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2 Lean Healthcare

3 Objective Create a more defect-free service Reduce/Eliminate waste and increase efficiency Increase patient and employee satisfaction Reduce costs Increase patient safety Enhance leadership and communication skills

4 What is Lean?

5 What is Lean? Lean focuses on eliminating waste in processes or systems Lean is not about eliminating people, but about using them more wisely Lean is about working with people to achieve continuous improvement activities to assist in reducing cost in an organization Lean is about understanding what is important to the customer Lean is an ever-evolving philosophy based on proven principles and practices aimed at the elimination of wastes. Lean is a compilation of world-class practices that will improve an organization through an evidence-based methodology.

6 What is Lean Thinking? Value Empowered People Value Stream Flow & Pull Perfection

7 Lean Principles Specify value Value is defined in relation to the customer Identify the value stream Exposes the enormous amounts of waste Create flow Reduce Waste (Noise) Reduce batch size and WIP Let the customer pull product through the value stream Make only what the customer has ordered Seek perfection Continuously improve quality and eliminate waste

8 Value Value added activity: An activity that adds value to the form, fit or function of a product or service, or an activity for which the customer is willing to pay Non value added activity (waste): Those activities that take time, resources, or occupy space, but do not add value to the product Necessary: Inspection Financial analysis Unnecessary (waste): Rework Extra handling Searching for tools Fine tuning Walking, unnecessary motion, transportation and setups Source: Boeing Production System, Lean Manufacturing Pocket Guide, 1999

9 Value Streams The set of all the specific actions required to bring a specific product through the three critical management tasks of any business: Problem Solving Sales Design Engineering Information management Logistics & Materials Management Physical transformation Production/Patient Care, Maintenance, Quality -Womack and Jones

10 Forms of Waste Lean methods tend to target 8 forms of waste. 1. Overproduction 2. Excess inventory 3. Defects 4. Non-value added processing 5. Waiting 6. Underutilized people 7. Excess motion 8. Transportation

11 Lean Six Sigma Belts Professional with basic working knowledge of concepts Leads Six Sigma project teams through DMAIC (Design, Measure, Analyze, Improve, Control) Leads Six Sigma project teams through Kaizen or Rapid Improvement Events Leader of Green and Purple Belt employees Mastered all Six Sigma concepts, mentors other Belt levels

12 Lean Belts Solid understanding of basic Lean principles and tools, able to lead tactical implementations driving improvement Experienced with value stream transformations Understand all aspects of Lean transformation across the entire enterprise

13 Why Lean Healthcare?

14 Why Lean Healthcare? The basic values of Lean Healthcare are to: Put the customer/patient first Define value in terms of the customer Learn to see the 8 wastes of Healthcare Make less is more the way to do things To be a Lean Thinker means to constantly strive to improve by focusing on driving out waste in all its forms. By attacking the ever present 8 wastes of Healthcare, greater value can be created with less effort.

15 Why Lean Healthcare? Lean is based on reducing costs rather than raising prices or reducing services. Source:

16 Why Lean Healthcare? Why implement lean into the healthcare industry 20,000 incorrect drug prescriptions per year in the US 500 incorrect surgical operations per week 50 new born babies dropped at birth per day Enormous defect rate (estimated at nearly 45% by the New England Journal of Medicine, June 2003) Cost escalation 60%-80% of costs can be reduced Work and patient flow will improve Patient as well as non-patient care processes will improve Improves morale, productivity and bottom line Source:

17 Why Lean Healthcare? Types of Healthcare Waste TYPES LABORATORY EXAMPLE PATIENT CARE EXAMPLE (ONCOLOGY) Defects Mislabeled patient specimens Wrong medication delivered to patient Overproduction Just in case blood tubes drawn from patients but not used Patients seen by MD faster than can be treated by chemo causing delays Transportation Moving specimens long distances from receiving to testing Long walks from MD clinic to chemotherapy Waiting Specimens waiting in batches for testing Patients waiting due to schedule exceeding capacity Inventory Expired test reagents Expired chemo drugs Motion Technologist waling due to poor layout Nurses searching for missing supplies Over processing Human Potential Time/date stamps on labels that are not used Time spent creating a schedule that is not followed Employee ideas not listened to Source:

