Lean Misconceptions. Learning Objectives. The Lean Name. Introduction LEAN = MEAN

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1 Copyright 2009 Lean Homecare Consulting Group, LLC Improve Efficiency and Decrease Costs with Lean Thinking: Lessons from Toyota New York Association of Homes and Services for the Aging Presented by Chris Calderone, MA, MBA This presentation is distributed for informational and educational purposes only. No citation, quotation, duplication, or distribution without the expressed written permission of the author. Learning Objectives Define (and understand) lean thinking Discuss waste in healthcare (LTC and other continuing care organizations) Demonstrate how lean techniques & concepts can help reduce waste within the care delivery processes Provide insight in order to begin successfully implementing a lean transformation Discuss lean leadership Introduction I am going to provide an overview of lean the topics and concepts I am going to review could be full day workshops by themselves You ll get much more out of this session if you think about your core business processes as I speak Administrative processes Care delivery processes The Lean Name Has its roots in Henry Ford s assembly line concept Japanese needed a more efficient method of production following WWII Took Ford s concept and perfected it The term Lean was used to describe Toyota s approach to manufacturing Defining lean What it isn t Lean Misconceptions LEAN = MEAN You get TO lean by improving your processes- you don t GET lean by reducing your workforce It s not about working harder It s not about working faster Not just another flavor of the month Not just common sense Not only for manufacturing

2 The Growth of Lean Lean has spread from the manufacturing sector Service-based businesses Insurance organizations, banks, government Hospitals and health systems have embraced lean Catching on in other parts of the healthcare continuum Lean and Healthcare Hospitals, health systems, and physician practices have been successful Impressive results relating to: Improved patient satisfaction Reduced costs (less waste) Improved outcomes Responsiveness, efficiency Improved staff satisfaction Some Lean Successes Category 2004 Results (after 2 years of lean ) Metric Change from 2002 $1,350,000 Dollars Down 35% Inventory Background Worked at the University of Michigan Health System - trained in lean thinking concepts Productivity Floor Space 158 FTEs 36% redeployed to other areas 22,324 Sq. Ft Down 41% Applied widely throughout the various hospitals and outpatient areas at UMHS Lead Time 23,082 Hours Down 65% People Distance Traveled 267,793 Feet Down 44% Product Distance Traveled 272,262 Feet Down 72% Why not take the same principles and techniques and apply them to other parts of the healthcare continuum? Setup Time 7,744 Hours Down 82% Source: Virginia Mason Medical Center and Institute for Healthcare Improvement Moving Beyond the Hospital Setting Used lean techniques - applied to home care and ambulatory clinics Successful at decreasing unnecessary costs Reduced unnecessary steps within various processes Improved patient satisfaction Improved staff satisfaction Improved outcomes Can Lean Apply to LTC and Beyond? Many similarities between continuing care facilities and other healthcare providers Both in the business of providing healthcare services to patients (residents, customers) Waste and inefficiency exists throughout the healthcare continuum regardless of the type of provider or type of organization

3 Issues Facing ALL Health Care Providers Lean is about reducing the time (and cost) involved in providing quality care that responds to the needs of customers, patients, and residents Increasing costs Decreasing reimbursement Increased pressure for quality and efficiency Uncertain & changing market conditions Burdensome regulatory environment: - HIPPA - Accreditation organizations, watchdog groups, etc - FDA, OSHA, state, local, & federal regulations - Medicare, Medicaid regulations, rules, and procedures Answer These Questions Do people spend too much time completing paperwork? Does work get completed that contains missing or inaccurate information? Do people spend time searching for information, supplies, equipment, etc Do different people approach similar work in different ways? Standard Work Do you get inconsistent results? If You Answered Yes to Any of These Questions Lean Techniques Might Just Be Worth Considering! Applying Lean Concepts Lean is a new concept for LTC and other continuing care providers Areas that could potentially benefit from lean: Reduce amount of nurse/staff overtime Reduce time spent searching for things Reduce time residents spend waiting for treatment, tests, and other routine care Reduce excessive inventory Improve overall financial performance My Definition of Lean A performance improvement concept designed to improve processes Lean thinking focuses on four areas: 1) Improving efficiency and optimizing workflow 2) Eliminating non-value added steps, activities 3) Effective workplace organization & visualization 4) Using tools & techniques to improve performance

