Lean Thinking in Healthcare WESTERN STATES MEETING JUNE 26-27, 2014

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1 Lean Thinking in Healthcare WESTERN STATES MEETING JUNE 26-27, 2014

2 Outline Implementing Lean In Healthcare What is Lean? Why Lean? Lean Principles and Concepts Spotlight on two lean applications: Clinical Laboratory Outpatient Clinic Keys to success Advantages and disadvantages

3 History of Improvement The notion of improving processes has been around for centuries Scientific Method Toyota Production System Deming/Shewart PDSA, systems thinking And a host of spin-offs - lean, six sigma, lean-sigma, business process reengineering.. scientific method e-fairprojects/project_scientific_method.sh tml

4 What is Lean Short for Lean Thinking Management System for Continuous Improvement based on the Toyota Production System Set of principles that guide organizational thinking based on two themes: Elimination of waste or non-value added activity (continuous Improvement) Respect for all people

5 What is Lean? Lean thinking advocates identifying and eliminating the extraneous steps and processes referred to as waste that are responsible for work delays and added costs. All that s left are the time, the people and the activities that add value to the customer (Connolly, Washington Post 6/4/05)

6 Basic Lean Concepts Scientific Method to seek perfection Continuous flow and progressive achievement of tasks Waste minimization Well defined, standardized processes Respect for people cultural enabler Build value for the customer Build teamwork, involve everyone Clear purpose enterprise alignment Align strategy, systems and performance

7 Patients Less waiting and delays Safe environment Employees Better work processes Organization Mission alignment Lower costs frees FTEs DB, 2006

8 Why Lean? Improve patient experience Faster turnaround time, less errors Improve the employee experience Faster turnaround time, less errors Discover additional capacity Free up FTE s Control cost Less resources devoted to wasteful processes

9 The Lean Process For each process: 1. Accurately specify the value desired by the customer. 2. Identify every step in the value stream for both product and employee activities; 3. Determine which steps are Value-Added and Non- Value-Added 1. A typical process is 95% non-value added 4. Discover solutions that link Value Added steps together and remove non value added activities. Redesign workflow processes, layouts, workstations and supplies

10 Improvement at its most fundamental Value Added Non-Value Added Definition- Any activity that contributes directly to satisfying the needs of a Customer Definition- Any activity that takes time, space, or resources, but does not contribute directly to satisfying the needs of a Customer Need time Need Met

11 Seeing Waste Forms of Waste Operational Waste Muda 7 wastes Waste = Non-Value Added Activity

12 The Seven Wastes (Muda) Overproduction- too much work done or work done too early Waiting- people, paper, information, supplies Overprocessing producing things in excess of value Inventory- excess stuff, or items waiting to be worked on Motion- operator movement not necessary to complete a task Defects- work that needs to be re-done/clarified Transportation- movement of something further than necessary

13 This is a Value Stream Problem DB, 2006

14 Eliminate the Waste Basic Concepts of Improvement Design the system/ process using these principles: Flow Pull Defect Free Visual Management Continuous Improvement Current State Apply Improvemen t Concepts Better State

15 Flow Principle Allow value to flow continuously to customer demand, in a standardized way Anytime work stops, waste is present

16 Lean Principle: Flow Flow is predicated on zero waste and no wait times Must eliminate barriers that impede movement of the product or the service If flow is interrupted, waste develops as inventory, extra steps or wasted motion Flow should be pulled, not pushed

17 Pull Principle Perform work only when you have a true need from the customer Utilize Pull Systems when work cannot flow continuously

18 Lean Concept: Pull vs. Push Push systems driven by the output of the preceding systems Work is pushed whether it is needed or not Pull systems driven by the needs of the receivers (customers) Customers pull the product to them

19 Lean Concept: Just-in-Time (JIT) Supply the customer with just what is needed, in the right amount, at the right time, every time. Can be applied to products or services The most effective mechanism for implementing lean thinking is adopting JIT and pull-from-demand flow

20 Pull true customer demand Pull patients into rooms when ready to be seen Resources or materials are pulled by customers when needed Blood products are pulled when needed Wheel chairs are pulled, not sequestered Flow when you can, pull when you must DB, 2006

21 No Batches or Queues!

22 Defect Free Principle Build quality into the process to exactly meet customer specified value the first time We always have time to do work the second time

23 Manage Visually Principle See normal conditions from abnormal conditions at a glance so corrective action can be taken in real-time Visual Management gives employees the knowledge and motivation to succeed!