18 Why Lean Healthcare? Lean healthcare can eliminate many obstacles to excellence, such as: Cumbersome information technology systems Worker frustration Inadvertent errors and oversights that can increase patient risk Inexpensive approach to fix a big problem Source:

19 What is Lean Healthcare?

20 What is Lean Healthcare? Lean healthcare is the successful adaption of Toyota principles to healthcare processes and management Continued removal of waste and non-value added activities Built in quality through stop and fix mentality Discipline or root cause problem solving Ongoing improvement through employee empowerment Source:

21 What is Lean Healthcare? Lean Healthcare looks at the process of patient care from a cross-functional viewpoint instead of from the viewpoint of individual functional departments Both outcomes and patient satisfaction depends on a healthcare experience that is a smoothly flowing series of connected steps

22 What is Lean Healthcare? PROBLEM SOLUTION RESULT Today healthcare is not designed to make the value stream of care flow smoothly Lean Healthcare Delivery System enabling those on the front line to work together to solve problems and take root cause measures Healthcare professionals in all units can focus on objectives GREATER PATIENT SATISFACTION AT A LOWER COST

23 Benefits of Lean Healthcare

24 Benefits of Lean Healthcare Lean Healthcare cuts out wasted time and resources Increases the efficiency of the process of admitting and treating patients Allows more patients to be treated Allows hospitals to leverage existing assets and generate higher margins Improve patient safety and care while creating a culture of continuous improvement Improve direct patient care processes

25 Benefits of Lean Healthcare Lean Healthcare reduces labor requirements and allowing caregivers to spend more time with patients Reduced waiting times Improved productivity and higher pay

26 Implementing Lean Healthcare

27 Implementing Lean Healthcare Lean methods can be used to improve patient flow through: Emergency departments Operating Rooms Patient Care Facilities Rethink current processes by looking across value streams instead of focusing on individual departments Value stream mapping proves effective in a hospital setting as processes are typically silo-ed and complex

28 Implementing Lean Healthcare The flow of work through healthcare is complicated yet much of the work is routine Identify this routine work and manage it separately and begin the virtuous lean circle Standardize steps, synchronize them so the work flows through each step without interruption and flow in line with real demand When you do this, you will eliminate lots of scheduling and queues enabling better planning

29 Implementing Lean Healthcare Utilize Heijunka or level loading schedules to reduce delays and solve capacity shortages Heijunka is a visual scheduling tool to achieve a smoother production flow The Heijunka box is generally a wall schedule which is divided into a grid of boxes. Each column of boxes represents a specific period of time, lines are drawn down the schedule to visually break the schedule into columns of individual shifts

30 Implementing Lean Healthcare The Heijunka box makes it easy to see what type of jobs are queued for production and for when they are scheduled Allows easy and visual control of a smoothed production schedule Horizontal rows for each product Vertical columns for identical time intervals of production This ensures that production capacity is kept under a constant pressure thereby eliminating issues

31 Implementing Lean Healthcare The full range of Lean tools can be applied to hospital environments Quick setup or SMED (Single Minute Exchange of Dies) are used to reduce the setup or changeover time for operating rooms or MRI machines Rapid Process Improvement Workshops Lean hospitals do not drive improvements from people doing their value added work faster. Lean improvements come from eliminating waste and delays, supporting those who do the value added work, providing more time for patient care and a focus on quality and kaizen.

32 Implementing Lean Healthcare Each customer, provider and support process contains many steps: Which steps create value solve the problem? Which steps waste time? What is the experience like for each involved party? Do queues really help? Do they change the amount of work to be done or smooth demand? Do they improve the utilization of our most expensive assets? Can we distinguish between actual and created demand?