4 Rethinking Processes Lean involves evaluating how care is delivered and rethinking processes to eliminate waste : - Extra steps - Excess paperwork - Searching - Redundant data entry Lean is About Reducing Waste Non Value-Added Steps, Tasks, and Activities Waste in Healthcare The 8 Wastes Types of Wastes Any healthcare service that consumes resources yet does not add value to the patient/customer Think of waste as anything you produce within your processes that a customer (or payer) isn t willing to pay for Non-value added tasks and activities Lean term is muda 1. Over-processing 2. Delays (waiting time) 3. Process (extra steps) 4. Inventories 5. Motion (people, items) 6. Defects 7. Untapped Resources 8. Misused Resources Do Any of These Forms of Waste Exist Your Operation? Examples of Waste in a Typical Healthcare Operation Top Forms of Waste Over Processing Waiting Defects Inventories Movement & Motion Multiple paper hand-offs, rechecking for signatures, authorizations, repeat paperwork, & excessive paperwork Waiting for authorizations, materials, signatures, physician orders, Rx, paperwork return, approval from others, system downtime, etc. Missing signatures, missed/late visits Excessive inventory, paperwork awaiting further processing, (confirmations, Rx processing, etc.) Missing charts (searching for files), searching for supplies and equipment Preparing for audits Tracking down paperwork Searching for patients, meds, charts, supplies, paperwork Excessive paperwork, information, forms, etc Nurse/staff overtime Incomplete/missing information collected

5 Seeing the Waste in Your Business People in downstream processes waiting for the completion of upstream processes Divide tasks, activities, and process steps into two categories: Non value-added tasks Value-added tasks What people are willing to pay for (valueadded) What people are not willing to pay for (non value-added) Value-Added vs. Non-Value Added What Tasks, Steps, or Activities Do You Consider to be Value-Added? Value-Added: Call lights answered promptly Accurate, timely paperwork Accurate, timely reporting Timely meals at proper temperature Coordinated communication Non Value-Added: Too much overtime Excessive waiting for treatment, meals, tests, approvals, etc Correcting records, charts, forms Searching for equipment, supplies Late, inaccurate communication Key Points About Waste Main product in most health care processes is information At the core of most workflow problems is the inability to efficiently and consistently disseminate information The right information at the right time, the right place, every time Waste is very common in systems where information flow is the main product Hidden Waste It s Very Real Reducing waste can result in reducing the hidden costs of inefficient processes Costs are hidden because you can t easily see them- they are difficult to quantify You don t trip over this waste like the waste on a factory floor But, the waste and associated costs are very real

6 A Lean Perspective Lean is not just about cost-cutting Cost-cutting tends is focused on numbers only Traditional Thinking: Cost + Profit = Price Lean Thinking: Price - Cost = Profit Lean is a way of thinking it is a mindset not just a program focused on cost-cutting! Price Unnecessary Costs (waste) = Profit Beyond Basic Cost Cutting Lean is an alternative to finance-driven costcutting initiatives Lean looks beyond basic cost-cutting exercises to create a culture of waste elimination and operational excellence Brilliant Process Management Process management Real-World Definition of a Process Textbook definition of a process A set of defined interrelated work activities that take inputs and transforms them into outputs that customers value A process is really: A set of activities, tasks, exceptions, and workarounds that have over time, evolved into the way work gets done Work often gets done in some informal, undocumented manner If formal documentation does exist all too often it exists only in the heads of the people doing the work Standard Work

7 The Workaround Culture People create workarounds because a process or system does not support the work that the process/system is supposed to create People are often credited for their ability to create workarounds they are said to be creative thinkers Not really creative thinking People Problem or Process Problem? People want to perform well and do a good job Good people trapped in bad or sub-optimal processes How can we help people perform better within processes? How can we reduce variation, decrease waste, and reduce rework? Can t turn you all into instant lean thinkers and process experts Intent is to demonstrate the potential of lean using a few examples Lean Principle #1 Standard Work The specific examples may not apply but the principles do! Reminder Standard Work As we go through the examples and techniques, think about your business and the daily processes within the business If you can t describe what you are doing as a process, you don t know what you re doing. --W. Edwards Deming

