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Is it as Simple as Picking a Performance Tool from

Manufacturing and Applying it in Healthcare?

Wendy M. Novicoff, Ph.D.Six Sigma Master Black Belt and Lean SenseiAssociate Partner, Creative Healthcare USA

Assistant Professor, Departments of Public Health Science and Department of Orthopedic Surgery, University of Virginia

Health System

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Quality Improvement Process

• Problem identification• Team selection• Improvement model (PDCA, Six Sigma,

Lean, etc.)• Improvement tools• Implement solutions• Hold the gains

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Making It Work

Q x A = E

BusinessResults

Quality of solution times its Acceptance = Effectiveness

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What is Lean?

• Lean is a methodology that is used to accelerate the speed and reduce the cost of any process by removing waste (non-value-added activities)

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What Is Lean Thinking?• Providing “a way to do more and more

with less and less – less human effort, less equipment, less time, and less space – while coming closer and closer to providing customers with exactly what they want.

JP Womack and DT JonesLean Thinking (1996)

Be “Lean,” Not “Mean”

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Types of Waste

MotionAny motion of the worker that does

not add value

WaitingWaiting on parts,

waiting on information

InventoryAny more than the minimum to get the

job done

Over ProductionProducing more than is needed

Defects/ReworkProduct or service not

meeting customer requirement

TransportationUnnecessary movement of

materials from one place to another

Over ProcessingAdding more value than the customer

is paying for

IntellectAny failure to fully utilize the time and talents of people

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Signs of Non-Value Added StepsLarge file areas & frequent archiving

Multiple approvals

Waiting time and multiple hand offs

Process is seen as complex (mystical)

Frequentrework

Written correspondence required for the process

to complete

Procedures passed on by word of mouth, no SOP’s or SOP’s don’t reflect actual process

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Five Principles of Lean Thinking

• Value• Value Stream• Flow• Pull• Perfection

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Value• Value can only be defined by the ultimate

customer• Value is created by the producer• We must fundamentally rethink value from the

perspective of the customer – a conscious attempt to define value in terms of specific products with specific capabilities offered at specific prices through a dialogue with specific customers

What is REALLY needed by the customer? This does not equal what WE think the customer needs!

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Viewpoint: Who is the Customer?

• Perception becomes reality and is therefore is a judgment of our service

Customerasks for

information

Customergets

answer

Long delay perceived by customer!

Our hard work at maximum efficiency –are All Steps Really Necessary?

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Value Stream

• The value stream is the set of ALL actions required to bring a product (or process) from concept to finished product

• Value stream analysis shows the value of each process step– Steps that unambiguously create value– Steps that create no value but are currently

unavoidable (Type 1 Muda)– Steps that create no value and can be immediately

eliminated (Type 2 Muda)

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Flow• All activities needed to design, order, and

provide a product or service occur in continuous flow – no stoppages, scrap, or backflow

• Batch-and-queue is the dominant set-up today; Flow thinking is counterintuitive to our culture of “departments”

The questions to ask (and hopefully answer) are: How does the entire process work together (or not)? How can we impact

the work of our suppliers to help with continuous flow?What if we don’t have control over all parts of the value stream?

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Cycle Time

Process Time

Delay Time+

Flow of Work

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Pull

• No supplier should produce a good or service until the customer downstream asks for it

• Make the customer tell you what they need instead of trying to “sell” something that you already have (Pull vs. Push)

• The demands of customers become much more stable when they know they can get what they want when they want it

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Perfection

• Perfection is achieved with the complete elimination of muda so that all activities along the value stream create value

• Transparency in the entire value stream is needed before perfection can be obtained

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Stable vs. Capable

• In Lean, we strive for stable, standardized processes that can be replicated at any time by any worker and give roughly the same result

• In Six Sigma, we want a stable process that is also capable, that is – it satisfies the customer specifications every time

• The ultimate goal is a process that is stable and capable with as little variation as possible either in process or the ultimate product

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DMAIC, DMADV, & LeanDefine

Measure

Analyze

DFSS ?

Improve

Control

Design

Verify

NO YES

Familiarize

Define Work Elements

Time Study Work Elements

Develop New Process Maps

Overall Fixture Needs

# of Work Stations

Balance the Flow

Station Fixture / Tool Needs

Lay Out New Line

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Getting Started – Guiding Principles

• The primary guiding principle should be that a quality process is safe, evidence-based, customer-focused, and efficient

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Guiding Principle #1

• Incorporate Lean Thinking where possible– Define Value in terms of the customer. Always define

in terms of the patient being the greatest priority.– Identify all parts of the Value Stream for potential

impact on process– Change batch processes to continuous flow– Move to a “pull” model instead of “push”– Strive for a defect-free process– Employ rapid identification & abatement of errors– Apply mistake-proofing techniques– Consider cross training opportunities