33 Implementing Lean Healthcare Lean healthcare challenges: Large number of patient lines Adult vs. Peds Specialty vs. Primary Care Inpatient vs. Outpatient Surgical vs. Non surgical Chronic vs. Acute Care

34 Implementing Lean Healthcare Lean Healthcare Challenges continued Each patient is unique More like a custom repair (job shop) than an auto manufacturer Almost infinite variability in mix of diseases and symptoms Variable: age, family, gender, race, social, insurances factors Variable: health habits, tobacco/alcohol/drugs, compliance Mental health as a primary or complicating problem Patient preferences must be respected

35 Implementing Lean Healthcare The lean journey is not an overnight change for an healthcare organization Leading hospitals need to implement infrastructures similar to a Lean Manufacturer: Lean Training Functions Internal ccnsultancies Kaizen Promotion offices Lean hospitals are making significant training and development investments to help teach their managers how to become true leaders

36 Implementing Lean Healthcare Learn Apply Analyze Make Lean Healthcare disciplines a regular part of the operating philosophy

37 Implementing Lean Healthcare Who s Involved in the Lean transformation? Executives Top management Middle managers Frontline workers EVERYONE COMPANY WIDE!

38 Implementing Lean Healthcare Lean should be part of the overall business improvement system for the organization Lean should be included in the strategic plan and conveyed through various goal setting activities Lean hospitals do more than implement just tools and technical methods: Lean is also a cultural change and a management system Lean takes: TIME EFFORT PERSISTENCE

39 Leading Lean Hospitals

40 Leading Lean Hospitals ThedaCare (Wisconsin) Virginia Mason Medical Center (Washington) Park Nicollet Health Services (Minnesota) NHS Bolton Trust (England) Avera McKennan (South Dakota) Florida Hospital (Orlando and Central Florida) Flinders Medical Centre (Australia)

41 Lean Hospitals

42 Seattle Children s Hospital Lean Initiatives; Results Over Past Three Years Total parenteral nutrition (TPN) medication error rates reduced by 66% Reduced patient time in hospital from 20 to 10 days in the inpatient Psychiatric Unit (can now accommodate 650 children vs. 400 a year) Patients spent 20% fewer days in the Intensive Care Unit Fewer emergency department patients leave without being seen at peak times (achieving a 0.7% rate, compared to a 2.4% national rate) Blood stream infections in our Intensive Care Unit declined by 50% Patients remained on ventilators 20% fewer days Patients see doctors sooner: appointment centralized scheduling times dropped 50% More patients treated without adding space Patient and family satisfaction and employee engagement increased

43 Seattle Children s Hospital Savings 3.7% reduction in cost per patient and $23M in related savings $2.5M reduction in supplyrelated costs 30,000 square foot reduction in design and construction of new ambulatory services building, achieving $20M cost avoidance $180M in capital cost avoidance of not building new patient rooms

44 Virginia Mason Healthcare Virginia Mason Production Systems (VMPS) Initiatives: Patient Safety Alert System Improves Patient Safety (PSA) 2002 to 2009, 14,604 PSAs reported Reduced processing time for PSAs from 18 months to 24 hours One-Stop Care for Patients with Cancer redesigned Reduced the length of Chemotherapy visit from 10 hours to 2 Saved 500 feet of walking at each visit Getting Back to Nursing Increased time spent with patients to 90% Hyperbaric Center Increases Patient Capacity Eliminated the need to build a new Hyperbaric Center Saved $2,000,000 dollars and increase capacity from 2 or 3 patients to 20 patients at a time Express Treatment in the Emergency Department Decreased the number of hours ED closed and unable to see new patients by 90% Faster Revenue Cycle - Improved Days Revenue Outstanding (DRO) Clinics 52.3(2003) days to 29.4(2009) Hospitals (2003) days to 42.6(2009) Cash Revenue Improved $471 million (2003) to $794 million (2009)

45 University of Michigan Health System Lean Initiatives Improving the Patient Journey Service correct upon arrival 31% Improvement Home unit placement correct 49% Improvement Precaution information available at admission 90% Improvement While maintaining diagnostic quality, radiation exposure minimization Reduced average CT radiation exposure by 43%

