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1
Introduction to Continuous Improvement
in HealthcareWhy Lean?
Why Lean in Healthcare?Lean PhilosophySeven Wastes
Reliable Methods as Countermeasures
• Hands-on consulting/training in Continuous Improvement
• Award winning Training Products• Lean practitioners with a passion for
Gemba-based learning• Promoting a culture of improvement• Not-for-Profit Organization
© Greater Boston Manufacturing Partnership
Our Mission Is Simple: to help companies become more productive and competitive through Continuous
Improvement education and implementation.
Shingo Prize
Shingo Prize
www.gbmp.org617-287-7737
Home of the Old Lean Dude, lean blogger
- a lifetime of lean stories to share -Sign up at www.oldleandude.org
“I would recommend participation to all healthcare department heads and quality improvement practitioners. GBMP did a great job applying the material to healthcare, "going to the gemba" after learning lean concepts and tools in order to apply knowledge learned in the classroom.”
- Christine McMullan, Director of Continuous Quality Improvement, Stony Brook University Hospital
Introductions
• Pat Wardwell, GBMP• Chief Operating Officer
• 25+ years Operations and Improvement Roles
• Lean Gold Certified• Shingo Prize Recipient• Shingo Prize Examiner• AME Excellence Award Council
and Assessor
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Why Lean in Healthcare?“While technologies and treatments have made enormous strides during my career, nuts-and-bolts hospital operations haven't.” – Dr. Patricia Gabow.
National Healthcare
ReformInsurance Coverage
Desire to Improve Quality, Cost, Delivery and Safety of Care
Payment SystemsReporting
Requirements
Waste
Errors
Cost
Staff Frustration
Waiting
Work-Arounds
Silos4
7
What Is “Traditional Operating Methods”?
Customer requirements not known
Batch processing Pacing to “maximize”
resources Processes/Equipment
keep running despite defects
Lack of standardization Questionable quality
Operator’s work out of control
Operators not working together
Limited communication between operators and management.
Management occasionally present
88
What Is “Traditional Healthcare”?
Patient requirements poorly communicated
Batch processing Unnecessary
procedures and tests Lack of standardization Long wait times
expected Questionable quality
Staff working out of control
Dr., nurse, and staff not working together
Limited communication between staff and management
Management occasionally present
9
What is Continuous Improvement?
• An approach to healthcare which strives to maximize value to the patient by maximizing the value of employees.
Stability
Standardization
Autonomation
JIT
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Concept of Value and Waste• Value Added
– Activities involved with the direct care of the patient– Activities the customer (Patient or Payer) is willing to
pay for
• Waste (Non-Value Added)– Activities that do not benefit the patient– Activities that fall under the 7 forms of waste– Activities not performed right the first time
• Necessary Non-Value Added (Incidental Work)– Activities causing no value to be created but which
cannot be eliminated based on current technology or regulations
What is Continuous Improvement? What is CI in Healthcare?
• The primary focus of lean or CI is in developing people as problem solvers and participants in process improvement.
• CI or lean is the creation of value for the customer through the relentless and iterative elimination of waste (muda), variation (mura) and strain (muri).
• Value is defined as any action or process for which the customer would be willing to pay.
• In Healthcare, value is defined as any action or process that directly contributes to the care of the patient.
“Care that is patient-focused, with less waste and cost and better medical outcomes” - John Toussaint, On the Mend 12
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Lean – The Big Picture10% Techniques & 90% People
Before strategy there is Philosophy.
Techniques are the means, not the ends
Management must lead.
At the center is Human Development.
Philosophy
Tech
niqu
es
Managem
ent
Human Development
14
Lean PhilosophyPatient is First . . .
• Patients expect zero errors• At an affordable price• With no waiting.
Old Thinking New Thinking
Errors Expected
Profit = Price - Cost
Maximize for Physician
Price = Cost + Profit
Zero Defects
No Patient Waiting
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Lean PhilosophyEmployees are the most valuable resource.
• People want to make valuable contributions to the world.
• Dissatisfaction is a normal and necessary condition for improvement.
• 95% of objection is cautionary.• If employees truly understand
value, they will gladly provide it.• People have limitless capability.
16
Lean Philosophy Direct Observation
• Direct observation on regular basis is critical to understanding.
• Best information for continuous improvement comes from direct observation and involvement with the people who do the work.
• Workplace is dynamic. • Go to Gemba often!
17
Lean Philosophy Kaizen (continuous improvement) is for
everybody, everyday.
• Kaizen is small changes for the better that come from the common sense and experience of the people who do the work.
• The more employees learn and use CI the better they become at problem-solving (tacit learning.)
• Continuous improvement never ends.
