Authors: Adriana L. Chavez, PhD; Tatiana Hmar-Lagroun, MBA

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1 Applications of Lean Methodologies at MD Anderson Authors: Adriana L. Chavez, PhD; Tatiana Hmar-Lagroun, MBA Acknowledgments: Victoria Jordan, PhD; Larry Vines, MBA; David Bivens, MS; Parviz Kheirkhah, PhD; Ron A. Phipps, MBA The University of Texas MD Anderson Cancer Center is a comprehensive cancer center devoted to cancer patient care, research, education and prevention. In the past year, MD Anderson provided care to more than 108,000 patients, resulting in over 1.2 million outpatient clinic visits and over 10.9 million pathology and laboratory medicine procedures. In addition to its 36 care centers and clinics, MD Anderson is the only comprehensive cancer center with its own Emergency Center. The large quantity of distinct processes and the high patient volume result in complex systems that can benefit from the use of the Lean methodology to reduce waste and increase efficiency. The Office of Performance Improvement at MD Anderson includes a group of fourteen Quality Engineers who apply Industrial Engineering methodologies and tools to improve patient care processes. The Quality Engineering group leads and facilitates process improvement teams consisting of clinical and administrative staff by applying the lean methodology. Projects range in scope from applications of a single Lean tool to multi-objective division-wide initiatives. Interactive Lean courses have been designed to provide training to frontline clinical and administrative staff who will lead process improvement projects in their areas. Close to 600 employees have been trained to date. A one-day course is designed for individuals who will serve as team members of lean projects, covers the basics of 16 Lean tools, and includes the Paper Airplane Lean Exercise to illustrate key Lean concepts with a hands-on experience. This

2 course is offered to departments interested in learning about process improvement, to teams already involved in improvement projects being led by engineers, and as part of an eight-day Clinical Safety and Effectiveness course that involves teams independently carrying out a process improvement project with Quality Engineers serving as facilitators. The Quality Engineering group also offers a two-day Lean course which provides more content depth and multiple hands-on activities designed in-house. This course is designed for individuals who will serve as team leaders of lean projects, and who will need a more in-depth understanding of how to apply the Lean tools. This course also covers other tools and materials for how to run projects, how to measure impact, and tips on how to deal with common challenges when leading projects. Lean tools have been applied in many areas throughout the institution achieving great results; here we provide some noteworthy examples. In the Perioperative Enterprise, lean tools including a value-stream map were used to identify opportunities for improvement. The ordering and delivery process for all perioperative consumable supplies was analyzed, resulting in the following changes being implemented. The point of supply delivery was changed to be the building in which they would actually be used. This reduced interdepartmental transfers by 80% and the corresponding interdepartmental transactions performed by the accounting department. Additionally, an automatic reordering process using bar code scanners was implemented, resulting in a 48% reduction of on hand inventory. These process changes also resulted in annual labor savings of $47,376, and the material restocking lead time went from 33.1 to 8.3 hours.

3 Value-Stream Map for Supply Delivery Process in Perioperative Enterprise In the Leukemia Center, a Lean team worked to streamline the patient flow and improve the patient experience by reducing patient wait time and walking distance. This specific patient population had to come to the center to draw blood multiple times a week. A spaghetti map was developed and it revealed that all patients (New, Follow-Up, Fast Track, etc.) had to walk through the same areas, which caused congestion in the center. Improvements included utilizing space that became available from another center to reduce congestion, routing each patient to the laboratory closest to their provider s clinic, arranging workstations close together, and using a pull system with lights as a signal for patients to flow through the process. As a result of these Lean implementations, the walking distance for the patient was reduced from 680 feet to 70 feet (a 90% reduction).

4 Spaghetti Maps to Reduce Patient Walking Distance in Leukemia Center, Before and After An initi ativ e in the Div isio n of Pharmacy resulted in the completion of ten projects over one month following a series of twoday and one-day Lean training sessions for 60 employees and 15 managers. The projects were carried out by pharmacy staff with minimal facilitation from Quality Engineers. There were no monetary investments required for any of the projects, and they have resulted in waste and

5 process time reductions, and financial savings. Results obtained include a 67.5% reduction in chemotherapy waste, generating annual savings of $578,640, and a 40% reduction in process time for telephone prescription, resulting in time savings that translate to an estimated $25,000 per year. The use of Lean tools has proven valuable at MD Anderson to improve efficiency in patient care processes. Some Lean improvement projects have been facilitated by Quality Engineers, while others have been designed and led by frontline staff trained in Lean methodologies. Improvements achieved through the use of Lean tools have reached many areas of our hospital, including Cancer Prevention, Nursing, Interventional Radiology, Emergency Center, Pediatrics, and procedure areas. A team from the Pathology & Laboratory Medicine led by their Project Director, also a Quality Engineer, won the Lean Best Practice Award from the IIE Lean Division at the 2012 IIE Conference for their implementation of multiple projects. Lean training efforts have expanded beyond MD Anderson to include the University of Texas System, as part of the UT Systems Engineering Initiative. The investment in a strong Quality Engineering group and the large quantity of Lean-driven projects and Lean training courses reflects the importance that MD Anderson places in delivering healthcare efficiently and effectively.