Case Study LEAN in Healthcare: Seeing with NEW Eyes

Transcription

1 Case Study LEAN in Healthcare: Seeing with NEW Eyes Presented May 19, APHL Annual Meeting EquiLABration Balancing Technology, Quality, & Advocacy Rick Panning, MBA, CLS(NCA) CEO, American Red Cross North Central Region ASCLS President,

2 Objectives Understand LEAN principles Why the Lean methodology was chosen for Fairview laboratories Review pilot implementation process at a large, suburban hospital Project results / lessons learned.

3 The building blocks of Performance Excellence Quality Improvement Methods (e.g., FOCUS-PDCA, LEAN, 7-Step, DMAIIC, Rapid Cycle Improvement) Accelerated Change X = Effective Performance Excellence Clinical and Financial

4 Why? What are our challenges? Cost versus Quality Increased awareness of medical errors Difficult to correct problems in complex health care delivery systems Solutions involve redesign and reorganization Patients needs are unmet

5 Remedy Recognize quality failings Define and prioritize problems Engage leadership, management and research tools to recognize and measure appropriate inputs and outputs Analyze relationships between variables Implement and sustained solutions

6 The American health care system is remarkable for its technological achievements, but it is also potentially dangerous even lethal in its execution.

7 Lean Philosophy Add value to a product with a minimum of non-value-added activity or waste Waste = unnecessary work, enforced idle time, unnecessary resource use, high inventory Muda is any human activity which absorbs resources but creates no value. ( T. Ohno, 1988) Waste is anything, time, costs, work, that adds no value in the eyes of your customer. (M. George, 2003) Customer defines value

8 History of Lean Production Toyoda Family Sakichi Toyoda late 1800s Inventor built weaving looms Developed automatic power looms Began the concept of mistake proofing Kiichiro Toyoda founder of Toyota Motor Company in the 1930s. Philosophy of company based on two pillars: build in quality (mistake proof) and just-in- time (pull system)

9 What is Lean? Relentless pursuit, identification and elimination of waste in all business processes in order to produce value for the customer.

10 8 Types of Waste Overproduction the MOST fundamental Waiting (time on hand) Unnecessary transport Over processing Excess inventory Unnecessary movement Defects and errors Unused employee creativity

11 The Lean Challenge Develop the ability: To recognize and identify waste To have the courage to call it waste To have the desire to eliminate it To eliminate waste To understand that waste Raises costs Produces no value Threatens jobs and employee satisfaction Adapted from SMC Group

12 Core Principles of Lean Start with the customer what value does the customer want from the process? One Piece Flow versus Batch & Queue First In/First Out Mistake proofing Unified Layout Standard Work Visual Management Control

13 Eliminating wasteful and meaningless work enhances the value of work for all employees and better serves our patients and community.

14 Case Study

15 Understanding the Need for Change How does your laboratory fit into the overall organization and provision of care? How can the laboratory enable high quality, safe cost-effective care? How is the laboratory performing? How will LEAN help you improve these measures? Productivity and Cost per test Turnaround time compliance Error rates (patient safety, quality)

16 Reasons for implementing LEAN at Fairview Southdale Planning for automation Planning for facility improvements / expansion Significant need to: maximize efficiency simplify processes improve patient care service

17 The Benchmarking and Performance Profiling Service

18 Clinical Lab LEAN Team Champions: System Laboratory President Hospital Vice President Site Laboratory Director Consultant Project Leaders Team members: POCT Supervisor CLS (day/evening) CLS (evening/night) Phlebotomist Manager Process Improvement Specialist

19 Product / Process Workflow The equipment layout does not allow for test, specimen and information to flow from one value-added step to another. The highest volume analyzer was the farthest from the pneumatic tube system Lack of standardized work Layout leads to batching. Work stations were unorganized- cupboards and drawers were filled with non-productive inventory The current equipment layout produces many isolated islands of work. inhibit the balanced distribution work poor utilization of equipment ineffective use of the technician time

20 Group Technology & Demand Data Average Daily Demand By Area Weekdays Number of Specimens tests of 121 represent 80% of total volume 4 analyzers perform 88% of total testing Hour of the Day V950 CD4000 Stago Centaur Manual Clinitek IL-Syn All Remaining

21 Project Goals & Value Stream Product Flow Operator Analysis Group Technology Job Guidance Cell Layout Work Station Standardized Work Performance Measures