8 Definition of Standard Work Simple written description of the safest, highest quality, most efficient way known to perform a particular process or task It describes the only acceptable way to do the process or task The standard is expected to be consistently followed and continually improved overtime It s about approaching similar work in a similar manner formalizing the informal Common Non-Standard Conditions Failure to perform an activity Failure to perform an activity at a required point in time (work sequence) Taking longer to perform an activity than it should Performing an activity in a way that will have a negative impact on a downstream process Standard Operating Procedure Can You Think of Where These Non-Standard Conditions Exist in Any of Your Processes? Businesses will often say: We already have standard work What they really have is a detailed work procedure often referred to as a Standard Operating Procedure (SOP) A SOP is not a replacement for standard work A SOP is much more detailed than standard work SOP used initially to train staff Bringing Standard Work to Life Standard Work Document: Key Points Include key parts of a process Using standard work documents to help guide people s actions Standard Work Instructions Workflow Diagrams Checklists It includes information on work sequence Any other elements to ensure that an activity is performed in a consistent way overtime (tips, important reminders, must dos etc ) It is a tool to achieve consistent quality of the output of the process, & the performance of the process itself

9 Timing Requirements Standard work should include expected time to complete tasks Expected time for entering patient information is 5 minutes if person is taking 15 minutes, may indicate nonstandard work Expected process times can be expressed as a range to accommodate the variability that exists Expected times are not intended to be punitive in nature Tips for Displaying Standards All of the key elements of the work are present, visible, and easy-to-read General rule is that standard work for a process be described on a one page document Display in area where the work actually takes place Avoid books of information/procedures (not creating a SOP) Example of Standard Work Instructions Name of Process: Standard Work Instruction Task Key Points Time / Timing Visual References 1. Enter Order - Enter demographics (name, DOB, ht, wt, 2-4 minutes 2. Prepare order - Enter Rx info, enter physician/referral info 2-4 minutes Intake, billing, shipping area, patient care areas etc 1 Use diagrams or screen shots here The Power of the Humble Checklist Can improve adherence to process standards and key process requirements: Adherence to standards of care went from 36% to 68% Some as high as 100% Checklists are not intended to be another piece of paper or form to be filled-out They are guides or visual reminders of the main steps that staff should follow each and every time Decreased Shipping Errors by 15% SAMPLE CHECKLIST STOP! Final Shipping Point Checklist 1. Special Instructions Followed 2. Ship-To Address Verified 3. Ship-By Date Noted 4. Inspection Completed 5. Proper packaging, labeling 6. Paperwork placed in return bin 7. Back-Order Status Noted 8. Back-Order Status Communicated Goal: 100% Accurate Orders Intake New Referral Checklist 1. Process Receipt of Referral: (fax, , phone, walk-in) Name Address Phone number DOB HT, WT Emergency contact Employer Diagnosis Social security number Drug allergies Advanced directives Yes No 2. Process Rx: Diagnosis noted on Rx Equipment/supplies noted on Rx Equipment/supplies appropriate for diagnosis Oxygen Rx elements of O2 Rx complete Proper signature 3. Process Insurance: Verify eligibility of primary Secondary payer? Determine deductible/co-pay amount Inform of co-pay amount 4. Prepare Documents: Delivery ticket load inventory, special instructions, deadlines EOB Estimate of Patient Cost PRINT DELIVERY TICKEY

10 Problem with Accurate Paperwork Paperwork Checklist Missing signatures Missing dates Clinicians in the field Incomplete paperwork cannot be confirmed which results in delayed billing and delayed cash collection Serial number(s) correctly noted Special instructions not followed or missed altogether Delayed return of completed paperwork Leadership engaged- worked with staff to design & deploy checklist Lot number(s) correctly noted Signature(s) present Date present If unable to visit patient CS notified Special instructions followed Paperwork turned in within 24 hours Goal:100% complete, accurate, timely paperwork 45 Days After Implementing Checklist Amount of paperwork complete and accurate increased from 84% to 96% Percent of paperwork returned within 24 hours increased from 68% to 89% Missing signatures and missing dates reduced by 7% Everyone followed the same process You can use the same approach in your operation in any area! The Same Principles Can Apply Checklist used as visual aids to help guide people (filling out forms, records, etc ) Ensure correct assist status and fall risk status is noted consistently Visual guides can be used anyplace where standard work can be implemented Can be applied to any business process or functional area Can be applied ED Admission to any business Report process Process or functional area Key points about process Important reminders The New ED Admission Report Process Is Intended To: Improve the coordination of care between the ED and various units throughout the hospital decrease inappropriate patient placement Improve communication and facilitate the exchange of information between the ED and various units throughout the hospital Decrease the amount of wasted time spent on the phone, waiting on hold, waiting for call backs, etc Improve both patient and staff satisfaction Please ensure that you follow the new ED Admission Report Process use the process map as a visual guide and reminder of key process steps that should be consistently followed. Process diagram Typical Benefits of Standard Work Productivity and efficiency improvements of 10% to 25% Greater flexibility to respond to changes in: Demand Activity patterns Staffing changes (unplanned absences, turnover) Improved customer service Reduces rework and errors Improved staff satisfaction

