Overview of Lean Principles Overview of Lean Principles and Continuous and Continuous ImprovementImprovement
Lean in HealthcareLean in Healthcare
What is Lean?What is Lean?
Definition-Definition-”The endless ”The endless transformation of waste into value transformation of waste into value from the customer’s perspective.”from the customer’s perspective.”
IT is a System Thinking Concept.IT is a System Thinking Concept.
A little HistoryA little History
The “4P” modelThe “4P” modelProblem Solving
(ContinuousImprovement
AndLearning)
Process(Eliminate Waste)
People and Partners(Respect, Challenge, and Grow
Them)
Philosophy(Long-Term Thinking)
Impact of Lean in the Impact of Lean in the IndustryIndustry
Direct Labor/productivity Direct Labor/productivity improvedimproved
45-45-75%75%
Cost ReducedCost Reduced 25-25-55%55%
Throughput/Flow IncreasedThroughput/Flow Increased 60-60-90%90%
Quality (Defects/Scrap) Quality (Defects/Scrap) ReducedReduced
50-50-90%90%
Inventory ReducedInventory Reduced 60-60-90%90%
Space ReducedSpace Reduced 35-35-50%50%
Lead Time ReducedLead Time Reduced 50-50-90%90%
Source: Virginia Mason Medical CenterSource: Virginia Mason Medical Center
Examples of Lean in Examples of Lean in HealthcareHealthcare
Adding greater “value-added” Adding greater “value-added” services services Same day office visitsSame day office visits Next day outpatient surgeryNext day outpatient surgery Next day mammogramNext day mammogram Quick & errorless billingQuick & errorless billing No wait emergency roomNo wait emergency room
TRADITIONAL CULTURE VS. LEAN TRADITIONAL CULTURE VS. LEAN CULTURECULTURE
TRADITIONALTRADITIONAL LEANLEAN
Functional SilosFunctional Silos Interdisciplinary teamsInterdisciplinary teams
Managers directManagers direct Managers teach/enableManagers teach/enable
Benchmark to justify not Benchmark to justify not improving; “just as improving; “just as good”good”
Seek the ultimate Seek the ultimate performance, the performance, the absence of wasteabsence of waste
Blame peopleBlame people Root cause analysisRoot cause analysis
Rewards: individualRewards: individual Rewards: group sharingRewards: group sharing
Supplier is enemySupplier is enemy Supplier is allySupplier is ally
Guard InformationGuard Information Share informationShare information
Volume lowers costVolume lowers cost Removing waste lowers Removing waste lowers costcost
Internal focusInternal focus Customer focusCustomer focus
Expert drivenExpert driven Process drivenProcess driven
Examples of process Examples of process improvement toolsimprovement tools
A3 reportingA3 reporting
Clean it up, Make it Clean it up, Make it VisualVisual
STRAIGHTEN
SHINE
STANDARDIZE
SUSTAIN
SORT
What is Waste in What is Waste in Healthcare?Healthcare?
Eliminating WasteEliminating Waste
OverproductioOverproductionn
Pills given out Pills given out early early
Treatments Treatments done to done to balance staffbalance staff
Duplication of Duplication of testtest
Eliminating WasteEliminating Waste
TransportationTransportation
Moving sameMoving same
patient, patient,
specimens, orspecimens, or
supplies, supplies,
workersworkers
Eliminating WasteEliminating Waste
MotionMotion Searching for Searching for
patients, patients, needed meds,needed meds, right charts, right charts, suppliessupplies
Eliminating WasteEliminating Waste
WaitingWaitingfor bed for bed
assignments assignments
or or
discharge, discharge,
or or
testing resultstesting results
Eliminating WasteEliminating Waste
ProcessingProcessing
RetestingRetesting More paperworkMore paperwork Duplicate Duplicate
proceduresprocedures
Eliminating WasteEliminating Waste
InventoryInventoryLinen (laundry)Linen (laundry)
Pharmacy stockPharmacy stock SuppliesSupplies Specimens waiting Specimens waiting
for analysisfor analysis
Eliminating WasteEliminating Waste
DefectsDefects
Medication errorMedication error Wrong Wrong
procedureprocedure Wrong patientWrong patient Missing Missing
informationinformation
The Toyota WayThe Toyota Way1414 Management PrinciplesManagement Principles
to LEAN Development Processto LEAN Development Process
LEAN Development LEAN Development ProcessProcess
1.1. Establish the vision for the Establish the vision for the futurefuture
Focus the organization on the PATIENTSFocus the organization on the PATIENTS Align Performance MeasurementsAlign Performance Measurements Set high expectations for success and Set high expectations for success and
low tolerance for failurelow tolerance for failureMethod:Method: Establish a core team of implementersEstablish a core team of implementers Focused training, reading, and Focused training, reading, and
benchmarkingbenchmarking Standardized, systematic, methodical Standardized, systematic, methodical
approachapproach Clearly define objectives and time tableClearly define objectives and time table Create success through pilots and spreadCreate success through pilots and spread
Mission StatementMission Statement
Develop the abilityDevelop the ability::To recognize and identify wasteTo recognize and identify wasteTo have the courage to call it wasteTo have the courage to call it wasteTo have the desire to eliminate itTo have the desire to eliminate itEliminate the wasteEliminate the wasteUnderstand that waste simplyUnderstand that waste simply
Raises costsRaises costsProduces no corresponding benefitProduces no corresponding benefitThreatens all of our jobsThreatens all of our jobs
You get what you expect and you You get what you expect and you deserve what you tolerate.deserve what you tolerate.