24 Lean Principle: Define and Standardize Processes Eliminate variation Define value-added processes through careful analysis Standardize the ideal process Events aren t always as they appear!

25 More Waste Equipment down time Excessive approvals Variation in practices Variation in skill levels Physical layout

26 Lean Principle: Center on the People Who Add Value Customer-focused and worker-focused Give people the highest skill level tasks that they are capable of accomplishing Train workers to detect defects Balance work among the team Move to team-oriented processes Make work easy with Kanban and visual prompts

27 Kaizen Rapid Process Improvement Purpose: To ensure sustainable change through aggressive improvement initiatives focused on reducing waste and increasing value Method: Cross-functional teams quickly implement Lean tools to find creative solutions at minimal costs Time Interval: 1-3 months

28 Kaisen Workshop Pre- Planning Process Goal and charter setting Team development Initial training Event Create current and ideal maps Create checklists and milestones Post- Planning Process Sustainability Plan

29 Value Stream Mapping Conduct team walk-through Take time observations Construct current state map for each process Determine whether each step adds value Look for push/pull systems Examine supply management first in, first out

30 Time Observations Time each task in the identified process Differentiate each as value-added time or non-value-added time Record reasons for interruptions and waiting and searching Observe at least five cycles for each process

31 Future Value Map Eliminates identified barriers Eliminates non-value added steps Depicts continuous flow, pull systems Eliminates hand-offs Creates parallel processes Uses visual controls (kanban) Changes in physical layout Includes prioritized change initiatives

32 Project Spotlight Lean Implementation in a Laboratory Scope - Core Testing Laboratory Closest process to manufacturing, an item is processed through a sequence of steps, value is added and product is given to customer Aim: To improve patient quality of care by eliminating waste and minimizing turnaround time through teamwork, education and the implementation of lean principles DB, 2006

33 Lean Core Lab Project Scope High Volume In-Patient & Out-Patient Tests Approx specimens/day 4.7 Million Tests per year (71% of total) In-Patient Measure - Collect Time to Test Result Time Out-Patient Measure - Patient Arrival Time to Test Result DB, 2006 Time

34 Phlebotomy Supplies Organized Sequence of use First-In-First-Out (FIFO) Visual management Re-supply quantities Standardized Carts DB, 2006

35 Stockroom Supplies Mgmt. -Phlebotomy Supplies allocated shelf space based on usage -Tags on shelf for each item include order#, minimum qty. and re-order qty. DB, Ordering performed twice per week utilizing a handheld device, order submitted electronically overnight, supplies arrive next day

36 Changes to Layouts & Workflow -Processor Work Zones 3 2 DB, Processor Steps: Get specimens Log in specimens Drop off specimen Place in centrifuges Return to repeat the loop

37 Changes to Layouts & Workflow -Inner Loop Work Zones DB, 2006 Inner Loop Technician(s) Steps: Load / Unload centrifuges at stations Load / Unload analyzers Complete auto-verifications Set aside those needing manual verification Repeat the loop for varied equipment Work per the demand needs Inner Loop Technologist(s): Load / Unload centrifuges Load / Unload analyzers Run auto-verifications Set aside those needing manual verification Repeat the loop

38 Changes to workstation design Standardized Workstations Visual Control of Workflow DB, 2006

39 160 In-Patient Turnaround Times Inpatient Order to Complete TAT Trends Baseline lab renovation LLT changes After renovation % improvement Mintues DB, 2006 UCL=100.1 _ X=93.6 LCL=87.1

