Introduction to understanding lean thinking in healthcare. Dr. Luke Feeney

Transcription

1 Introduction to understanding lean thinking in healthcare Dr. Luke Feeney

2 Beginning with the end in mind 1. Webinar objectives 2. Solid foundations (Introduction, understanding waste, concepts, principles and benefits) 3. Introducing a selection of tools and techniques 4. A quick word on Lean-Six Sigma 5. Final thoughts

3 1. Webinar objectives To present an introductory guide to promote critical, lean healthcare thinking to underpin better understanding of lean concepts, principles, techniques and tools in healthcare and thereby contribute to improving efficiency, quality and patient safety

4 2. Solid foundations: Introduction Developed in the 1950s by Toyota (Toyota Production System or TPS) based on the work of W. Edwards Deming and commonly referred to as lean thinking or just simply lean. Aims to: Streamline organizational processes to improve quality and patient safety through waste reduction and increased efficiency. To provide internal/external customers/clients with value through minimizing wasted time, effort and cost Identify and modify/eliminate non-value add activities and actions to reduce waste and provide improved organizational capacity and performance (Institute for Healthcare Improvement, 2005; Lord & Smith, 2014; Powell, Rushmer & Davies, 2009; Spath, 2013).

5 2. Solid foundations: Introduction (cont.) Through the disciplined application of critically selected lean principles, techniques and tools, healthcare organizations commit to identifying and eliminating waste in their systems and processes resulting in improved efficiency, quality and patient safety for all our customers/clients - external and internal. In an ideal lean-focused or lean-cultured healthcare organization, each staff member will arrive into work each day critically considering how they can improve their work environment and services through reducing waste to underpin continuous quality improvement. (Ahlstrom, 2010; Spath, 2013)

6 2. Solid foundations: Waste in healthcare Anything other than the minimum amount of organizational equipment, space and staff time which are essential to add value to an organization s healthcare product or service. underpins underpins Understand your customers/clients => someone who uses something produced or provided by a previous step in a service process: Patients, their family, the public potentially seeking healthcare services, etc. The internal customers/clients operating along a patient pathway or journey. (Lord & Smith, 2014)

7 2. Solid foundations: Waste in healthcare (cont.) Type Description Example Correction Rework and repeat work due to faulty processes Patient readmission Waiting Staff can t process their work as waiting for people, equipment, information, etc. So many!! Transportation Moving materials unnecessarily Centralised storage Over-processing Unnecessary processing adding no value Duplication of information Inventory Too much work in progress and/or stock Excess stock not being used Motion Unnecessary people motions, travel, walking, searching Requirements for work out of reach Overproduction Producing more than is needed, or earlier than needed Requesting unnecessary tests (Adapted from Lord & Smith, 2014).

8 2. Solid foundations: Concepts Leadership Strategic framework Lean concepts Culture Process (Institute for Healthcare Improvement, 2005)

9 2. Solid foundations: Concepts - leadership (Institute for Healthcare Improvement, 2005) Leadership Whole-system approach only successful when enabled/ facilitated by senior leadership - not simply delegated. Will require change (traumatic and challenging!), strong, committed, inspirational and critically knowledgeable leadership essential. Simply stated, organizational leadership, aligned and supportive of the vision, principles and understanding of lean, is a CRITICAL FOUNDATION for the successful lean implementation!

10 2. Solid foundations: Concepts - culture (Institute for Healthcare Improvement, 2005) Culture A lean culture is an organizational environment or framework within which lean techniques and tools can be successfully implemented and sustained. Clear lean-aligned organizational mission, vision and objectives to ensure the right organisational choices. Seek to flatten or level structures to eliminate hierarchy and organize staff into operational teams based on products or services provided.

11 2. Solid foundations: Concepts - culture (cont.) (Institute for Healthcare Improvement, 2005) Culture Functional silos Multidisciplinary, collaborative teams Direct, order and just as good Name, blame, shame and re-train Teach, enable, facilitate excellence Systems analysis (RCA) Individually-focussed incentives Team-focussed incentives Suppliers suspicion ( enemies ) Suppliers are partners in excellence Protect information Collaboratively share information Internal, expert-driven focus External process-driven customer focus

12 2. Solid foundations: Concepts - process (Institute for Healthcare Improvement, 2005) Process Creates exactly right value for customers/clients in every step. Capable of producing a good outcome every time. Available to produce the desired output and quality every time. Adequate and does not cause delay (a non-value add activity). Flexible to respond to different customers/clients and needs. Linked by a continuous flow throughout all process steps.