22 RESULTS - 2 Major changes Implementation of one automated work cell Previously in 2 separate rooms Previously in 6 separate workstations Implementation of one-piece flow phlebotomy process and testing (24/7) Patients drawn and sent one at a time Testing processed individually or in very small batches

23 Cycle Time Goal PRE-Lean Standard: Results reported within 60 min from the time the sample was received in the lab POST-Lean Goal: 95% of tests will be reported within 30 minutes from the time the patient is drawn

24 So what did we do?

25 Getting Started EXPOSE THE CLUTTER Remove cabinet/cupboard doors Empty drawers and discontinue using them Move all non-productive inventory to temporary holding area

26 Phlebotomy Tray Standardization No Standard Work Lack of Organization

27 Visual Management Control / Tool Presentation

28 Determining the Layout Product Process Flow 1. Videotape the product moving through the process from start to finish 2. View steps and measure timeframes ORDER LABEL SPECIMEN RESULT

29 Determining the Layout Product Process Flow 2. Break down the activity of the product into distance traveled and time spent in: Storage Transportation Inspection Value added processing Non-value added processing

30 Morning Pick-up Distribution of Total Time

31 Distribution of Total Time STAT Draw for Vitros product Flow

32 Determining the Layout Product Process Flow 3. Draw a point to point diagram showing the route the product has traveled Tube System SPECIMEN PROCESSING 94 sq ft CLERICAL AREA 382 sq ft wall 24 sq ft Dr. Carlson's Office 75 sq ft CLOSET 15 sq ft BATH 32 sq ft Cell Dyne 4000 M R 6 HEME/COAG SEROLOGY 552 sq ft CHEMISTRY 1080 sq ft MICROBIOLOGY 666 sq ft T LIVING AREA 7952 sq ft

33 Determining the Layout Group Technology Definition: The grouping of similar and recurring tasks so that the products can be produced on multipurpose lines 1. Look at annual product (test) volumes and demand data by the day and by the hour 2. Establish patterns in process steps

34 Determining the Layout Cell Layout Design a layout giving prime location to highest volume analyzers Set up flow for 80% of high volume tests and low volume critical tests Design layout in a cellular formation to achieve efficient walk patterns and flexibility in number of operators Priorities in order of importance: 1. The activity of the product 2. The activity of the operator 3. The flexibility of the operation 4. The method of measuring performance

35 Determining Standard Work Operator Analysis Videotape the activity of the operator to determine: Which tools and supplies are needed at the work station What is the order of job steps How many seconds does each job step take Break down the activity of the operator into time spent into pre-determined categories

36 Determining Standard Work Job Guidance 1. Document suggestions to eliminate or decrease required waste 2. Determine what the order of job steps should be 3. Estimate how long the job step should take based on video tape analysis

37 Determining Standard Work Work Station 1. Design a proposed work station with the tools and supplies needed for one day s work 2. Arrange the tools and supplies in order of use corresponding with the job guidance steps of that work station 3. Determine operator walk pattern Setting Up the Work Station We shadowed and labeled the permanent location of each tool and supply We set up a two-bin supply replenishment system We color coded tube racks to clarify the status of our specimens

38 Cell Layout Job Guidance Work Station Standard Work Package

39 Performance Measurement Monitor vital statistics - are we achieving our goal? (95% of tests will be reported within 30 minutes from the time the patient is drawn) Identify reasons for not achieving goal - downtime tracking Resolve highest frequency issues

40 06/30/05 Coulter (HGB) Vitros (K) Stago (INR) Clinitek (UMAC) Centaur (TROP) Total Tests Total Tests 42 Tests <25 Min Tests <40 Min 39 Tests >=25 Min Tests >=40 Min 3 % Tests <Threshold 91.3% 95.9% 93.6% 97.1% 92.9% % Tests >Threshold 8.7% 4.1% 6.4% 2.9% 7.1% Coulter (HGB) TATs Vitros (K) TATs 91% Tests <25 Min 96% Tests <25 Min 9% Tests >=25 Min 4% Tests >=25 Min Stago (INR) TATs Centaur (TROP) TATs 94% 93% Tests <25 Min Tests <40 Min 6% Tests >=25 Min 7% Tests >=40 Min Clinitek (UMAC) TATs 97% 3% Tests <25 Min Tests >=25 Min