40 Minutes DB, 2006 Outpatient Turnaround Times Outpatient Overall Average TAT Trends Inlab to Complete DICT renovation baseline After renovation ACB opens 28% improvement UCL=43.1 _ X=39.1 LCL=35.1

41 Other Results Labs consolidated from 4 labs to 2 labs Capital equipment for new building eliminated No lab or phlebotomy hiring needed for new building Staffing scheduled to better match demand Improved performance measurement Daily raw data database for detailed analysis Flow Roadblock log / tracking ROI Breakeven at 14 months DB, 2006

42 Project Spotlight: Implementing Lean in an Outpatient Clinic Setting Aim: Decrease patient wait time by 25% from appointment to completion of doctor visit within 6 months. Implementation plan included weekly working meetings culminating in a week- long kaizen event Strong, visible support from leaders Team selected from the front line

43 Patient Flow Baseline Process Sandee Break Room Clean Utility Workroom 1 Workroom 4 Workroom 5 Reception Desk 1 3 Workroom 2 Endocrine lab 8 Internal Medicine Floor Plan Waiting Area Triage 5 Consult Room Business Center

44 Patient Flow New Process Notes on new process: 1. Patient receives forms to fill out Clean Utility as he/she arrives 2. Vitals now part of the rooming process 3. Rooming controlled by room cards and information board next to receptionist area, if slot is empty on board, you know room is occupied, if card is there you know room is available 4. Less travel for the patient Sandee Workroom 1 Break Room Workroom Workroom 5 Checkout 4 Reception Desk 1 Workroom 2 Endocrine lab Enter/ Exit 5 Internal Medicine Floor Plan 2 Waiting Area Triage 5 Consult Business Center Room

45 Results: Outpatient Clinic Kaizen Patient Flow Walking distance: 216ft down to 108ft Exam room wait time decreased by 43% Wait time from a patient s appointment to completion of doctor visit reduced by 33% Productivity Clinic setup time reduced by 52% Quality Defects Patients with a return appointment in 2 weeks or less that leave the clinic without their schedule dropped from 41% to 18% DB, 2006

46 Lean Concepts Utilized In Solutions One Piece Flow Batching eliminated- centrifuging, front desk preparation Setup Time Reduction 45 of sorting eliminated plus no paperwork processed for no-shows, documents printed real time Kanban and Visual Management Room cards and clinic board utilized to manage patient flow Patient checklist placed in each room to put patient in charge of their visit Supply inventory managed with cards

47 Lean Concepts Utilized In Solutions Standard Work Teams designed new process, then standardized and trained personnel to follow new process Balanced Work Some activities re-distributed to better match patient flow Employees flexed responsibilities to even out the amount of work between employees

48 Advantages of Lean Will remove waste Personnel time Supplies ( inventory control) More apt to hold the gains due to physical changes in the process Will reduce cycle times Buy-In from employees because they are involved in developing the future processes, however.

49 Disadvantages Be prepared to handle moral issues: Physical layout of the work space will likely change Employee s level of cross training may increase Solutions will probably include some form of standardization Can be apprehensive about the future of their job Many solutions involve facilities and/or Information System changes DB, 2006

50 Keys to Success Employee Involvement Provide time for a dedicated team to participate with defined timeline Move decision- making to the lowest levels Train all involved Willingness to implement solutions Once a solution is identified as better than the way it s done now, put it in motion Avoid analysis paralysis ; don t sacrifice better for best Don t underestimate the human side of change Upper Management Support How will the gains in the loss of FTEs be realized? Communicate with a single voice Provide the ability to implement solutions, smooth the way with support from outside departments, including IS and Facilities

51 SLIDES AND CONCEPTS COURTESY OF SHERRY MARTIN, NQC COACH EXTRAORDINAIRE

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