Lean Methods for Lean Times Premier Annual Breakthrough Conference Orlando, FL June 21, 2006

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Lean Methods for Lean TimesPremier Annual
Breakthrough Conference Orlando, FL June 21, 2006
Jonathan Flanders, MHSA, BSMT, MT
(ASCP) Lean/Patient Safety Officer
June 12, 2002
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Session Objectives

• Define how the Lean Production Model can be used
  operationally, clinically, financially and in
  supply chain to improve clinical outcomes and
  patient satisfaction.
• Explain strategy of using Rapid Improvement
  Events (RIEs) to drive change operationally and
  culturally.

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What Does Lean Healthcare Look Like?
Adapted by J. Flanders from J. Liker, 2006
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Based on the 5 Principles of Lean Thinking

• Value What is the customer really buying?
• Value Stream How value is created delivered?
• Flow Improve the value stream
• Pull Triggering every flow from actual demand
• Perfection Continuous improvement forever

source LEAN THINKING, Womack and Jones, 1996.
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Memorial Health Lean Transformation Roadmap
Decide
Prepare
Start
Accelerate
Expand
Decide
Prepare
Start
Accelerate
Expand
1 month
6 months
8 to 12 months
2 to 4 years
5 years
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Memorial Health Lean Transformation Roadmap
Expand
Decide
Prepare
Start
Accelerate

• Actions for Senior Leadership
• Find a change agent
• Get lean knowledge
• Find a lever
• Decide on a path to follow
• Commit time and resources to Lean

• Deliverables
• Visits to other organizations and attendance at
  conferences
• Understanding that costs and wastes continue to
  increase while reimbursement decreases
• Intent presented to leaders
• Partnership with a consultant

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Memorial Health Lean Transformation Roadmap
Expand
Decide
Prepare
Start
Accelerate

• Actions for Senior Leadership
• Select Sensei
• Begin Lean training
• Create support infrastructure
• Prepare redeployment policy
• Conduct enterprise wide value stream
• Develop first year plan that sets an aggressive
  pace of change
• Share the vision for Lean transformation

• Deliverables
• Engaged consulting support from Simpler
• Leaders participated in awareness workshops
• Lean Oversight created and core team established
• Identified and prioritized value streams and
  metrics
• Implementation plan
• Communication Plan

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Memorial Health Lean Transformation Roadmap
Expand
Decide
Prepare
Start
Accelerate

• Deliverables
• Ideal, future, current state maps
• Baseline of current performance
• Lean dashboard
• Improvement plan
• Alignment Review
• Financial, cell and facility assessment audits
• HR, budget, and policy decisions to support
  improvement
• Model cell and value stream

• Actions for Senior Leadership
• Map value streams
• Support pilot project teams (RIEs, projects and
  Just Do Its)
• Establish assessment and measurements
• Initiate infrastructure for project, resources,
  training, reward and recognition, scoreboards and
  communications
• Remove or re-assign antibodies

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Memorial Health Lean Transformation Roadmap
Expand
Decide
Prepare
Start
Accelerate

• Actions for Senior Leadership
• Reorganize by product family
• Greatly increase activity
• Initiate strategy deployment
• Integrate into other business processes
• Expand knowledge and teaching of lean principles
  to leaders
• Take corrective actions to remove problems in
  quality, cost and morale

• Deliverables
• Process village and monuments removed
• Strategic deployment plan
• 3P, project management, pull systems, visual
  management

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Memorial Health Lean Transformation Roadmap
Expand
Decide
Prepare
Start
Accelerate

• Actions for Senior Leadership
• Leverage knowledge and savings
• Expand lean enterprise to payors, suppliers,
  community partners
• Manage cultural transformation
• Instill perfection mindset

• Deliverables
• Expanded market share
• Growth strategies funded by savings
• Reduced cost burden to community
• Shared risk models
• Transition to a balanced top-down, bottom-up
  improvement

