the value stream all value-added steps
  across departmental boundaries (the value
  stream), eliminating steps that do not create
  value
• Make value flow continuously eliminate causes
  of delay, such as batches and quality problems
• Let customers pull value avoid pushing work
  onto the next process or department let work and
  supplies be pulled as needed
• Pursue perfection through continuous process
  improvement

Ref Mark Graban, Lean Hospitals (CRC Press,
2009).
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Specify Value

• or activity reduces risk and/or uncertainty in
  the product or process
• or iterations or experiments are planned and
  controlled

• Customer is willing to pay for activity
• Activity is transformative, moving the product
  closer to what the customer wants
• Activity is done right the first time

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Identify the Value Stream

• All the actions required to transform a good or
  service from an initial state to a outcome
  desired by the customer
• Actions include problem solving, physical
  transformation, information management
• Something flows in a value stream, e.g. in
  healthcare
• Patient value streams
• Meds and materials value streams
• Information (records) value streams

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Patient Value Stream
For a given medical condition, the patient value
stream has many actions and is fragmented among
numerous care givers
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Make Value Flow

• Creating flow
• Focus on what is flowing through the process
• Eliminate bottlenecks, minimize buffers

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4 - Let Customers Pull Value

• In a Push system, each activity delivers its
  output when it is done
• Results in build up of batches with lots of
  inventory defective goods pile up
• In a Pull system every activity delivers its
  output just as the next activity needs its input
• Triggered by the end customer
• Results in smooth flow with no batches or voids
• Minimizes inventory and rework due to defects
• Pull systems can be implemented in material flow
  using a Kanban approach
• Implementation for people flow is more challenging

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5 - Pursue Perfection
Improvement ?
Time ?

• Lean is not a set of tools. It is a continuous
  improvement mindset using multiple PDSA cycles.

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PDSA and PDCASDSA and SDCA

• Deming is credited with the improvement cycle,
  but he cites Shewhart as the originator
• Plan-Do-Check-Act (PDCA) is commonly used
  identical to PDSA
• Standardize-Do-Study-Act (SDSA) or its equivalent
  SDCA is a little different
• Standardizing work allows one to implement
  continuous improvement (next module)
• Imai advocated standardization before continuous
  improvement, i.e. SDCA before PDCA
• Nelson, Batalden Godfrey advocate PDSA before
  SDSA

Both standardization and continuous improvement
are central to Lean Thinking
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• Two major pillars of lean thinking
• Continuous Improvement
• Respect for People

Workers are encouraged to use their full
capability to improve their own work environment
RefY. Sugimori, K. Kisunoki, F. Cho, S.
Uchikawa,Toyota Production System and Kanban
Systems - Materialization of Just-In-Time and
Respect-For-Human Systems, International Journal
of Production Research, Vol. 15, No. 6 (1977),
pp. 553-64
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People are the Heart of Lean
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Some Examples of Lean Healthcare Improvements

• Allegheny Hospital, PA
• 95 reduction in patient deaths related to
  central-line-associated blood stream infections
• Virginia Mason Medical Center, WA (2006 examples)
• 100 reduction in incomplete med or solution
  identification
• 35 reduction in lead time for ambulatory care
  visits
• ThedaCare, WI
• Waiting time for orthopedic surgery reduced from
  14 weeks to 31 hours (from first call to surgery)
• 72 reduction in nurses wasted time per shift
• Park Nicollet Health Services, MN
• 16,290 hours wait time per day eliminated for
  patients staff
• 229 additional patients seen each day
• 265 miles cut per day from staff walking

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Lean Is A Journey Not An End State

• Manufacturing and service examples
• Toyota 1950s now
• Nucor Steel 1972 now
• Southwest Airlines 1985 now
• Rockwell Collins 1995 now
• Healthcare examples
• Pittsburg Regional Healthcare Initiative 1997
  now
• Virginia Mason Medical Center 2001 now
• ThedaCare 2002 now
• Park Nicollet Health Services 2003 now

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Wrapping Up

• Lean Thinking is not about influencing the
  content of those moments when patients and staff
  are in contact. It is about giving more time for
  those moments, making them easier to perform and
  less prone to error, by simplifying sequences,
  making what has to be done more transparent,
  removing re-duplicative and unnecessary steps,
  and making hard to perform steps easier to get
  right.

David I Ben-Tovim, et al, Lean thinking across a
hospital redesigning care at the Flinders
Medical Center, Australian Health Rev, Feb 2007,
Vol 31, No 1, pp10-15
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Take Aways

• Many imperatives are driving the US healthcare
  improvement movement
• Lean six sigma can contribute to healthcare
  improvement
• 6S is a simple and effective lean tool
• Fundamental principles of lean thinking are
  value, value streams, flow, pull, perfection
• Respect for People is the other pillar of lean
• Lean is a way of thinking, not a set of tools
• Lean is a journey not a state

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• WELCOME
• to
• The Start of
• Your Lean Journey!

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What is the most important thing you learned from
this module?Write a short answer on a 3 x 5 card
46
Reading List - 1

• Anon, Crossing the Quality Chasm A New Health
  System for the 21st Century, Committee on Quality
  of Health Care in America, Institute of Medicine,
  2001
• Bahri, S. Follow the Learner The Role of a
  Leader in Creating a Lean Culture, Lean
  Enterprise Institute, 2009
• Black, John R., The Toyota Way to Healthcare
  Excellence Increase Efficiency and Improve
  Quality with Lean, ACHE Management Series Book,
  2008
• Deming, W.E., Out of Crisis, MIT Center for
  Advanced Education Services, Cambridge, MA 1982.
  MIT Press, Cambridge, MA 2000
• Graban, Mark, Lean Hospitals Improving Quality,
  Patient Safety, and Employee Satisfaction,
  Productivity Press, 2009
• Imai, Masaaki, Kaizen The Key to Japans
  Competitive Success, McGraw-Hill, 1986
• Kohn, Linda T., Corrigan, James M. and Donaldson
  Molla S., Editors, To Err is Human Building a
  Safer Healthcare System, Committee on Quality of
  Health Care in America, Institute of Medicine,
  2000
• Liker, J. The Toyota Way, McGraw Hill, New York,
  2004
• Nelson, E.C., Batalden, P.B., and Godfrey, M.M.,
  Quality By Design A Clinical Microsystems
  Approach, Jossey-Bath, San Francisco, 2007

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Reading List

• Reid, T., The Healing of America A Global Quest
  for Better, Cheaper, and Fairer Health Care,
  Penguin Press, 2009
• Sahney, V.K., Evolution of Hospital Industrial
  Engineering From Scientific Management to Total
  Quality Management, J of Soc for Health Sys, Vol
  4, No 1, 1993
• Spear, Steven J., Fixing Healthcare from the
  Inside, Today, Harvard Business Review, Sept
  2005
• Toussaint, J. and Gerard, R., On The Mend
  Revolutionizing Healthcare to Save Lives and
  Transform the Industry, Lean Enterprise
  Institute, 2010
• Womack, J, Jones, D. and Roos, D., The Machine
  That Changed the World, Rawson Associates, New
  York, 1990
• Womack, J. and Jones, D., Lean Thinking, Simon
  Shuster, New York, 1996

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Acknowledgements

• Earll Murman MIT
• Steve Shade Purdue
• Whitney Walters University of Michigan Health
  System
• Deanna Willis Indiana University School of
  Medicine