Terrigal Burn MD Lean Physician Champion Palo Alto Medical Foundation 1
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LEAN: BLIND MEN AND ELEPHANT 3
Academic: UC System, Stanford, U of Michigan, Beth Israel Deaconess, U of Oregon, Duke, UNC Large Groups: Kaiser, Cleveland Clinic, Mayo, Henry Ford, PAMF, CPMC, Group Health/WA, Virginia Mason, Everett Clinic, Sutter Internationally: Australia, UK, Netherlands 4
Working with people The experimental method Problem solving Continuous improvement Data driven Demonstrably able to improve outcomes 5
91,000 20% 17.6% Every system is perfectly designed to get the results it gets. Don Berwick MD, IHI 6
Everything was going so well up until a few minutes ago! 7
Work system is simple enough that a small group of people can design it and run it capably. Business is primarily an economic activity, and can be controlled through economic tools Extrinsic Motivation Accounting and Budgets Scientific school of reductionism - understand something through breaking it up in its irreducible parts. Taylor/Sloan - top down. Top is smart, bottom is less educated, less capable. 8
"Bottom" is not less educated, less capable. The work is too complex to be completely understood by anyone across the entire system People want more than money - meaning, growth Scientific reductionism is not definitive: dynamic, adaptive and interrelated systems, models of individuals behaviors, behavioral economics. 9
Expensive Dissatisfying Slow, bureaucratic organizations that don't respond well or quickly to external opportunities or threats Not enough time in the day to plug all the holes with heroes -Mark Hallett MD 10
To create stable, reliable and capable systems made up of the processes of work, and the processes that support those processes, to support the people who create value for the patient (caregivers) 11
lean six sigma Performance improvement The xx Way Continuous improvement Process improvement 12
1926 Toyoda Automatic Loom Works Toyota Production System: deep thought, experiments, and aggregating practices and ideas from US supermarkets, Henry Ford, TWI, W Edwards Deming, Walter Shewart 50 years later, Toyota s system is a worldwide model In the early 90 s, James Womack coined the term lean manufacturing Lean thinking started to appear in healthcare organizations by the mid-90 s: Overlake Hospital, Group Health (Boeing), Pittsburgh Regional Healthcare Initiative (Alcoa) Now 100s of healthcare organizations are using Lean thinking 13
An organizational culture developed over years An operating system founded on two principles: Continuous Improvement Respect for People A set of tools to accomplish the work 14
Are my staff and doctors treated with dignity and respect by everyone in our organization? Do my staff and doctors have the training and encouragement to do work that gives their life meaning? Have I recognized my staff and doctors for what they do? 15
Why not make the work easier and more interesting so that people do not have to sweat? The Toyota style is not to create results by working hard. It is a system that says there is no limit to people s creativity. People don t go to Toyota to work they go there to think Taiichi Ohno A bad system will defeat a good person every time. W. Edwards Deming Complexity is a crude state; simplicity is the end of a process of refinement. -Pascal Dennis 16
Use your mind first, not your money Challenge current thinking Look for leadership at all levels Replace we can t with we don t know how to do it yet Remember that you are the experts It s better to get 50% improvement today than wait months hoping for perfection 17 17
LEAN CULTURE: PROBLEM SOLVING 18
LEAN CULTURE: 19
An organization of people that have developed the ability to relentlessly reflect, seek out waste, and eliminate it while simultaneously improving the customer s experience. A set of concepts, principles and tools used to create and deliver the most value from the customer s perspective while consuming the fewest resources by fully utilizing the skills and knowledge of those who do the work. 20
Traditional Thinking Attack direct labor Quality, cost and cycle time (speed) are addressed individually and often seen as conflicting Manage by results Optimize subsystems Use information technology as the answer Lean Enterprise Thinking Attack waste, complexity and variation Quality, cost and cycle time (speed) are addressed concurrently and are seen as highly related Manage by process and results Optimize the whole system (including suppliers and customers) Use information technology as an enabler of lean processing 21
Physicians & Staff Care for Patients Department (or Site) Primary Care or Specialty Division Division Executive Leadership Support Caregivers & Remove Barriers Tier 1: Department Physician Leads & Department Staff Managers Tier 2: Physician Division Heads & Directors Tier 3: RCC (Divisional Medical Directors, Ops. VPs & Support Leaders) Tier 4: Chief Medical Officer & Chief Operating Officer Leadership 22
Strategic Deployment Value Stream Improvement Daily Engagement 23
Align the organization vertically Push decision making for how to meet goals and improve value closer to where the value is created. Create measurement and feedback systems that are linked with a system for checking performance Put a spigot on the amount of work that we "pull" into the system 24
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first and foremost, the performance of the whole value stream (is) the only issue of relevance to the customer. James Womack Lean Thinking 28 28
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Standard Work Basis for improvement Hardest for managers, the more senior the more difficult Visual Systems Make the work, and the problems, visible Continuous Improvement A3 thinking and coaching PDSA 30
Value Stream Mapping Rapid Process Improvement Workshop (RPIW) A3 thinking, root cause analysis Model Line implementation Training Within Industry (TWI) 5S (Sort, Simplify, Sweep, Standardize, Sustain) PDCA Plan, Do, Check, Adjust Rapid Process Design/3P Front Line Improvement (FLI) Standard Work, Leader Standard Work 31
THE 7 TYPES OF WASTE Over-Producing Producing too much of something required or before it is required (e.g. scheduled patients, handouts) Defects Redoing or reworking, managing customer complaints, errors and mistakes-wrong medication Inventory Visible work-in-process (idle or finished), excess or unneeded stock, supplies, files, or copies; and hidden inventory all information and knowledge-in-process required to complete visible work-in-process Waiting Time Delays and queues of all types; waiting for calls, signatures, supplies, equipment, meds, labs, people and other resources Motion Time spent looking for information, people, supplies and equipment; unnecessary and non-value adding work movements Transport Multiple handling steps and needless movement of people, material and information Over-Processing Complex process flows or production work the customer does not want, including redundant and inspection. Product choices that confuse customers. Organization boundaries which introduce inefficiencies and frustrate customers. 32
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Visual Minimized Continuous Management Waste Flow 35
Work as a team Manage systems visually Participate in observation and coaching Give input for the process of continuous improvement Restore the joy in medical practice 36
All knowing In charge Autocratic Buck stops here Impatient Blaming Controlling Patient Knowledgeable Facilitator Teacher Student Tenacious Communicator Humble 37
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QUESTIONS? 39