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Memorial Health Lean Transformation Roadmap
Expand
Decide
Prepare
Start
Accelerate

• Value Streams
• Emergency Department
• Surgical Services - SSI Bundle
• Pain Management Clinic (Six Sigma Lean)

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the "magic" of Rapid Improvement Events is simple

• highly focused teams
• right people involved
• accountability "by Friday"
• close observation (see waste)
• application of proven principles
• experienced coaching

measurements -gt targets action -gt deliverables
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Emergency Department Value Stream Results
KeyMeasures
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Emergency Department Value Stream Goals

• Decrease ED average LOS for discharged home
  patients by 40 from 152 min. to 91 min. by
  12/31/2006
• Decrease ED average LOS for admitted patients by
  40 from 440 min. to 264 min. by 12/31/2006
• Reduce use of overtime by 50 from 7.74 to 3.87
  by 12/31/2006
• Reduce patient identification errors by 50 from
  1.29 to 0.64 by 12/31/2006
• Reduce medication errors by 50 from 0.74 to 0.37
  by 12/31/2006

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Emergency Department Events

• Value Stream Analysis July, 2005
• RIE for Triage/Registration Process August 2005
• RIE for Radiology Process September 2005
• RIE for Acute Care Flow October 2005
• RIE for Laboratory Process November 2005
• 6-S Event for Trauma and Cardiac Rooms January
  2006
• RIE for Medication Process February 2006
• Flow Cell Assessment for all Processes March
  2006

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ED Triage/Registration

• Focus Combine triage and registration to reduce
  wait times, improve safety, create standard work
  and improve patient flow

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ED Imaging Process

• Focus Standard work for physicians, visual
  management of imaging results, and improve
  transport process.

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Laboratory/Medication Processes

• Focus Standard work for ordering, specimen
  collection, administration and visual cues for
  results.

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6-S Events

• Focus Sort, Straighten, Scrub, Standardize,
  Sustain, and Safety for all Trauma and Cardiac
  Rooms

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Emergency Department Value Stream Metrics
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Surgical Services Value Stream Results
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Surgical Services Value Stream Goals

• Reduce SSI rate by 80 implementing the SSI
  bundle by 12/31/06
• Increase on-time starts of all surgical cases by
  50 from 11 to 17 by 12/31/06

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Surgical Services Events

• Value Stream Analysis July 2005
• RIE for Surgical Site Infection Bundle August
  2005
• RIE for Day Surgery September 2005
• RIE for Posting/Scheduling October 2005
• RIE for Pre-Surgical Testing November 2005
• RIE for Operating Room Turnover January 2006
• Flow Cell Assessment for all processes February
  2006
• 6-S Event for Pre/Post Anesthesia Care Unit
  April 2006

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Surgical Services Events

• August Accomplishments for SSI Bundle
  Implementation (IHI)
• Implemented SSI bundle
• September Accomplishments for Same Day Surgery
• Standard work implemented for RN, Tech and Unit
  Secretary
• Improved direct patient time and patient
  experience
• Implemented in-room registration for most
  patients
• Improved accessibility to Pyxis supplies
• Implemented fanny pack for mobile supplies

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Surgical Services Events (Cont.)

• October Accomplishments for Posting
• Creation of standard work for Posting staff
• Developed or revised forms used for surgical
  posting
• Developed standardized script for Posting staff
• Piloting new process for Savannah Surgical Group
  and Savannah Colon Rectal Surgery
• November Accomplishments for PST
• Creation of standard work for Interview RN,
  Resulting RN, Resource RN, Chart Coordinator
  PCTs
• Magnificent revision/consolidation of Informed
  consent procedure and all signature requirements
  down to 1 (10 yrs of work in 1 week)
• Patient Centered Focused process.
• Redesigned anesthesia process to decrease calls
  rework
• Improved supply an equipment management

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Surgical Services Events (Cont.)

