Introduction to Lean Management: continuous process improvement in healthcare and in the library CHLA/ABSC 2014 Francesca Frati, MLIS ffrati@jgh.mcgill.ca
At the end of this introductory course you will be able to: Describe the basic principles of Lean management. Identify selected Lean Six Sigma tools and describe their uses. Identify potential Lean projects in the healthcare/library environment. List barriers/facilitators to implementing Lean.
Total 4 hours Agenda ~15 mins: Welcome and introductions ~50 mins: Brief introduction to Lean Six Sigma ~1 hour: Case studies exercise 30 mins: Break ~1 hour 15 mins: Brief introduction to Lean Six Sigma tools and conclusion ~10 mins: Quiz
What can healthcare and libraries learn from car manufacturers? Customer (client, patient, patron)-centric approach- they define value not us Rapid process improvement methodologyefficiency, waste reduction, standardization
What is Lean? Continuous improvement methodology developed by Toyota in the 1950 s: TPS (Toyota Production System) Next big manufacturing innovation since Ford assembly line Pull flow - Just in time approach allows for more flexibility Customer (or client or patient or patron) determines value decrease non value added activities Streamlines processes and eliminates waste
The 14 principles of The Toyota way 1. Plan for the long term- even at the expense of short term gain 2. Aim for continuous process flow- eliminate idle time 3. Use pull systems- produce as needed, minimize inventory 4. Level out the workload- avoid spurts and starts 5. Get it right the first time- stop to fix problems as they occur 6. Standardize- create stable and predictable processes 7. Use visual control- simple visual indicators, short memos even for important messages 8. Use reliable tested technology 9. Grow leaders from within- instead of hiring from outside 10. Nurture staff in a stable environment, encourage creativity 11. Respect partners and suppliers- maintain strong relationships 12. See for yourself- don t rely on theories or what other people tell you 13. Decide slowly by consensus, implement rapidly but cautiously 14. Become a learning organization; combine reflection with continuous process improvement Toyota Way, 2004
5 Principles of the Lean system Define the value from the point of view of the customer (patient/patron) Pursue perfectioncontinuous quality improvement Identify value-added steps and eliminate steps that do not add value Avoid pushing work on the next customer or department- let work and supplies be pulled as needed Keep process flowing smoothly by eliminating causes of delay (bottlenecks & constraints) Adapted from Lean Hospitals Graban, 2009, p. 36
The 8 wastes (sometimes known as The 7 wastes ) Problem i.e. waste Overproduction Waiting Transport Over processing Inventory Motion Defects Unused creativity Solution just in time instead of just in case keep employees busy instead of idle between tasks avoid unnecessary transport of goods or materials avoid unneeded steps avoid extra raw material, too many works in progress, accumulating finished product avoid unnecessary movement by employees as they go about their tasks prevent errors instead of spending time identifying and fixing them listen to your employees, avoid untapped human resources potential When talking about waste in Lean you may also come across the Japanese terms muda, mura, and muri.
Value added Customer decides what value is! Not easy concept Most of what we do is non-value added because it does not directly impact our users Value added = providing consumer health info to patient Not value added = indexing records in patient education database Can t increase what is value-added, but can decrease what is non value-added
Lean measures- world class standards OEE- overall equipment efficiency- how efficient is your equipment? (99% WC) PCE- process cycle efficiency- how efficient is your process? (35% WC, <1% for health care) MVA- measurement of value added- how much of the process is made up of value-added activities? (65% WC) FPY- first pass yield- how many items require no reworking (error free) (99% WC) Takt time- pace of process- how fast does an item (or patient) have to move through the process in order to meet demand? Varies according to process
OEE (overall equipment efficiency) And you thought you didn t need to learn algebra!
Remove as much nonvalue added activity as possible! In a nutshell
Lean = speed
What is Six Sigma? Developed by Motorola in the 1980 s Methodology that focusses on minimizing variation in the process and error in the product Uses statistical measurement (6 sigma = 99.9997% right the first time) Sustained quality improvement DMAIIC Belt system for training (White, Yellow, Green, Black)
DMAIIC Define Measure Analyse Innovate Implement Control
Make change happen fast! Kaizen Rapid improvement workshop 3-5 days Analyze, Innovate, Implement phases of DMAIIC Sponsor to oil the wheels of change Lean agent (s) to facilitate using Lean tools and project management tools Team - Key decisionmakers - Key participants of process Types of Kaizen: Blitz IMPACT Kaikaiku Gemba Teian Team leader to ensure implementation and control
DMAIIC: Define Identify the problem- formulate the question What is the scope of the project? Ensure commitment of all stakeholders- who are they? Plan measure phase- what do you want to measure? How will you do this?