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Guiding Principle #2

• Use a selected data-driven methodology with measurable performance goals and objectives that is applicable and appropriate. – Six Sigma DMAIC or DMADV– Rapid Action Planning (RAP)– PDCA– FMEA

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Guiding Principle #3

• Consider Human Factors– Reduce noise– Minimize interruptions– Minimize fatigue/boredom– Simplify– Use forcing factors– Employ recovery factors– Use affordances and natural mapping

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Guiding Principle 4 and 5

4. Assure visibility– Know locations of customers, staff,

inventory, equipment– Involve customers in the process

5. Automate where possible– Bar coding, automated forms– Scheduling

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Guiding Principles 6, 7, and 8

6. Standardize wherever possible7. Make it scalable, adaptable, flexible (for

new technology or systems)8. Assure accessibility of information, close

to point of service

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Guiding Principles 9 and 10

9. Incorporate fiscal accountability– Define project as cost savings, revenue

increase, or “soft dollars” only– Take into account budget issues (ability to

add staff or equipment)10.Consider impact on current list of

precarious events/regulatory requirements

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Stakeholder Analysis

Key Stakeholder

StronglyAgainst

Moderately Against Neutral Moderately

SupportiveStrongly

Supportive

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Executives X

Administrators X O

Nurses X O

Physicians X O

Surgical Techs X O

Scheduling X O

Stakeholders StronglyAgainst

ModeratelyAgainst Neutral

ModeratelySupportive

StronglySupportive

Strategies to Improve Support and Reduce Resistance

Stakeholder & Resistance Analysis – Example

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Three D’s MatrixApproach Examples

Data Charts, graphs, statistics

Demonstrate Show how project will positively impact people and processes

Demand Negative consequences if actions aren’t followed

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Pay-Off Matrix

High payoff

Low payoff

Easy effort High effort

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Common Tools & Underlying Principles

Tools• 5S• Kaizen “Blitz”

– Takt Time– Standard Work– Spaghetti Diagram– Load Leveling– Visual Controls– Mistake-Proofing

• Value Stream Map• Set-up Time Reduction

Principles• A bad process beats a good

employee nearly every time• Those closest to the problem

have the greatest knowledge• No excuses given or

accepted• Small, quick fixes add up

faster than than big, slow ones

• Improvement is the journey, not a destination

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5S: Work Place Organization• Sort: separate locally

needed from unneeded items

• Simplify: establish a specific “home” for each item

• Sweep: throughout each day, constantly tidy the work place

• Standardize: ensure that processes are consistent among all

• Sustain: repeat the loop, always improving

2. Simplify

5. Sustain

1. Sort

3. Sweep

4. Standardize

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Kaizen “Blitz”• Designated team attacks a specific “line of sight”

problem: throughput, cycle time, etc.• 2-3 days of learn-by-doing• Team sees tools and immediately applies them on the

specific problem• Report out with solutions

– Process managers attend– Solutions classified: immediate / medium term / long term– Every suggestion must receive response:

• Approval• Rejection with specific reason• Specific conditions needed before implementation

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Takt Time• Lean strives to make each unit of work happen as identically as

possible• Takt time provides an ideal target for how often a unit of work should

be completed, using the formula below

• Available time: total minutes (or seconds) per day, during which workers are expected to be at their stations – leave out breaks, standard meetings, meals, etc.

• Demand: average number of times the process operates during a day

Takt Time =Available Time

Demand

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Standard Work• If everyone does the “same” work his or her unique way, the

outcomes will experience unacceptable variation• Standard work identifies the best-current-knowledge way to

perform a process, and then ensures that everybody does it that way

• It works when those closest to the problem are given:– Accountability to develop and sustain standard processes– Guidelines to know what must never be changed (usually

outcomes, only occasionally procedures)– Tools & techniques to make it happen– Autonomy to implement changes that don’t require

additional resource– Support for changes requiring additional resources

• Standard work is developed by consensus, and then enforced strictly

• Improvements always permissible and encouraged, within the above guidelines

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Spaghetti Diagram• Compelling map of movements

associated with a process– Can represent workers or the

“work” (samples, patients, etc.)– Be sure to show backtracking,

loops, etc.• Simple rearrangements can

lead to big improvements– Improved layout of work

stations– Identify where to keep physical

items• Example at right: fast food

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Load Leveling• Try to ensure that work is spread out over a work period

to decrease overburdening, decrease fluctuations –balance is key!