LEAN Development LEAN Development ProcessProcess
2.2. Develop your objectivesDevelop your objectives Look at your key processes or Look at your key processes or VALUE VALUE
STREAMSSTREAMS Patient Journey (ERPatient Journey (ERRadiologyRadiologyClinicClinicORORBilling)Billing) Charge capture (Clinical ServiceCharge capture (Clinical ServiceBilling Billing
Insurance)Insurance) Operating Room flow (Scheduling, consent, pre-Operating Room flow (Scheduling, consent, pre-
op visit, prep,….)op visit, prep,….) These support your “These support your “ProductsProducts” which ” which
might be might be Office visitOffice visit Inpatient stayInpatient stay Visit to the EDVisit to the ED
How do your Internal and External How do your Internal and External Customers define ValueCustomers define Value
LEAN Development LEAN Development ProcessProcess
3.3. Selection of Team MembersSelection of Team MembersCharacteristics:Characteristics:
Technology curiosityTechnology curiosityCommon senseCommon senseInner confidenceInner confidence
(create structure, Win allegiance, (create structure, Win allegiance, instinctive reactions)instinctive reactions)
Cross Functional Team:Cross Functional Team:Manager/Supervisor from the areaManager/Supervisor from the areaOperators from areaOperators from areaFunctional departmentsFunctional departments
(HR, Lab, Pharmacy, Admitting, (HR, Lab, Pharmacy, Admitting, Surgery, Materials Management,etc.)Surgery, Materials Management,etc.)
RESOURCE MATRIXRESOURCE MATRIX
NAMENAME TITLETITLE SKILL SKILL 11
SKILL SKILL 22
SKILL SKILL 33
SKILL SKILL 44
LarryLarry
MoeMoe
CurlyCurly
LEAN Development LEAN Development ProcessProcess
4.4. Initiate TeamInitiate TeamTraining:Training:
Read required literatureRead required literatureAttend team and leadership training, lean Attend team and leadership training, lean overviewoverview
Tools:Tools:Standardized analysis and simulation toolsStandardized analysis and simulation toolsVideo cameras, TVs, and VCR’sVideo cameras, TVs, and VCR’sComputers, Printer, and ProjectorComputers, Printer, and Projector
Facilities:Facilities:Lean War Room located in the operational Lean War Room located in the operational areaareaOffice area appropriately furnished and Office area appropriately furnished and suppliedsupplied
Resource and Innovation Resource and Innovation Center Center
LEAN Development LEAN Development ProcessProcess
5.5. Select Pilot AreaSelect Pilot AreaSelection Criteria:Selection Criteria:
Contributes to key competitive strengths Contributes to key competitive strengths of businessof businessInnovation has a good chance of successInnovation has a good chance of successSignificantly tests the innovationSignificantly tests the innovationSolutions are transferable to other areasSolutions are transferable to other areas
Baseline the current process Baseline the current process
Do an initial walkthroughDo an initial walkthrough
Baseline AnalysisBaseline Analysis
1.1. # patients transferred from ED # patients transferred from ED to inpatient bed within 1 hour of to inpatient bed within 1 hour of decision to admitdecision to admit
2.2. Time to third next available apptTime to third next available appt3.3. # tests/day or # tests/week# tests/day or # tests/week
Keep it simple - look at 25 Keep it simple - look at 25 patients/wk collected over some patients/wk collected over some time period including weekends time period including weekends and at nightand at night
LEAN Development LEAN Development ProcessProcess
6.6. Activity of ProductActivity of Product
Videotape: selected productsVideotape: selected products
Analyze videotape and segregate:Analyze videotape and segregate:
travel time and distancetravel time and distance
storage time and typestorage time and type
inspection timeinspection time
non-value added processing timenon-value added processing time
value added processing timevalue added processing time
Map the flow of the product:Map the flow of the product:
Process ChartsProcess ChartsProcess: Emergency room admissionSubject: Ankle injury patientBeginning: Enter emergency roomEnding: Leave hospital
Step no.