46 ThedaCare Lean Initiatives Introduced standardized processes for emergency heart attack and stroke treatment Code STEMI and Code STROKE dramatically reduces the time it takes to receive life saving treatment Productivity up 30% in Radiation Department Wait Time for Alcohol and Drug Treatment Down by 75% Halved the time it takes to complete admissions paperwork Savings of $24 million in 7 years

47 Denver Health Authority Lean Initiatives The Denver Health LEAN process has generated $124 million in financial benefit since Denver Health ranks #1 in the country among academic medical centers in patient survival. Denver Health is the first healthcare organization in the world to be awarded The Shingo Bronze Medallion for Operational Standardized Treatment of Patients with Alcohol Withdrawal Reduced ICU utilization by 1 day with a savings of $2,000,000 per year Pediatrics/Teen Clinic flow Reduced Cycle Time from 46 minutes to 24 minutes

48 Pittsburg Regional Health Lean Initiatives Process Time Improvement for New Employees obtaining keys 44 to 2 days to Day of Orientation Right Meals to Patients Every Time Error proofed the pathway to enter food orders in the EMR100% of meals delivered correctly and screened for allergies Green Room 5S Work Place Organization for Mental Health Workers (MHW) Medical Health Workers can assemble supplies in 16 seconds 85% improvement On Time Discharge with Belongings and Survey Patient Satisfaction 68% Improvement Discharge Note Percent 15% Improvement Completed Discharge information in Chart 94% Improvement Information relayed to patient 72% Improvement Information relayed to next provider 5S ed the property room:; installed bins cost of replacing lost items immediately plummeted In Patient Survey Activities and Pathway defined Increase Survey Participation from 30% to Over 70%

49 Operational Excellence - UMMC Lab Decrease Loss of POC Test Kits Decrease Overtime by changing an existing staff nurse position to a resource nurse position Increase Supply Room Charge Compliance %

50 Management versus Leadership Management Planning and budgeting Organizing and staffing Controlling and problem solving Leadership Establishing direction Aligning people Motivating and inspiring Produces a degree of predictability and order and has the potential to consistently produce the short-term results expected Produces change, often to a dramatic degree, and has the potential to produce extremely useful change

51 The Eight-Stage Process of Creating Major Change 1. Develop a vision and strategy 2. Create a guiding coalition 3. Communicate the change vision 4. Establish a sense of urgency 5. Empower broad-based action 6. Generate short-term wins 7. Consolidate gains and produce more change 8. Anchor new approaches in the culture

52 Creating Change Successful change of any magnitude should go through the eight steps outlined. Skipping even a single step or getting too far ahead without a solid base almost always create problems. The key to creating and sustaining change lies within the leader

53 Summary of Lean Healthcare

54 Summary American healthcare is in crisis The industry is struggling with skyrocketing costs, poor quality, nursing shortages and employee dissatisfaction Healthcare providers are realizing the imperative of improving quality and safety and eliminating waste as strategies Lean healthcare is a way to transform your entire organization into a safe and high-quality, highperforming healthcare deliver system Lean Healthcare is the how to of managing change and creating continuous improvement

55 Summary Lean thinking embeds quality at source into every process with big implications for mortality and medical errors It frees up the latent capacity in current systems without requiring new capital It releases more time to spend on solving the difficult cases As you improve current processes you see new opportunities for designing alternative ways of delivering care with different working practices and the right equipment There is no one lean best way but several!

56 Summary Lean healthcare doesn t happen unless: Someone is responsible for rethinking the whole process Is supported by all those involved in running the process The organization, with expert help, develops a future state plan that shows where to conduct breakthrough improvement events and where to use lean tools

57 The Bottom Line Healthcare facilities must find ways to conserve resources in order to keep costs contained and reduced to ensure patient health and safety. This can only be accomplished by reducing waste through continuous improvement Lean Healthcare will improve profitability for your healthcare organization