• Example: Products B and C take longer to make/process than Product A

Product 1 2 3 4 5 6 7 8

A X X X X X X X X

B O O O O

C OO OO OO OO

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Visual Controls

• Visual displays can make people’s jobs easier

• Images, not words• Simple is better

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Mistake-Proofing• Simple tools to minimize

likelihood of errors– Usually < $100– Wait until root cause of

problem is known• Hierarchy of solutions

1. Eliminate step altogether2. Replace step with error-

proof one3. Design step to prevent error

from happening4. Detect error before it moves

on5. Mitigate impact of error

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Value Stream Map (VSM)• Straightforward to create, a little complex to interpret• Includes process steps and much more:

– Queues– Times (value-added & NVA)– Usage rates– Shipment quantities & frequencies– Flow of information (orders, forecasts, etc.)

• Current State map exposes primary areas of waste• Future State map provides plan of attack for

improvement– Immediate / medium term / long term– Shows where further evaluation is needed

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VSM Example: Insurance Claims

Future State

Current State

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Total Productive Maintenance

• Each operator is charged with maintaining their supplies and equipment

• Key issues in TPM– Preventive maintenance– Corrective maintenance– Breakdown maintenance– Maintenance prevention

• Six big “losses” in TPM: Equipment breakdowns, set-up and adjustment delays, minor stoppages, reduced machine speed, process defects, reduced yield

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Quick Change-Over• Objective: minimize NVA time that customers,

equipment, or facilities are in transition between tasks

• Basic concept: classify setup tasks as “internal” or “external”– Internal setup: activities that happen when equipment

is out of service: cleaning rooms– External setup: activities that can be done while

equipment is actively in use: delivering or replenishing supplies

– Objective is to convert as much internal to external as feasible, and then to speed up remaining internal time

• Example: NASCAR pit stops

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Productivity• Quick Change-Over• TPM• Spaghetti Diagram

Inventory Control• Just-in-Time• Load Leveling• Flow Processing• Kanban

Where to Start With LeanEnterprise Wide:Work Place Management:• 5S• Value Stream Map

Localized:Standard Work• 5S• Kaizen• Visual Controls• Mistake-Proofing

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Elements for Successful Projects

• High frequency events (hourly, daily, weekly)

• Established measures and data collection• Narrow scope• Jurisdiction – authority to make changes• Significant business impact ($$,

satisfaction, growth etc…)

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But What Is Really Needed?

• Support from Management

• Sponsor• Owner• The “right” team

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Problems In Project Identification • Having a predetermined solution • Trying to make “everything” a project

instead of making reasonable or necessary changes (Just Do It)

• Projects that focus on improving inputs exterior to the department or company– Increases complexity and time for project– Great likelihood that solution may not be

implemented unless project partnering exists

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Questions to Ask (and Answer)

• What concerns you the most about the current process?

• Why should we do this project NOW instead of later?

• How do we prioritize multiple projects?

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Project Selection & Rating ToolDirections: rate each category on a 1 to 5 scale (see below for definitions). Add the category scores to get a final rating. The goal is to

get a project with the highest score.

Category Project #1 Project #2 Project #3 Project #4

Current performance gap (1 = gap is small; 5 = large gap with ideal performance)

Cost to business if NO changes made (1 = low cost; 5 = high cost)

Impact on customer satisfaction (1 = low impact; 5 = high impact)

Degree of waste (1 = little or no waste; 5 = lots of waste)

Customers can be defined (1 = not easily defined; 5 = easy to define)

Inputs can be identified (1 = hard to identify; 5 = easy to identify)

Outputs can be identified (1 = hard to identify; 5 = easy to identify)

Data is available (1 = difficult to collect or manual; 5 = easy to obtain, electronic)

Team needed to understand / identify solutions (1 = team NOT needed; 5 = team definitely needed)

Team has authority to implement solutions (1 = little or no authority; 5 = has authority to implement)

Manageable project scope (1 = very large scope; 5 = contained, narrow scope)

Alignment with Strategic Plan ( = not aligned; 5 = good alignment)

Total Score

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Discussion• What is the process of project and

student selection at your institution? • How does project selection tie to the

strategic plan/business goals of your institution?

• What is the Executive Team’s role in project development?

• How are Sponsors/Champions selected, supported, and held accountable?

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The Good, the Bad, and the Ugly

(Names have been removed to protect the guilty)

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The Bad and the Ugly

• Not preparing the organization for change• Switching priorities (customer satisfaction

vs. saving/generating money)• Lack of accountability• “Flavor of the month” approach

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The Good (to Great)• CEO and leadership engaged in rollout, project

selection, and accountable for follow-up• All leadership (managers and above) required to have at

least two-hour training session• All leaders required to participate in one project per year

as either Project Champion or “support” person• All employees required to attend at least 20-minute

introductory session• Core group of employees trained as project leaders• Broad-based, multi-modal communication plan• Semi-annual project fairs in public areas

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Presentation Summary

• Much potential for a combined Lean and Six Sigma approach to projects – don’t forget to consider a “retooling” of previous projects

• Keys to success: manageable projects, the “right” people, management support

• Leadership support is critical no matter what the improvement methodology – are your leaders willing to ask and answer the tough questions?