13 2. Solid foundations: Concepts - strategic Strategic framework Problem solving Solve problems by root cause analysis People and partners Respect, challenge and grow them Processes Eliminate waste The right process will deliver the desired result Philosophy Long term thinking Continuous improvement (Liker, 2004)

14 2. Solid foundations: Principles 1. Specify VALUE from the customer/client viewpoint 5. Pursue PERFECTION in quality and quantity by continuous improvement Introduce standard working Remove waste Set up visual management Eliminate batching Identify root causes 2. Identify the VALUE STREAM and remove waste 4. Initiate FLOW in alignment with customer/client demand ( pull ) Make value FLOW 3. (Adapted from Institute for Healthcare Improvement, 2005; Lord & Smith, 2014)

15 2. Solid foundations: Principles => project stages (Adapted from Institute for Healthcare Improvement, 2005; Lord & Smith, 2014) 1. Specify value 2. Identify value stream/patient journey 3. Make process and value flow 4. Let the customer pull 5. Pursue perfection

16 2. Solid foundations: Benefits Activity which benefits/is impacted Benefit/impact (validated industry average 1 ) Direct labor/productivity improvement 45% - 75% Reduced costs 25% - 55% Increased throughput/flow 60% - 90% Reduced quality defects/scrap 50% - 90% Reduced inventory 60% - 90% Reduced space 35% - 50% Reduced lead time 50% - 90% 1 Summarized results following a five (5) year evaluation study of various companies in various industries implementing lean from one (1) to more than seven (7) years. (Adapted from the Institute for Healthcare Improvement, 2005)

17 2. Solid foundations: Benefits - healthcare Elimination/reduction of waste => better management of resource costs. True value processes => for all stakeholders. Improvement of process and patient flow => greater/faster services. Elimination of ineffective effort => increase in productivity. Safer/more reliable services using standardized procedures/equipment. Improved staff morale => lean is best delivered as a bottom-up approach. Reduced incidents of errors and mistakes. Improved patient education. Reduced wait times. Improved clinical outcomes. Increased staff productivity. Reduced clinical and management costs. (Institute for Healthcare Improvement, 2005; Lord & Smith, 2014; Powell et al., 2009)

18 3. Tools/techniques - introduction Lean stage ALL stages Suggested tool/technique Change management; project management; PDSA; Six Sigma; Data collection/analysis; A3 reporting; Visual management; Kaizen events; Brainstorming; Affinity diagram. 1. Specify value Voice of the customer (VOC); Gemba walk; Kano model. 2. Identify the value stream and remove waste Flowcharting; Value stream mapping; Takt time/rate. 3. Make the process flow 4. Let the customer/client pull Flowcharting; 5S s; RCA; Defining Takt time/rate. 5. Pursue perfection

19 3. Tools/techniques - data collection/analysis Before starting a lean project or activity it is vital to establish organizational understanding of what the aim of the project or activity is and what the measures to prove success or failure are. Examples can include: # patients on waiting lists Length of stay Admissions/readmissions Patient experience Waiting days Staff morale Turnaround times # incidents/defects # complaints Cost Quality Answers key measurement questions : How will you achieve an understanding of a current state? How will you know where to focus your change/improvement efforts? How will you know if your lean project/activity has made a difference? Don t forget to baseline!! (Agency for Healthcare Research and Quality, 2014; Benneyan, Lloyd & Plsek, 2003; Lord & Smith, 2014; Spath, 2013)

20 3. Tools/techniques - data collection/analysis (cont.) IMPORTANT FOOTNOTE: Better is not measurable Soon is not a timescale Some is not a number More, faster, safer or more cost effective can only be measured if organizations understand how many, how fast or how expensive their processes, products and/or services were to begin with... (Lord & Smith, 2014)