DMAIIC: Measure Map the process- gather data Use any project management tools you can to visualize the data (SIPOC, Value stream mapping, diagrams, charts etc.) Use lean tools to measure the process- how does it work now? Conditions for success (what are the risks? What are the potential barriers?) Recommendations for improvement- what needs change? Not solutions (yet)
General to specific Mapping the process VOP- voice of process- how does the process work now? What are the steps? SIPOC Value stream mapping Task description- Swim line VOE- voice of employee- people engaged in the process VOC voice of customer- people determining value
SIPOC High level description of the process http://en.wikipedia.org/wiki/sipoc
DMAIIC: Analyse Done as team during Kaizen (rapid improvement workshop) Analyse data gathered in Measure phase Search for fundamental causes not solutions (yet) Use tools: Brainstorming Value stream mapping, swim line diagram etc.
Value stream mapping More detailed description of the process than SIPOC Nurses place a PICC line for a patient (PICC = peripherally inserted central catheters) New process = 36% decrease in the average time to line placement and in a 50% decrease in the number of PICC referrals to interventional radiology (IR) Kim et al 2006
Swim line diagram Even more detailed description of the process- tasks by department- can also be drawn horizontally http://en.wikipedia.org/wiki/file:approvals.svg
DMAIIC: Innovate (Solutions) Done as team during Kaizen (rapid improvement workshop) Identify solutions- what can be done to improve current practice? Use tools & concepts Identify and eliminate bottlenecks an constraints Reduce WIP (works in progress) Pull flow Reduce inventory etc.
Bottleneck vs constraints A bottleneck slows work down in the process. There is only one for each process. A constraint prevents the whole system from reaching its potential. There can be many in a process. A constraint can be a bottleneck but a bottleneck is not always a constraint (if demand is below the capacity made possible by the bottleneck).
Reduce batch size: Works in Progress (WIP) Fewer works in progress decreases lead time (lead time = time it takes from the beginning to the end of the process)
Reduce inventory The idea is to have as little inventory as possible. This works with pull flow - you tailor the supply to the demand so there is little need for inventory. Need less storage space. A small amount of inventory is a useful buffer.
DMAIIC: Implement (iterative process) Plan, pilot, evaluate, tweak Action plan, communication plan, change management plan, risk management plan Pilot test implement the changes Evaluation- evaluate the success of the changes Make new changes based on evaluation- change is iterative
DMAIIC: Control (maintain successfully implemented changes) Now that you ve got it right: Ensure long-term sustainability- how to make sure the new process is maintained? Control plan! Indicators, benefits. Iterative improvements- continuous improvement
Six Sigma = quality
What is Lean Six Sigma? Combines quality and consistency with speed (efficiency+ simplicity + no waste) Uses both sets of tools: DMAIIC + Kaizen + process mapping Eliminate 8 kinds of wastes Belt system for training Brought to healthcare in 2000
Case study instructions Each pair 20 mins (3 pairs): Each pair identifies 2 steps in DMAIIC in case study article, and describes how they were or were not illustrated in the case. Were there any barriers or facilitators to success mentioned in article? One member of each pair 5-7 mins each: Present findings to rest of participants. Each participant 2-3 mins each (time permitting): Would you undertake a similar project in your environment? Why or why not? What other project might you undertake in your environment?
Facilitators (AKA conditions for success) A process (or space) in need of improvement Well defined problem Discrete and attainable goals Support from administration Buy-in of all stakeholders Participation of key decision-makers Participation of people engaged in the process Understanding of process improvement & Lean/Six Sigma Rapid implementation Culture of change Change management!
Barriers Poorly defined problem Scope too big for facilitators/team Impetus not shared by all- comes from above or from below External influences that cannot be controlled Decision-makers not part of team Loss of team members Time constraints- Kaizen not possible Budgetary constraints Process is interdependent with other processes that are not within project scope No change management awareness or plan
Barriers in Healthcare Big differences between manufacturing and healthcare! Much harder to control a process that may involve many departments, people, unknowns, changing evidence etc.