11 Fragmented Task Behavior Where Can You Benefit from Implementing Standard Work? Get People to Approach Similar Work in a Similar Manner So you can get more consistent (and correct) results! Busy offices and administrative areas can have a single staff member performing over 100 discrete tasks per eight hour shift Little or no structure: Work sequence Timing of tasks Prioritization of tasks & activities Expected completion times A person has 40,000 50,000 thoughts per day Why Process Drift? Very difficult to make improvements if a process is nothing more than a series of random events People tend to drift away from established work procedures over time People will often make changes that they perceive will help themselves Changes always impact downstream processes Well-intentioned people create short-cuts They are unaware that short-cuts (and failure to follow process) create unwanted effects for others Help others see their place in the referral-tocash timeline or in a patient care timeline It starts here Rework Delay The Use of Workflow Diagrams Rework Rework Delay Delay Delay Helps to create linkages between people s behaviors in terms of completing tasks and the direct impact they have on a process Can help people understand how their actions impact cash collections Gets people to think beyond their individual areas Foster Line of Sight Thinking

12 Common Objections to Standard Work We can t standardize, we have way too many different processes: You can standardize more than you realize 80/20 rule focus on the few that cause a majority of the issues We just have too much variation in the office area does not lend itself to standard work Most variability is due to lack of standard work Three Lean Best Practice Approaches 1. Managing interruptions effectively 2. Laser-like focus on communication & information sharing 3. Increasing knowledge of entire business process and the role of other areas/people Interruptions An interruption is known as a random arrival in lean lingo Referred to as a "random arrival" because people's reaction to them is often random and non-standardized Instances where staff must stop their work to deal with issues that are not a part of the core process in which they are working in Examples of Random Arrivals Phone calls Questions from staff Urgent s (requests, questions, etc ) Interruptions and Work Habits Workers are interrupted in their tasks every 11 minutes Constant interruptions reduce efficiency by 20% to 40% so office work is not getting done as fast as possible Workers are losing 45 minutes a day due to poor work habits Calculates to 4 ½ work weeks a year Key Points About Interruptions Interruptions are often controllable- the key is to understand their nature, frequency, and duration The use of a log can uncover surprising information and patterns that can be used to modify a process in order to reduce random arrivals Source: Dan Markovitz, TimeBack Management

13 Interruption and Random Arrival Log Name: Will L Month: December 2008 Department: Customer Service Job Title or Function: Intake No. Date Start Time End Time Name Discussion Topic Notes An Example of Managing Interruptions Warehouse staff assumed a majority of calls received from customer service staff were related to requests for product information/pricing 1 12/01/08 9:55 AM 10:15 A.M. Bill Smith 2 12/01/08 10:16 AM 10:20 A.M. Phone call, called wanted to know status of nurse visit called scheduling to check status Phone call, called wanted to know status of wound care supply delivery called warehouse to check Interruption log revealed that 52% of all calls were about delivery status Created an electronic delivery log that allowed staff to check on status without having to call Required delivery staff to contact PT with expected delivery time and backorder status/notification Controlling Interruptions If someone is being constantly interrupted due to their ability, skill, and knowledge, then cross-training should be pushed If interrupts are considered a necessary and unavoidable part of the process, then develop standards to better contain and control non-essential interrupts Limit non-essential interrupts (info not needed in real-time) to a certain time frame Communication Cross-Talk - group huddles What went well? What did not go well? Lessons learned Where can we reduce waste? What special issues, concerns, or problems did you experience in your area? This is an example of building connectivity within AND between your processes Example of Using Communication Regular (brief) meetings between staff, nurses, aides, etc. At every shift change Increased flow & transfer of information Improved patient satisfaction During shift huddle included staff from other areas Spreading Business Process Knowledge Job shadowing: Not intended to create cross-functional experts, just want to enhance awareness of what other people and other areas do You can use a diagram for an order/referral-tocash process or any patient care process, admin. process, etc. create a mental model for staff Will help to foster connectivity and line-of-sight thinking

