Transforming Healthcare Leaders Pursuing Perfection Embracing a Culture of Process Improvement and Value Driven Outcomes: What is Lean in Healthcare? University of Utah Health Care J. Michael Rona September 17, 2012
Introduction
Core issues
Is this who we are?
Manufacturing's dilemma...
Implementing the Toyota management system value perfect map pull flow
What is its power?
Looking in the mirror How?
Strategy without traction How?
Strategy with traction: Toyota management system How?
Why TPS or lean production?
By what method?
Taiichi Ohno "You should submit wisdom to the company. If you don t have any wisdom to contribute, submit sweat. If nothing else, work hard and don t sleep. Or resign. Used with permission of John Black and Associates
The seven wastes Overproduction Defective Products Time on Hand (Waiting) Movement MUDA Transportation Stock on Hand (Inventory) Processing Used with permission of John Black and Associates
Validated industry averages Direct labor/productivity improved 45-75% Cost reduced 25-55% Throughput/flow increased 60-90% Quality (defects/scrap) reduced 50-90% Inventory reduced 60-90% Space reduced 35-50% Lead time reduced 50-90% Summarized results, subsequent to a 5-year evaluation, from numerous companies (over 15 aerospace-related). Companies ranged
Quality & cost: the ventilator bundle at Virginia Mason* quality cost 40 600,000 35 500,000 30 25 400,000 20 300,000 15 200,000 10 5 100,000 0 incidents in 2002 Incidents in 2004 0 in 2002 in 2004 *Improving Healthcare Using Lean Production Methods - Robert Chalice
GI/endoscopy at Virginia Mason* percent change Room turnaround Margin per room Arrival to discharge New patient wait Clinic access 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% *Reducing Waste in the US Health Care System - Roger Bush -jama 2007
12 years later... If you are dreaming about it you can do it. Chihiro Nakao
Recent results Emergency Department Revenue Cycle Operating Room Start time and Room Turnover Value Stream Mapping and new space Patient Safety Sentinel Event Resolution LOS Reduction 60% 5% Volume increase Unit cost reduction 6% Impact $500,000 $ 7 million in 6 months Additional 1500 hours of operating room time 15% space reduction & $7 Million savings 145-245 days to 5
Toyota management system
Toyota management system Hoshin kanri people standard work takt time production Just in time materials standard WIP flow production system Jidoka equipment andon & availability pull system production leveled production (heijunka) cost reduction through the elimination of muda 5S
activities connections pathways improvement leadership A P C D standard work zero ambiguity continuous flow scientific method Socratic method
Activities
activities standard work
Right process = right results Standardized tasks are the foundation for continuous improvement and employee empowerment
Standard task
Standard sequence
Standard time
Standard work-in-process inventory
Standard work documentation area/location: subject observed (pt, nurse, etc): standard work sheet date of observation: operation from: start time: sequence: to: observer: process: end time: area/location: time observation form date of observation: subject observed: start time: process: observer: observation time step observations description of operation no. 1 2 3 4 5 Mode (most freq. occurring) task time remarks area/location: process: item name: step no. work description standard work combination sheet time man auto walk operator being observed: prepared by: date prepared: no. required per day / shift: manual: - - - - - - - - - - - - - - - - - - - - - - - - automatic:...................... takt time required: current: waiting: = = = = = = = = = = = = = = = = walking: ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ operation time (seconds / minutes) 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 5 10 95 100 process: sum of operator cycle times takt time percent load chart operation from: sequence to: sum of operator cycle times takt time =! O.C.T. T.T. = prepared by: date prepared: team members = requireed standard work instruction quality check safety precaution standard WIP # pieces of WIP takt time elapsed time for one observation quality check safety precaution standard WIP notes: - Add notes about related policies or any acceptable exceptions in sequence of steps who must adopt this process: Describe roles and types of work units takt time: GOAL: List key quality and lean targets STEP NO. OPERATOR TASK DESCRIPTION TOOLS/ SUPPLIES REQUIRED CYCLE TIME time totals total time for one observation operator operator cycle time version: approved by: sponsors: Page 1 of (fill in total # of pages)
Use only reliable, tested technology
Connections