Barriers in the library Customer-driven, just-in-time, minimal inventory approach may not be optimal Stock gaps Late purchases Unplanned acquisitions Ceynowa, 1997
Tools and methods We ve already seen SIPOC Value stream mapping or process mapping Continuous flow Kaizen Inventory
Tools and methods cont 5 whys- ask why until you find the cause (solution should be based on actual fundamental cause) Pareto analysis/chart- helps determine which solution will have most benefit Ishikawa (fishbone) http://en.wikipedia.org/wiki/file:ishikawa_fishbone_diagram.svg#filelinks
Tools and methods cont Root cause analysis- another way to identify fundamental cause of problem Visual mapping- workflow, how do people move in workspace? Gemba walk- walk the floor, see for yourselfdon t rely on reports
Tools and methods cont 5S to eliminate waste: Sort, Straighten, Shine, Standardize, Sustain 1. Sort: clear out rarely used items (weeding) 2. Straighten: organize & label (classification system) 3. Shine: Clean (shelving, dusting) 4. Standardize: rules to sustain (policy & procedure) 5. Sustain: Regular audits
Tools and methods cont Poka Yoke- preventing error (train goes over road on bridge so no collision possible) Kanban- signals the need to replenish supplies (insert in Filofax reminding you to get new year for agenda- supports pull flow)
Tools and methods cont Andon- visual cues, often lights (can be used with Kanban) Work cells- how you move through space and how close workers are to each other effects efficiency and flow
Lean in the library Several case studies published (academic setting): Reducing shelving time- University of Chicago Regenstein Library (Kress, 2008- see case study exercise) Improving self service at circulation kiosks -Newcastle University Library, UK (Kumi, 2006) Improved efficiency of electronic reserves- University of Notre Dame Library, Indiana (Tuai, 2006) Improvement of academic library websites- Loughborough University, UK (Manuel, 2010) Streamlining and centralizing lending, reference and information services- University of South Australia Library (Cother, 2009) Improving ordering and receiving- Wichita State University, Library and Inductrial Engineering Dept. (Gwen, 2005) Streamlining acquisitions- (Happel, 1994) [in German]
Six Sigma in the library One case study published (academic setting): Application of Six Sigma in the Indian Statistical Institute Library (Bangalore): A Case Study (Dutta, 2004) [no abstract]
At the Jewish General Hospital Commissioning of biomedical equipment Includes reception and installation of equipment New critical care pavilion building meant a huge increase in orders of biomedical equipment. Existing commissioning process could not handle increase. New process and dashboard for tracking projects was needed to ensure deadline was met.
At the Jewish General Hospital cont. Departments involved in process: Biomedical engineering Receiving IT Technical services Construction Clinical Users Planning and transition Team Additional Stakeholders Purchasing Hospital administration Suppliers Maintenance
Other examples in healthcare Emergency rooms- reducing waiting time for patients by reducing WIP Youtube video Rooting Out Waste in Health Care by Taking Cue From Toyota :
Dr. Hartley Stern, Executive Director - Jewish General Hospital Nov 2012
Lean & Six Sigma = Speed & Quality A philosophy? An ideology? A culture? A methodology? A set of tools? All of the above! http://en.wikipedia.org/wiki/file:zeedonk_800.jpg
References Ceynowa K. 'Toyotismus' in der Bibliothek? Worauf sich Bibliotheken einlassen, wenn sie sich auf 'Lean Management' einlassen. 'Toyotism' in the library? How libraries are affected, when they become involved in 'lean management'. Bibliotheksdienst. 1997;31(8):1501-1516. Graban M. Lean hospitals : improving quality, patient safety, and employee satisfaction. Boca Raton: CRC Press; 2009. International Organization for Standardization. Quantitative methods in process improvement -- Six Sigma -- Part 1: DMAIC methodology. International Organization for Standardization, 17 May 2011. Accessed 27 May. 2014 from: Lean Six Sigma: http://www.iso.org/iso/catalogue_detail?csnumber=52901 Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: What can hospitals learn from a world-class automaker? Journal of Hospital Medicine. 2006;1(3):191-199. Kress NJ. Lean Thinking in Libraries: A Case Study on Improving Shelving Turnaround. Journal of Access Services. 2008/09/30 2008;5(1-2):159-172. Liker JK. The Toyota Way. McGraw-Hill: New York; 2004. Linovati instructional materials. 2012 Wikipedia contributors. "Six Sigma." Wikipedia, The Free Encyclopedia. Wikipedia, The Free Encyclopedia, 22 May. 2014. Accessed 27 May. 2014 from: http://en.wikipedia.org/w/index.php?title=six_sigma&oldid=609700214