14 Lean Principle #2 5S: Creating the Visual and Highly Organized Workplace What is This? 5S The Visual Workplace Sort -keep only what is needed red tagging Straighten make sure everything has a place Sweep/Shine clean areas help expose abnormal conditions 5S The 5S method is a concept intended to create a clean, highly organized, & efficient workplace Standardize develop method to monitor and maintain the first three S s Sustain use self-discipline to maintain the 5S workplace Why Sort? Get rid of unneeded items Free up valuable floor space to organize needed items Reduce inventories Free-up resources Improve flow of people, information, & materials Sort- Red Tagging Are there any items not necessary to fulfill a purpose/function which are currently in the immediate work area? Red tag unneeded items Identify items that could potentially be removed from immediate work area Red-tagging gives you a good visual of how much clutter you have

15 Office and Warehouse Junk Piles of Stuff from Office 5S Event Post Red-Tag Event Office Supplies From People s Desks 5S Before and After A PLACE FOR EVERYTHING AND EVERYTHING IN ITS PLACE!

16 Staff Searching for Meals Before Lean After Lean This is excess inventory- how much does this cost?

17 Training Aid Helps to Maintain the 5S Environment Name Action Catch Phrase Use of Color-Coding for Organization Sort Remove unnecessary items from the workplace When in doubt, throw it out Straighten Locate everything at the point of use A place for everything, and everything in its place Red bins = diabetic supplies Sweep Standardize Clean and eliminate the sources of filth Make routine and standard for what good looks like The best cleaning is to not need cleaning See and recognize what needs to be done Green bins = oxygen disposables Yellow bins = catheters Product locator maps Sustain Sustain by making 5S second nature The less self-discipline you need, the better Can color-code files too Assess Worker Movement (Footsteps) Assess & Improve Walk Pattern Metric Base After Improvement How can you optimize the flow/movement of people, materials, and equipment? RN assessment time per patient (min) RN walking distance per patient (meter) Patient prep to surgery per patient (min) % % % Best Practice Use of Visual Signals Provider delayed return of signed forms: Developed program to interface with software system Wall mounted monitors tracked receipt of pending paperwork changed color based on number of days outstanding - Improved overall turn around time (TAT) by 21% - Increased staff motivation- and performance! Wall monitors

18 Visual Controls Consider using status boards and/or wall-mounted monitors to communicate real-time work status Helps create a heightened sense of awareness Example of Work Status Boards The use of status boards, standard work documents, and other visual aids in the work area is a key lean concept A form of visual sense-making Arrival Signals Know when work has arrived at the next step in a process (and when its ready to move on) A New Fax Has Arrived! As simple as using color-coded magnets on in-baskets or color-coded Post-It tabs Provider had a light that turned-on when paperwork was ready for the next step This is known as visual signaling Be creative

19 Creating a Lean Flow Avoid lumps of work piling-up Visual management practices combined with standard work practices can help reduce errors and the rework that these errors create Don t process larger piles of work over a compressed time frame Reduce piles- process work at regular, predetermined intervals over a longer period of time More on Lean Flow Batch size reduction Work-leveling Focus intensely on cross-training as much as possible: More flexibility when staff are unavailable Able to adjust for fluctuations in volume Can increase staff satisfaction as they expand their skill-set and knowledge base Drowning in a Sea of Waste LTC and other providers devote a lot of resources (and money) to: - Completing paperwork documentation - Attending meetings - Entering data A lot of manual work Can leverage technology much more effectively to become more efficient Leveraging Technology Some organizations are relying on voiceassisted care technologies and less on laborintensive data entry Has resulted in: Reduced nurse overtime Enhance data and information capture Increased reimbursement Greatly reduce paperwork Voice Activated Technology Enables caregivers to multi-task Work more efficiently Helps to speed up work Helps to reduce errors Documentation at the point of care Facilitates efficient communication among staff

20 Healthcare Providers & Processes A Healthcare provider has many processes and core business processes Lean Principle #3 Process Management Learning to See Several sub-processes As a healthcare provider, you deliver services and products through a series of processes A value stream is a fancy word for a process Idea Behind Value Stream Mapping First Input Process Visualization Before you can improve a process, you have to understand it you have to be able to see the process Final Product The Value Stream Map Low-tech, visual representation of every step within a process The work (current state) becomes visible Understand how work flows Provides a blueprint or plan for future improvement If you change the way you look at things, the things you look at will change. - Unknown Provides an effective, new way to see a process