41 Proposed Layout After LEAN One person walking 6 cycles in 30 min and operating 6 work stations Label Bio Haz Sam ple V950 Cap s Misys Monitor Label Misys Monitor Diff & Kit Testing Label Misys Monitor Misys Monitor Core Work Area for the Clinical Lab Scientists who perform LEAN in 90% Laboratory of all Lab Operations tests

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43 Post-project Productivity Area Before After % Improve Phlebotomy (M-F, day shift) 10 FTE 5 FTE 50% Core Lab (M-F, day shift) 8 FTE 4 FTE 50% Total Lab 62 FTE 51.2 FTE 20% (target 58) (actual daily staffing deduction of 35%)

44 Collection to Result (Compliance within 30 min.) (Improvements over 3.5 years)) Hemoglobin Dec. 2002: 40% June 2005: 91% Potassium Dec. 2002: 12% June 2005: 96% PTT Dec. 2002: 5% June 2005: 94%

45 Premier LabFocus: Cost per test Dec.2002: $9.00 July 2003: $8.00 Dec. 2003: $6.75 Mar. 2004: $6.45 Sept. 2004: 6.24 (31% improvement) June 2005: $5.99 (45% improvement)

46 Premier LabFocus: Productivity (test/hour) Dec. 2002: 4.75 July 2003: 5.50 Dec. 2003: 6.40 March 2004: 7.05 September 2004: 7.40 (>50% improvement) June 2005: 7.72 (62% improvement) Ability to absorb increased test volume

47 June 2005 Benchmarking

48 Summary of Benefits Testing thru-put (TAT) reduced by 50% Productivity improvement >40% Cost reduction at 28% Space savings of >450 ft2 Standardized work practices Reduction in Errors and Error Potential Performance measurement Elimination of excess unused inventory ($16,100) Elimination of visual noise 100% cross-training of staff

49 Additional Benefits Development of a core team of people that has implemented Lean Manufacturing and are therefore available to spread the benefits organizationally Standard Work and Standard performance measurement tools developed 2004 employee engagement score in clinical lab rose by 0.48 on a 5 point scale improved add l Laboratory recognition from customers Laboratory recognized as a pioneer within organization

50 Key Learnings Change is stressful Constant and repeated communication Coordination with IMS, facilities, vendors, other depts. High visibility of the LEAN team and manager has increased trust and engagement. The staff is able to see the Waste of previous process. Need to help staff understand their professional contributions are valued and needed.

51 After the Project is Finished Insure that day-to-day operational leadership maintains the gain (supervisor) Compliance with standard work is the key Track down-time and evaluate reasons Measure daily, weekly, monthly Keep measures in front of staff Share positive feedback and impact on patient care with staff Laboratory professionals need to understand that the change made a difference.

52 Systemwide: Cost per test improvement Lakes: 10% Northland: 13% Red Wing: 12% Ridges: 15% Southdale: 33% Riverside: 13% Hibbing and University: cost has gone up by 5-10%. No Lean changes at this point Productivity Improvement Lakes: 16% Northland: 30% Ridges: 43% Southdale: 53% Riverside: 28%

53 Another way Kaizen events shorter, more targeted improvement Training Assessment and observation Multiple, shorter projects to try suggested improvements and modify real-time Used at the American Red Cross for improvements in the collections/donor process

54 Introduction Goal: Reduce Health History Total Process Time from average of 25 minutes by 30% to 50% in the North Central Region by the end of April 2008 Reduce Process Time by eliminating Non Value Add (NVA) time Create Standard Work Match Cycle time to Takt/Customer Demand Results: Reduced Health History time at Over-Goal Drives from 34 minutes to 21 minutes No increase in Staff / Increased Productivity by 39%

55 Improvement Idea - Flip Card BEFORE Health historians can't see if histories are occupied. Staff walk the length of all the histories looking for a vacant booth. Staff can t tell when donors are done with SAHH and waiting. Donors had to stand and wait for staff to finish health histories No way for staff to tell which booths are occupied.

56 Improvement Idea AFTER Create flip signs for visual cues of HH Status. - Ready Pink -In-Use Orange - Re-check - Yellow - 2RBC green Quality Improvement- Improved donor confidentiality. Improved donor confidentiality

57 Improvement Idea - Flip cards -Before- -After- Walking distance decreased from 257ft to 114 ft (approx 48 secs per staff per history)

58 Other changes in health history Priming the pump match initial process to donor flow (takt time) Layout of health history table (presentation of tools) Layout of printer table (presentation of tools) Managing breaks match process to donor flow (takt time)

59 Lean Balance