Time (min)
Distance (ft)
Summary
Number of stepsActivity
Time (min)
Distance (ft)
Step description
Insert Step
Append Step
Remove Step
1 X Enter emergency room, approach patient window 2 X Sit down and fill out patient history3 X Nurse escorts patient to ER triage room4 X Nurse inspects injury5 X Return to waiting room
6 X Wait for available bed 7 X Go to ER bed8 X Wait for doctor9 X Doctor inspects injury and questions patient
10 X Nurse takes patient to radiology
11 X Technician x-rays patient12 X Return to bed in ER13 X Wait for doctor to return14 X Doctor provides diagnosis and advice15 X Return to emergency entrance area
16 X Check out17 X Walk to pharmacy18 X Pick up prescription 19 X Leave the building
0.50 1510.0 -0.75 403.00 -0.75 40
1.00 -1.00 604.00 -5.00 -2.00 200
3.00 -2.00 2003.00 -2.00 -1.00 604.00 -2.00 1804.00 -1.00 20
Transport 9 11 815 Operation 5 23 —
Inspect 2 8 —
Store — — —Delay 3 8 —
LEAN Development LEAN Development ProcessProcess
7.7. Group Technology AnalysisGroup Technology Analysis Process sequenceProcess sequence Pre- Post data collectionPre- Post data collection Identify number of possibilities Identify number of possibilities
and combinationsand combinations Identify commonality within each Identify commonality within each
product familyproduct family Plan analysis phasePlan analysis phase
A3 reportingA3 reporting
LEAN Development ProcessLEAN Development Process
8.8. Line/Cell visionLine/Cell vision Product flowProduct flow Operator activityOperator activity FlexibilityFlexibility Zero defect productionZero defect production
Group TechnologyGroup Technology
Machine 1
Machine 2
Machine 3
Machine 4Machine
5
Materials in
Finished goods out
One Worker, Multiple MachinesOne Worker, Multiple Machines
LEAN Development LEAN Development ProcessProcess
9.9. Activity of OperatorActivity of Operator Map work patternMap work pattern
VideotapeVideotape
Analyze what is value added, required Analyze what is value added, required waste, and pure wastewaste, and pure waste
Point to Point diagram representing Point to Point diagram representing movement of operator in work areamovement of operator in work area
Time studies analysisTime studies analysis Document new processDocument new process
Point to PointPoint to Point
LEAN Development LEAN Development ProcessProcess
10.10. Develop Standard WorkDevelop Standard Work
Define job steps, standard times, Define job steps, standard times, and material location within and material location within each order of processeach order of process
Define takt time Define takt time
Establish Line BalanceEstablish Line Balance
LEAN Development LEAN Development ProcessProcess
11.11. Improve Line flexibilityImprove Line flexibility Videotape – selected setups and Videotape – selected setups and
operatorsoperators Document improvement Document improvement
suggestions related to – suggestions related to – preparation, organizationpreparation, organization
““Milk runs”Milk runs” Document new processDocument new process
LEAN Development LEAN Development ProcessProcess
12.12. Design and approve Line Design and approve Line LayoutLayout
Design ConsiderationsDesign Considerations
Steps to approve new LayoutSteps to approve new Layout
LEAN Development LEAN Development ProcessProcess
13.13. Performance MeasurementsPerformance Measurements ID standard work, source quality ID standard work, source quality
controlcontrol Monitor performance and Post Monitor performance and Post
resultsresults ID ‘hit list’ and resolve identified ID ‘hit list’ and resolve identified
problems on a 90 day cycleproblems on a 90 day cycle Monitor changes on 30/60/90 days Monitor changes on 30/60/90 days
cyclecycle
LEAN Development LEAN Development ProcessProcess
14.14. Develop a business caseDevelop a business case Compare base conditions with projected Compare base conditions with projected
lean conditions (benchmark or audit)lean conditions (benchmark or audit) Output ratesOutput rates Floor spaceFloor space InventoryInventory LaborLabor
Document cost of implementationDocument cost of implementation Present findings to senior managementPresent findings to senior management
Include all stakeholders and decision makersInclude all stakeholders and decision makers Let the facts speak loudlyLet the facts speak loudly