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Toast KaizenEvent Metrics
Measure Current Target
Lead Time 4.2 min. 2.2 min.
Floor Space 24 sq. ft. 4 sq. ft.
Steps 25 4
Customer Happy? No Yes
Job Easier? No Yes
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Lean Summary• Everybody, everyday!• Patient focused.• 10% techniques &
90% people.• Is taken in small
steps. • Produces orders of
magnitude benefits.• Is not consistent with
traditional approach.
21
Benefits of Lean
• Highest Quality• Lowest Cost• Shortest Time• Safer for Patient• Least Strain for Caregiver• Greatest Productivity• Better use of Space• Greatest Margin Flexibility• There are no limits to
improvement!
Connects Patient to Staff
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Process - Operation Model
Process
Operation
Admissions
Screening
Reading
Feedback
Patient A Patient B Patient C
Main Reception
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Process - Operation ModelMain Reception
Admissions
Screening ReadingFeedback
Waste
95% of process is waste.
24
Seven Wastes
3. WaitingTo get inTo get outFor resultsFor medication, for food
Searching, walking, backtracking, reaching, bending, climbing, taking eyes off of work
4. Motion
Patients and providersInformation
Supplies
2. Transportation
In patient roomsIn stockroomsBetween departments
In hallways1. Inventory
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Seven Wastes Patient being asked the same questions, unsafe or strain producing, Unnecessary, irrational
5. Processing
Infections, wrong site surgeries, medication errors
6. Defects
Excessive tests, unnecessary treatment
7. Over-production
Worst Waste
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Reliable Methods• 5S - Workplace Organization • Problem Solving for CI Teams• Value Stream Mapping• Continuous Flow• Standardized Work• Kanban/ Pull Systems• Visual Control Systems• Set up Reduction• Poka-yoke/ Error Proofing• Heijunka/ Level Scheduling
Identify reliable methods.
Keep all employees practiced.
Create a favorable environment.
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S1 – Sort Out
S2 – Set Locations
S3 – Shine
S4 – Standardize
S5 – Sustain
5S - The First Improvement
Continuous Flow (Cells)• Reorganizing physically
and organizationally for improved flow.
• All steps used to complete a prcess are placed in sequence of production. No space between steps.
• No material build-up between operations.
• One piece flow.
31Spaghetti Diagram
Lab Flow
32
Standardized Work• Best (current) combination of people,
machines and material to complete process for patient demand. • Takt Time – time allowed by customer to complete
the process• Cycle time - time to perform the process, including
machine and manual time• Work Sequence - order of operations to complete
the process • Stock on Hand – inventory required to maintain flow• Key safety and inspection points
33
Kanban• Kanban eliminates
overproduction.• Kanban re-integrates
inventory data with material.
• Number of kanban cards controls level of inventory.
• Delays (unavailable kanban) are highlighted immediately.
• Kanban is like money, always try for less money in system.
34
Visual Control SystemsLetting the Process Speak
Visual Indicator
Visual Signal
Visual Control
Visual Guarantee
35
Reducing Interruptions and Improving Patient Safety
• A study involving nine San Francisco Bay Area hospitals focused on improving accuracy in administering drugs - with particular emphasis on reducing interruptions that often lead to mistakes - resulted in a nearly 88 percent drop in errors over 36 months at those hospitals.
36
Set-up Reduction
• Reduce every set-up by “59/60th’s”
• Separation of external from internal tasks• external = process running
internal = process stopped • Convert internal to external
tasks• Minimize adjustments• Improve overall set up• Focus on waste, not operation
Patient Room
Operating Room
Equipment
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Poka-yoke
• Poka-yoke means to avoid (yokeru) inadvertent errors (poka).
• “Preventing the act of forgetting what you have forgotten” -- Shigeo Shingo.
• Respect the intelligence of staff by taking the judgment out of repetitive tasks where errors are likely to occur.
Defects = 0
Cannot connect to the wrong tank!
38
Continuous Improvement Summary
• Develop from Need• 90% People (Patients
and Employees)• Focus on Workplace • Create Kaizen Way• Incremental use of
reliable methods to counter 7 wastes
5S and VSM
Continuous Flow
Standardized Work
Pull Systems
39
Key Points• Three aspects to TPS
• Technical – tools like 5S, Kanban, Set Up Reduction
• Philosophy (see below)• Management – new strategy,
policy and organization• TPS (Lean) Philosophy:
• Patient First• Employees most important
resource• Direct observation. (Go see!)• Kaizen – small changes for
the better, everybody, everyday
• 7 Wastes• Storage• Transportation• Overproduction• Processing• Motion• Defects• Waiting
• Basic hierarchy of improvement• JIT• Autonomation• Standardization• Stability
Create a favorable environment: 90% people,10% methods!