21 3. Tools/techniques - A3 reporting Define problem or opportunity: (What is the problem/opportunity for improvement to be solved?) Project management details: (Project team member; approvals, dates, etc.) Current state: (What is happening now? Use value stream maps, measurements, data graphs, etc.) Desired future state: (What does the desired future state look like? A value stream map is recommended.) Problem/opportunity for improvement objective(s): (Stated in SMART format - specific, measurable, achievable, relevant/results oriented, time-based/bound.) Action plan: (The what, why, whom, when and how, based on the PDSA cycle - plus progress update entries.) Waste identified: (Correction (defects), waiting, transportation, over-processing, inventory, motion, overproduction.) Outputs (results) and measures: (What was the PDSA cycle? Timeline? Before-after data collection comparison and analysis using diagrams, charts, graphs, etc. plus return on investment analysis.) Root Cause Analysis (RCA): (What is the root cause of the problem/opportunity for improvement? Use 5-whys, fishbone/cause-effect diagram, etc.) Post-project next steps: (What are the next steps? Are there any issues still remaining? Is follow-up required?) (Adapted from Lord & Smith, 2014)

22 3. Tools/techniques - Kaizen event (George et al., 2005). Kaizen, a Japanese word for continuous improvement (literal translation to become good through change ) is a method for accelerating the pace of process improvement - of restructuring and reorganizing all aspects of an organizational system to ensure that it operates at its optimum efficiency Characteristics: Teams work for 3-5 days exclusively. Dedicated resources including 100% dedicated/protected staff time. Scope and purpose critically defined and cannot be altered. Basic baseline data collected prior to start. Implementation is immediate and completed within the event timescale. Actions not completed with the timescale, completed within 20 days. Senior management ensures support in place.

23 3. Tools/techniques - Kaizen event (George et al., 2005). Day Activities Team fully briefed on project including scope and purpose; training provided (as required); all clarification requests and questions addressed; data collection/measurement started through the creation and validation of a value stream map (including observation of the process) Measurement continues until all data is collected then project focuses on data analysis to support identification of root causes of issues or problems with current processes. By afternoon, project team will have progressed onto working on improvement solutions including developing criteria, evaluating alternatives, conducting a pilot, etc. Pilot improvement implementation completed with progression onto policies, procedures, protocols, guidelines, training and other appropriate resources to assist with broad implementation. Presentation of Kaizen event results (outputs), clarification and answering of any questions plus seeking of senior management approval and mandate for full-scale implementation. Full-scale implementation consulted on, and guided by, Kaizen event team, and must include on-going evaluation to ensure reliability and sustainability.

24 3. Tools/techniques - Voice of the customer An understanding of the wants and needs of customers/clients - internal and external. Fundamental to any business or service and through implementation of the outcomes of VOC data gathering (as well as other quality improvement principles!), healthcare organizations can critically engage all stakeholders - staff, patients, patient families, etc. - in the design and improvement of services. (Health Quality Ontario, 2013)

25 3. Tools/techniques - Voice of the customer Method Focus groups Provides Information from customers/clients with similar product/service needs; mid-to-low level participation. Interviews In-person: Telephone: Personal/unique perspectives; high-level participation; flexibility with questioning; in-depth understanding. In addition: widely dispersed customers/clients; low cost data. Surveys Complain feedback or data Quantifiable and statistically meaningful responses; information from many customers/clients; confirmation of theories developed which are based on other forms of customer/client contact Deep understanding of experiences of products/services from internal and external customers/clients. (Health Quality Ontario, 2013)

26 3. Tools/techniques - Gemba walk Element Go see Implementation guidance Gemba walks should provide deep understanding of the alignment of organizational purpose, process and people by leaders and managers walking around with staff working at the sharp end. Ask why Ask what?, why?, what if? and finally, why not? to provide deep understanding of what processes take place, why, what improvements could be achieved by making changes and why we should improve. Show respect Leaders and managers must show respect to all staff as well as customers/clients - especially the staff who are delivering the value-creating work of the organization; equally important to identify signs of disrespect towards staff (overburdened/stressed) and customers/clients (poor service delivery/poor quality service). (Adapted from Shook, 2011)

27 3. Tools/techniques - Value stream mapping VSM provides a visual representation of all the activities and actions currently required to deliver a product or service (internal or external) documenting work activities and information movements throughout an entire patient pathway - from origin to final point of service delivery. A desired, improved future state VSM is similar with the exception that it is designed and developed by an improvement team based on analysis of the current state VSM to ensure improvement through changes. (Lord & Smith, 2014)

28 3. Tools/techniques - Value stream mapping (cont.) & 5 7 (Lord & Smith, 2014)