activities connections standard work zero ambiguity
Jidoka
Chain of customers
Stopping the line
Build a culture of stopping to fix problems Three elements of lean approach to quality: Successive checks Self checks Poka yoke
Hierarchy of visual management Preclude Prevent poka-yoke Alert Integrate Publish Broadcast 5S Visual control Visual display
Pathways
activities connections pathways standard work zero ambiguity continuous flow
Value
value 95% added waste operations 5%
Value stream map process step wait time process step wait time LT = 117:15 CT = 47:36 process cycle times process cycle times process lead time
Create continuous flow to bring problems to the surface
The seven wastes
Healthcare services Inpatient Outpatient Patients waiting Administrative support staff members Transportation Healthcare processes Patients waiting Doctors, nurses and lab technicians Assessment Patients waiting Medical specialists and clinical support staff Procedure Patients waiting Healthcare operations
Takt time
Operations-based layout imaging admitting 8 waiting room 7 pharmacy operations area laboratory diagnosis
U-shaped cell image lab diagnose ops admit pharm 7 8 wait
Kanban systems Cell 3 full empty Cell 2 full empty Cell 1
Improvement
activities connections pathways improvement A P C D standard work zero ambiguity continuous flow scientific method
Benefits
Implementing the Toyota management system value perfect map pull flow
A3 document system Proposed team charter A3-T Theme: Improve process reliability to decrease process lead times PROBLEM STATEMENT During the past three years, process reliability has declined by 10% and lead times have grown by 12%. This has contributed to a significant deterioration in customer experience and an estimated % increase per unit costs. TARGET STATEMENT We will increase process reliability and lead time by 15% by the end of the current fiscal year. This should contribute to yearly 7.5% (approximately) reductions in per unit costs and to similar cost reductions in sustaining costs. PROPOSED ACTION In the coming year, we propose that all service lines and departments, guided by their value stream maps, will work to promote process flow by eliminating the seven wastes in their most critical processes. Through the catchball process, service lines and departments will interpret the overall targets of 15% improvements in reliability and lead time by explaining how these improvements will be made in the context of their respective operations. Although all staff members should be involved in measuring their own process quality, it is recommended that a control part, i.e., a frequently repeating patient experience or (in the case of some services lines and departments) service be chosen as a representative measure at the service or department level. Where appropriate, service lines and departments are encouraged to employ the resources of the organization s KPO. IMPLEMENTATION PLAN ANALYSIS Process lead time is a function of how quickly we find and remove the seven deadly wastes: overproduction, waiting, transportation, movement, inventory, overprocessing, and of course defects. The presence of these wastes greatly increases the transactions cost of health care, and can be measured in terms of extended lead times, as we wait or search for the people, medicines, materials, or information necessary to complete our work, or while we stop to rework errors and defects, or while we stop to deal with the collateral damage of such errors and defects. By systematically eliminating the seven wastes, we increase process availability, efficiency, and quality, promoting the flow of patients, medicines, materials, and information throughout the healthcare system. Date: Reporting Unit: Operations management team CHECK AND ACT (verification and follow up) Progress toward our targets will be checked frequently on the shop floor through the systematic adoption of visual management systems and daily stand-up meetings. In addition, site managers will conduct weekly standup visual reviews with all managers in attendance. Furthermore, the President s Diagnosis will be implemented, based upon the Transformation Ruler. Monthly local self-audits will be conducted. Once a year, the CEO and President will conduct a formal diagnosis and make visits to each site. A3 document system 2007 rona consulting group Page 1
PDCA plan act do check
New measures of excellence
Leadership
activities connections pathways improvement leadership A P C D standard work zero ambiguity continuous flow scientific method Socratic method
Base decisions on a long-term philosophy
Grow leaders who are teachers
Develop your people
Respect your partners
Adult learning & Training Required
Discussion