• January Accomplishment for OR Turnover Process
• Developed SOPs in compliance with JCAHO and Red
  Rules (Found areas of non-compliance and
  rectified)
• ID high priority supply and instrument need (ie
  specimen containers, larger trash bags, and O2
  tanks and holders facilities will attach O2
  holders to all new beds by 2-28-06)
• Developed checklists and forms (Room cleaning,
  supply equipment needs for TF cases, and PCT
  transport form
• Developed Production Control Board
• Revised workflow for ORST into PODS
• Identified communication needs between workgroups
  (Recommended implementation of Vocera for ORST
  and PST)
• Identified additional visual and work flow needs
  (Navicare Screens and additional Printer)
• Trained coordinators on new process and obtained
  their buy in for implementation

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6-S Event in PACU

• Focus Sort, Straighten, Scrub, Standardize,
  Sustain and Safety central desk and medication
  room.

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Surgical Services Value Stream Metrics
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Define Charter Pain Management Clinic
Project Definition
Project Deliverables/Benefits
Problem Statement The Pain Management Clinic
(PMC) is currently experiencing median LOS of 110
min. (95 CL from 93 to 130 min.) and patient
satisfaction scores of 74, which results in loss
capacity and potential revenue for Memorial
Health. Inefficient scheduling and high LOS
result in 745 per month use of OT. Project
Scope The project will include all patients seen
in the PMC. The boundaries of the project
include Physician order to discharge. Project
Aim To reduce median LOS times by 25 from 110
min. to 83 min. by 4/30/06. To improve overall
patient satisfaction score from 80 to 90 by the
end of 2nd quarter 2006.
Key Deliverables Increased case load
capacity Single-piece flow for patient
experience Increased customer satisfaction Busine
ss Case Total hours worked/day from 9.2 to 6.9
results in capacity for 3 cases per day, 15 per
week or 750 per year. Average operating income
for PMC of the past 5 years is 411 per case. If
targets are reached and cases are scheduled to
match capacity, then PMC could realize potential
increase in operating income of 308,250.
Elimination of overtime will result in savings of
8940.
Roles Responsibilities
Process Area Lynn Melton, RN, Elizabeth
Richardson, Yolanda Andrews, Suzanne Thompson,
Willette Cook, Stephen Rogers, M.D., James
Routon, M.D. and Joyce Steuber, Patient
Champion Ramon Meguiar, M.D.
Process Owner Michele Stephens, N.P.
Project BB Jonathan Flanders
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Analyze Statistical Analysis
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1
4
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Conclusion The analysis showed that the only
statistically significant cause of variation at
the 95 CL was the type of procedure.
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Analyze Value Stream Analysis (Current State)
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Analyze Value Stream Analysis (Current State
Continued)
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Analyze Value Stream Analysis (Current State
Continued)
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Analyze Value Stream Analysis (Current State
Continued)
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Analyze Root Causes Vital Few Xs

• Procedure type The current scheduling model
  does not account for different procedure types
  which have been statistically significant to the
  average LOS for PMC at the 95 CL.
• The current patient flow process is not capable
  of meeting the desired average LOS of 83 min.
  The current process is 69 waste or non-value
  added activities to the patient.
• The current staffing model does not appropriately
  utilize human resources.

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Improve Future State Map
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Improve Future State Map Continued
Improvement Summary Current State 24 steps, 145
min. total, 101 NVA min., 44 VA min. (68
Waste) Future State 13 steps, 94 min. total, 45
NVA min., 49 VA min. (48 waste)
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Improve Project Plan
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Improve Risk Assessment
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Lessons Learned

• Lean is hard work!
• CEO, SLG and Physician support is vital
• Gaining buy-in from those doing the work is the
  key to meaningful improvement and sustainability
• Scope of value streams and projects
• Data measurement systems needed work
• Good value streams and good data and important,
  so dont rush
• Committed and educated resources are a necessity

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Lean Methods for Lean TimesPremier Annual
Breakthroughs ConferenceOrlando, FL June 21, 2006
Questions?
June 12, 2002