29 3. Tools/techniques - Value stream mapping (cont.) 4 core techniques to assist with development of improved future state: 1. Eliminate: wherever possible eliminate process steps not required/no value. 2. Combine: if it is not possible to eliminate, combine (as is appropriate). 3. Simplify: consider how/where processes can be simplified (no compromises!). 4. Sequence: review the sequence of events/activities to promote efficiency. Additionally important to consider: Takt time = the rate of work required to keep up with service demand. The removal of waste. The introduction of value flow. Available work-time Demand (Lord & Smith, 2014)

30 3. Tools/techniques - 5S s Step Definition Example Sort What is needed from what is not - keep only what is needed in amounts needed only while needed! Remove out-of-date/broken stock, equipment, etc. Set in order Arrange required items so they are easy to access and use - including storage locations. Clear labels and descriptions, colour coding, etc. Sweep/shine Create a clean and tidy work environment - no dirt, mess, clutter and dust - all the time! Clutter-free with highest standards of infection control Standardize 1 st 3S s part of everyday activities and implement standards and procedures for routine tasks. Clear roles/responsibilities for all; standardize A-D-T. Sustain Monitor, measure, evaluate to continuously improve and sustain gains. Culture of vigilance, CQI and critical evaluation. (Lord & Smith, 2014; NHS Institute for Innovation and Improvement, 2007)

31 4. A word on Lean-Six Sigma The key to effective Lean-Six Sigma implementation is to find the best combination of both approaches - for example: Adopting Lean concepts to focus on what adds value to a patient process and then apply Six Sigma tools to help better understand and manage variation once the value add (value stream) is collaboratively agreed. A practical approach will avoid confusion with integrated definitions, terminology, etc. by using Lean and Six Sigma where necessary - that is use Lean where Lean is necessary or Six Sigma where Six Sigma is necessary. Common sense (Lean) + Common science (Six Sigma) = potential uncommon results and benefits for healthcare! (Bevan, Westwood, Crowe & O Connor, 2006)

32 5. Final thoughts Healthcare can/must learn and implement lean concepts/principles. In the final analysis, lean can reduce/eliminate wasted time, Great news - the lean message is 100% positive - adding value to patient care, money improves and quality energy, and safety creating - creating a system a virtuous that circle is efficient, not a vicious effective one! and responsive to patient needs - the real customers/clients at the heart of everything that is seen and done in healthcare. You need leadership and leaders; willing/competent staff teams; be courageous, forward-thinking and sharing your experiences, creating an organizational culture for lean thinking - be lean champions! (Institute for Healthcare Improvement, 2005; Jones & Mitchell, 2006)

33 References Agency for Healthcare Research and Quality. (2014). Using Quality Measures. Retrieved April 13, 2015, from Ahlstrom, J. (2010). Using the 5S Lean Tool for Health Care. Healthcare Information and Management Systems Society. Retrieved from Benneyan, J., Lloyd, R., & Plsek, P. (2003). Statistical process control as a tool for research and healthcare improvement. Quality & Safety in Health Care, 12(6), Bevan, H., Westwood, N., Crowe, R., & O Connor, M. (2006). Lean Six Sigma: some basic concepts. NHS Institute for Innovation and Improvement. George, M. L., Rowlands, D., Price, M., & Maxey, J. (2005). The lean six sigma pocket toolbox. New York: McGraw-Hill. Health Quality Ontario. (2013). Quality Improvement Primers: Voice of the Customer. Health Quality Ontario. Institute for Healthcare Improvement. (2005). Going lean in Health Care. Institute for Healthcare Improvement. Jones, D., & Mitchell, A. (2006). Lean thinking for the NHS. London: NHS Confederation. Liker, J. (2004). The Toyota Way: 14 Management Principles from the World s Greatest Manufacturer (1 edition). New York: McGraw-Hill. Lord, Z., & Smith, L. (2014). Bringing lean to life: Making processes flow in healthcare. NHS Improving Quality.

34 References Agency for Healthcare Research and Quality. (2014). Using Quality Measures. Retrieved April 13, 2015, from NHS Institute for Innovation and Improvement. (2007). Going lean in the NHS. NHS Institute for Innovation and Improvement. Powell, A., Rushmer, R., & Davies, H. (2009). A systematic narrative review of quality improvement models in healthcare. Scotland: Healthcare Improvement Scotland. Retrieved from w.aspx. Shook, J. (2011). How to Go to the Gemba: Go See, Ask Why, Show Respect. Retrieved from Spath, P. (2013). Introduction to healthcare quality management. Chicago, Ill.; Washington, DC: Health Administration Press ; AUPHA Press.