21 Always Begin With the As-Is Process Don t map-out the ideal or planned process map the current state Select a process with a manageable and logical start/end point Gather people that work in the day-to-day process They will almost always tell you how the process is supposed to work Go to the Gemba Can t simply ask people how the process performs Basic Steps: Value Stream Mapping Identify all main process steps in proper sequence Identify more detailed tasks that take place at each process step Identify any tools used at each step Identify technology used and people used at each process step Identify process-level metrics where ever possible Process-Level Metrics A VSM differs from a basic flow chart because a VSM includes key process-related data Typical data to measure & assess: First-time-quality Process time Wait time Lead time First Time Quality (FTQ) How often you complete a step in a process without requiring rework Example: Amount of complete & accurate paperwork Process (or cycle) time Time it actually takes to complete a task within the process Example: Filling out a form Wait time Step within process, being worked on, not yet complete Example: Waiting for information, waiting for equipment Lead time Cycle time + wait time VSM Data Definitions The Importance of Process-Level Metrics Pushes accountability to the lowest level Pushes learning to lowest level Allows variation and problems to surface Serves as focus indicator

22 Analyzing the Value Stream Map Once you have completed the current as-is value stream map, identify waste: Rework loops Handoffs & Bottlenecks Excessive waiting Low first-time-quality Assess technology does it help or hinder? Seek to reduce steps, digitize, combine or eliminate Look for Non-Value Added Steps Ask: Is the step, task, or activity essential for providing care? Would the patient or resident be willing to pay for this activity or step? If you removed the step, would it have any impact on the process? If you answered no to these questions, then the step or activity is non-value added Major Process Step Process Metrics Task Details Technology Used People Available Lessons Learned From a VSM Exercise Eliminated an entire step that added 5-7 days onto lead time (order received until equipment delivered) Combined the previous separate steps into one process step (reduced hand-offs) Every hand-off almost always results in a new queue forming (waste) Lots of disagreement about timing & sequence Go See Those who assume they know the process, without having mapped it, will probably find surprises when they map the process Data are of course important, but I place greater emphasis on facts. -Taiichi Ohno

23 It is assumed that there will always be problems around planning & problem-solving No problem is problem! Preventing Patient Falls Patient Movement Remember Know Risk Status and Assist Level Before Moving Patient! You must bring your processes to life put your processes on the wall Maps stay on wall to allow others time to reflect and provide input Process Mapping Summary Visually demonstrates the sequence of events that affect or produce an outcome Try to capture the amount of time it takes to complete each major process step Always begin with the current, as-is process Involve people that are actually working within the process Key to Successful Process Mapping First get the primary process steps down Then dive deeper into each piece of the map Goal is to ultimately uncover each step and each layer of complexity

24 You can apply the same process mapping technique to any of your patient care or administrative processes! Lean Leadership The Role of Leadership in Lean The tools and techniques won t work without leadership commitment and engagement Leadership is what will determine success or failure of a lean initiative Definition of lean leadership: Helping people address problems and seize opportunities to make your organization better The Missing Link Lean leadership is often the missing link between theoretical solutions and actual practice Successfully applying this link is the difference between superficial attempts at lean implementation and full deployment Remember, avoid drive-by lean In a Lean Business.. Managers are responsible for defining processes, tracking process performance & process improvement Most managers fail to understand the concept and instead rely on firefighting Good process management is the difference between being reactive vs. being proactive Effective Lean Leaders Coach and develop others Cultivate lean thinkers throughout the business not just an army of cost-cutters Strive to institutionalize lean create a new mindset people focused on waste elimination and process excellence Helps others to relentlessly focus on reducing waste and improving processes

25 A Lean Leader s Responsibilities Take away excuses from the people working in the processes by: Implementing standard work as much as possible Providing formal training (lowest level) Providing consistent feedback Creating more visible, highly-organized workplace Placing problem-solving responsibility on them Excuses The coach s job is to take excuses away from the player no travel problems, no equipment problems, no bad practices, no bad game plans so that there is nowhere for the player to look but in the mirror. Barry Melrose (Canadian Hockey coach) Lean Leaders and Standard Work It is the responsibility of managers and supervisors to ensure standard work is followed Staff not following a process provides an opportunity for leaders to affect process improvement Simply allowing people to consistently circumvent established process will result in endless variability Seven Things Not You Should Not Do 1. Don t let yourself get talked out of doing it 2. Don t give it a name 3. Don t make a speech or a company wide announcement 4. Don t make it the responsibility of one area 5. Don t isolate it from the day to day business 6. Don t order coffee mugs, tee-shirts, banners, etc Don t worry if you are not sure what you are doing A Roadmap to Lean Educate management and other leaders Beginning the Lean Journey: Tips on Getting Started Then train to the lowest level in the organization Explain what lean means, why it s important Provide rationale for the need to become efficient given current market conditions: Payers are not going to give you extra money Can t really set your prices Current economic environment

26 Lean Education Very important part of a lean transformation Most organization have some success with lean Strong correlation between the level of success and the amount of education provided I don t have the money to train Why Continue to Pay for Waste? Yet money is available to continue funding the waste that is present in operations Waste has essentially been budgeted and approved It s difficult to quantify, you can t see it Why not dedicate resources to creating a culture of waste elimination? Lean Building Blocks Stage 1 Stage 2 Stage 3 Stage 4 Lean Awareness Preparing for Lean Implementing Supporting Lean Intro-Lean Thinking: Leaders Staff Seeing the need VS Mapping basics Basic tools: 5S Standard work Lean Assessments: Identify waste Select targets Prioritize projects Project selection Select teams Baseline metrics Change Mgt. Project Mgt. Standard work Lean Leadership Lean Metrics Post Project Metrics Key Points Training Seek Out Waste Start Small! Never Ending It begins with leadership Recap Implement standard work wherever you can Clarify roles & responsibility Use checklists and visual aids to help guide people in their daily work Use mistakes & missteps as learning opportunities Use process-level metrics Toyota Production System (TPS) You will make mistakes It is not just about recovering from mistakes It is also about learning from the mistakes In healthcare, we make mistakes and just recover

27 Traditional Business vs. Lean Business Traditional businesses think of a plan: - As a prediction of what will happen Lean businesses think of a plan: - As an experiment to be conducted - To tell us what we didn t know about the work - You won t know until you try - Observe, assess, and change plan as needed Workers and Managers Should Experiment as Frequently as Possible Spear, 2004 Having the Right Focus Don t be overly focused on the tools alone Understanding and applying lean tools does not mean you are a lean organization Tools can be applied Rules, Not Tools Must pass the acid test : - Do the results last beyond a few months? Have you really changed behaviors? Profile of a Successful Lean Businesses They experiment with process changes They cultivate lean leaders & leadership behaviors They embrace lean problem-solving Have a project management orientation View lean as an organizational way of life not just a one-time process improvement project Successful Lean Businesses Achieve fewer defects Use less time to complete work Have minimal rework Are more consistent Achieve greater customer (patient) satisfaction Solid profit and market performance

28 No Magic Recipe for Lean Take a pragmatic approach Final Thoughts Harness early adoption of select lean tools Gain some early (and visible) success Work closely with staff & leaders in the organization that have influence Focus on developing work standards and visualize the work as much as possible through visual management Something to Consider.. Lean (or any P.I. approach) is not just a program: It s the way you work Quality and P.I. is not something you do, it s who you are Most P.I. efforts have a top-down approach Front-line staff must be the driver of P.I. initiatives, otherwise, they won t be sustainable A Change in Thinking The fundamental reason for Toyota s success is a superior lean business model in which senior managers focus on turning every process into a brilliant process rather than making the numbers and keeping the assets busy in their area. Every manager and employee takes responsibility for solving problems to further improve these processes. A problem solving, process focus drives the efforts of the whole company. Dan Jones - LEA E-Newsletter Effectiveness Can = Simplicity Recommended Resources Organizations AME Books: Lean Thinking overview of the lean concept Learning to See Process mapping workbook Lean Solutions The Toyota Way Contains 14 management principles According to statistics, since the icon of the fly has been in use, it improves the aim. If a man sees a fly, he aims at it. The general hygiene in the toilets has improved by 80%

29 Lean Homecare Consulting Group, LLC Lean thinking training seminars & workshops Leadership and communication training 5S workshops 5S implementation Process evaluation & process redesign Workflow optimization tactics and training Project management Service for LTC and Homecare providers Phone: