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A Brief on LEAN Fundamentals for HealthcareJerry Green, PhDJune 28, 2016
© 2016 International Business Machines Corporation
Housekeeping
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© 2016 International Business Machines Corporation
First: What is LEAN?
Cycle-time reduction through waste elimination
• Tools and techniques that focus eliminating non-
value added activities (waste).
• A LEAN Organization produces what is needed,
when it is needed, with the minimum possible
amount of resources.
• A LEAN organization maximizes the ability of all
employees to add value.
– LEAN is about employee empowerment
– LEAN will NOT work in Command and Control
organization
When cycle-time is
the problem
© 2016 International Business Machines Corporation
Always LEAN first
Use LEAN before deploying other methodologies or your
organization will spend unnecessary time improving activities
that should have been
– eliminated,
– automated,
– or significantly simplified.
LEAN can be deployed within other frameworks such as
PDCA/PDSA or traditional DMAIC.
© 2016 International Business Machines Corporation
Agenda
• Why is LEAN important to healthcare?
• The five LEAN Steps & Tools
1. Define Value
2. Map the Value Stream
3. Eliminate the Waste
4. Implement the Solution and Pull Value
5. Maintain the Gain and Pursue Perfection
• In Conclusion
• Q&A
© 2016 International Business Machines Corporation
Five Step LEAN Process
1. Define Value from the customer’s perspective.
2. Map the Value Streams and identify issues and constraints. Things that impede what the customer wants.
3. Eliminate the Waste and allow the customer to flow through
the value stream without interruption.
4. Implement the Solution and let the customer Pull Value
through the work flow.
5. Maintain the Gain and Pursue Perfection
Define
Measure
Analyze
Improve
Control
Within DMAIC
© 2016 International Business Machines Corporation
Plan
Do
Check
Act
PDCA
Plan
WHY IS LEAN IMPORTANT TO
HEALTHCARE?
© 2016 International Business Machines Corporation
TechnologyIBM WH
EMRMIDASEtc…
PeopleKnowledge,
Skills,Abilities
ProcessWays of Working
The way we work is constantly changing
Training & ExperienceProcesses
Systems
Tools
© 2016 International Business Machines Corporation
Process flow
optimized
and aligned
to the
technology Upfront pre-visit
planning
eliminates
downstream
rework cycles
Team members
collaborate in
huddles to
prepare for
patient arrivals
Downstream
wait time is
eliminated as
workers and
supplies are
ready when the
patient arrives
Patient is
ready with
Labs, Med
list, etc
All team members
ebb and flow to keep
patient moving
through the work flow
without waiting or
interruption
Patient is at
the top of the
clinical
universe
Upfront pre-visit planning
is most efficient at
reducing care gaps. All
other methods require
getting the patient back in
the office.
They’re already here!
All team
members work
at the top of
license (what is
legally allowed]
Percentage
of “No
Shows”
reduced with
remind
An uninterrupted flow for the patient is the end goal
Example not meant to be read© 2016 International Business Machines Corporation
Transparency is critical: Identifies the area to focus on
Helps to create a sense of urgency and ensure that the
project team focuses on the right areas of the value
stream.
© 2016 International Business Machines Corporation
Client Feedback from LEAN Workshops
• Reduced the percentage of billing errors by 50% +
• Designed a virtual visit process for wellness exams
• Designed a process to track patients through the system using rfid
• Designed a discharge process to align to Transition
• Improved the cycle time for patients to get into chemo chair from 8.5 hrs to 2.5 hours
• Decreased hand-off issues occurring during shift changes for 2 discharge groups
• Decreased fall prevention percentage
• Decreased cycle time for OR equipment sterilization
• Decreased the # of incomplete orders for an entire healthcare system
• Improved ability to hit on elements of ACO commitments
• Improved the capacity of clinics in which Outreach was driving up demand
• Decreased the cycle time for hiring clinical staff impacting percentage accepting
• Reduced wheels in and wheels out cycle time (45 to 20 min)
• Streamlined specimen processing cycle time and standardized across all shifts
• Designed a Comprehensive Primary Care initiative to reduce A1C scores for a population
• Reduce the approval process cycle time for high priority projects in a healthcare system
• Reduced cycle time for patient diagnostic communication in oncology process
© 2016 International Business Machines Corporation
1. DEFINE VALUE FROM THE
PATIENT’S PERSPECTIVE.
© 2016 International Business Machines Corporation
Always start with a Charter
No Charter, No Project
• Releases approved resources
– A living document: “progressively elaborated”
– Helps control “scope creep”
• All Charters must at least identify a:
– Definition of problem to solve
– Champion to approve
– Project Leader
– Project Team (5-8 recommended)
– Scope (What is included and excluded)
• Boundaries for project team
– Goal(s): The Key Measure(s) and can be multiple
Example not meant to be read
© 2016 International Business Machines Corporation
Define the Voice of your Customer (VoC)
• Who is our customer(s)?
– Internal VoB / external VoC
• What do they want?
– What do they care about? (willing to pay for)
• When does the customer need the output?
– Covered in Waste/Flow
– How often do they need what we’re providing them?
• Overall, what value are we providing them?
Identify these for your process, dept. or organization
Don’t forget the Voice of your Business (VOB)
© 2016 International Business Machines Corporation
First, brainstorm using the 5M & P method
People Method Machine Material Measurement Mother
Nature
Physicians
Nurses
Analysts
Patients
Qlty Mgr
Etc…
Processes
Methods
Check Lists
Approaches
Workflows
Etc...
Laptops
Medical Eqp.
SW
Programs
Vehicles
Routers
Etc…
Sponges
Paper
Glue
Tile
Desks
Etc…
Thermometer
Story Points
Blood
Pressure
Lab Scores
Coordinate
Etc…
Temperature
Rain/Wind
Policies
HIPAA
NCQA
Etc…
© 2016 International Business Machines Corporation
From the 5M and P identify the Customers
• Primary entity needs must be met
• However, needs go well beyond
that of the primary entity
• Keep these stakeholders at the
front of mind as you go through the
LEAN steps
© 2016 International Business Machines Corporation
Satisfaction
Dissatisfaction
FunctionalDysfunctional
The Kano Model
Expected: Customer
clearly ask for this
Basic Needs:
Customers expect
this without having to
ask for it
If included, patients/customers will be satisfied
If omitted, patients/customers will not be dissatisfied
If included, patients/customers will NOT be satisfied
If omitted, patients/customers will be dissatisfied
Wow: Delighters
customers don’t
know exists
“Wants” that
patients/customers
may not think to
ask for
Items
move
down
over
time
© 2015 International Business Machines Corporation 24
KANO
• What’s important:
– Not to forget Basic Needs
– To reaffirm what the
customers are asking for,
the Expected Needs
– Not trading Basic Needs for
Wows
– To ensure that all
stakeholder needs are
cared for in the new design
(5M and P)
© 2016 International Business Machines Corporation
2. MAP THE VALUE STREAM
AND IDENTIFY ISSUES AND
CONSTRAINTS.
© 2016 International Business Machines Corporation
Use the 5M’s & P to help identify what goes into the map
Methods
Processes
Materials
Supplies
Mother Nature
Policies, Weather
Measurement System
How things are measured
Machines
Equipment, HW & SW
People
Any person
© 2016 International Business Machines Corporation
A SIPOC can help when there is ambiguity about a process
EMR System
Medical Supply
Companies
BD Medical
Syringes
IBM
Etc...
Appointment
Sign in Form
Lab Results
Patient Summary
Etc…
Vital Signs
Head
Ears
Nose
Mouth
Etc…
Diagnosis
Orders
Treatment Plan
Supply Ordering
Etc…
Patient
Clinic
Etc…
S I P O C
Suppliers Inputs Processes Outputs Customers
© 2016 International Business Machines Corporation
Think Horizontally, NOT Vertically
• It is natural to think only about my own functional area
• Vertical Thinking
– Many defects occur during the handoff or downstream
– Vertical thinking will not show after handoff issues
• Horizontal Thinking
– Visualize the “Entity” flowing through the process – end to end
– Start at the point the entity first enters the flow
– End at the point the entity is no longer touched by the process
• If a coffee shop had bad tasting coffee, the cause could be anywhere
in the process, not just in the coffee pot.
– Identify the Value Stream for Coffee
– Field to Cup
© 2016 International Business Machines Corporation
What is a Process Map?
Action Step
?
Decision
or Path
• Visual representation of a process flow
– Illustration of what actually happens
– Shows the flow of a process
• Demonstrates scope of a project
– Start and end; steps and decisions
© 2016 International Business Machines Corporation
Standard Process Map Symbols
Start Stop
Process Step or Operation
Decision
or Transport of movement
Storage, waiting time
Delay
24
A complex process step
that could be broken out
into it’s own map
© 2016 International Business Machines Corporation
Always map the current state in detail
• Effective change agent
– Evokes an emotional response
• Becomes a common language
• Identifies sources of waste
• Identifies the potential inputs, actions and
decision points that may impact a
process and its outputs
• Serves as the foundation for process improvement activities
“…and then it ends here”
Start here
Visual and
engaging!Easy to
do!
© 2016 International Business Machines Corporation
Example of a Cross-Functional Value Stream Map
Original Paper Map completed in our workshop
Turned into a Cross-Functional Value Stream Electronic Map
Examples not meant to be read in detail© 2016 International Business Machines Corporation
Registration w/Exam Exam w/Treatment
50/day 20/day 50/day
Treatment
40/day
• Removing all the NVA could improve patient satisfaction, but capacity for
this workflow would not increase.
• The overall capacity of a process = the single largest “constraint”
• The exam would need to be mapped in detail to identify and
DOWNTIME, then eliminate waste in the value added step
Time the activities and identify the constraints
CAPACITY
Backlog
or WIP
Capacity: 40/day
0% 100% 0% 90%VA: 80%
VA
NVA
© 2016 International Business Machines Corporation
A Few Process Mapping Tips and Hints
• Use mapping paper and sticky notes to make changes easy
• Involve Subject Matter Experts or you may be remapping
• Be the entity flowing through and capture everything– Even wait points and rework loops
• Start and Stop at extremes
• Only one activity per sticky
• Don’t put swim lanes on the paper map– Instead, write down the swim lane on the sticky note pad, put on the left
• For decisions, show the percentage that goes down each path (even if
just estimated)
• Don’t have naked lines (email is not an activity but a line, label it as
such, driving, email, meeting, face to face etc.)
– Transportations go on the lines, so show how it was transported to the next
process step
© 2016 International Business Machines Corporation
Use the LEAN criteria to identify non-value add activities
(NVA) in the value stream
The LEAN criteria for a patient centered value stream
1. The patient must care about it
AND
2. The activity must change the patient or knowledge about the patient
AND
3. The activity must be done right the first time
© 2016 International Business Machines Corporation
To identify non-value added activities, it helps to think
about the 8 LEAN Wastes in the Muda Wheel
Defects - Incorrect data entry, incomplete information,
mistakes
Overproduction - Preparing extra reports, making too
much
Waiting – Batching work, downstream step is not ready
uNused Creativity - Not working at the Top of a
License
Transportation - Travel to/from facilities, walking to
copy machine
Inventory - Purchasing supplies in bulk and storing in
cabinet
Motion - Extra steps and movement during an exam
Excess Processing - multiple sign-offs, most
meetings, downstream inspections, rework, approvals
Defects
Transporta-
tion
Over -
Production
Waiting
Motion
Unused
Employee
Talent
Inventory
Non Value
Added
Processing
Waste
“muda”
Muda Wheel
© 2016 International Business Machines Corporation
Conduct a Value Add Flow analysis: Red Dot/Green Dot
• Red and Green
dots were used to
decide if an
activity was a
Value Add [Green]
or Non-Value Add
[Red]
1. Customer cares about it
2. It transforms the entity
3. It is done right the first time
Activity does not meet
the value add criteria
Evaluate via VA CriteriaChange Management
Starts Now
© 2016 International Business Machines Corporation
A Spaghetti Diagram Map is another good way to
identify process flow issues, especially Transportation
• A “Birds Eye” view of the flow of a process
• Can identify areas in which
– Activities could be done in parallel
– Walking can be addressed via redesigning
the work area
• U Shaped work areas could reduce walk
time
• Moving supplies, equipment, files closer
• iPads
• Etc…
1 3
2825
16
15
18
17
5 6 7 8
9 10 11
26
27
12 13 14
19 20 21
23
24
31
32
33-36
37-43
44
45
46-47
50-51
48-49
52 53
54
55
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59
62 63 64
6566 67 68 69
72
96
70
71
89
81
736
6 75
8283CHANGING HALLWAY
79 77
80
766
74
6 84
86
93 92 88 95
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91
0
2
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100
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60-61
101
1 3
2825
16
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31
32
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37-43
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50-51
48-49
52 53
54
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56
57
58
59
62 63 64
6566 67 68 69
72
96
70
71
89
81
736
6 75
8283CHANGING HALLWAY
79 77
80
766
74
6 84
86
93 92 88 95
94
87
90
91
0
2
97
98
100
22 79
6
104
103
102
60-61
101
IMPLANT
OXID, P-
P+
BASE
TEOS-NI-TEOS
EP
EMITTER
S-FIELD
DC, PT SILICIDE
1ST METAL
3RD CONTACT
2ND METAL
© 2016 International Business Machines Corporation
3. ELIMINATE THE WASTE AND
ALLOW THE PATIENT TO
FLOW THROUGH THE VALUE
STREAM WITHOUT
INTERRUPTION.
© 2016 International Business Machines Corporation
Ensure continuous flow in your design so the entity
(patient) never waits
IDLE WORKERS
VS
IDLE PATIENT
© 2016 International Business Machines Corporation
5 Why
Problem Statement: An item was missing in the Exam Room
A new delegate was never appointed
Why was an item missing from the exam room
Someone forgot to re-stock
The Kanban card was not pulled in time
The key person went on vacation, no backup
WHY?
WHY?
WHY?
WHY?
WHY?
There may be more than one “Why” for each
issue and each “Why” can have multiple paths
© 2016 International Business Machines Corporation
Using a Fishbone (Ishikawa Diagram) with the 5M’s and
P and the 5 Why can help identify root causes
1. The Problem statement is the Fish head
2. Use the 5Ms and P as the major bones
3. Use the 5 why process with each failure mode to move from
symptoms and get to the root causes for each bone
4. Place the root causes on the diagram as smaller bones
© 2016 International Business Machines Corporation
Use the FMEA (Failure Modes and Effects Analysis) to
calculate the Risk Priority (what to do first, second etc.)
Process
Step/Input
Potential Failure
Mode
Potential Failure
Effects
S
E
V
Potential Causes
O
C
C
Current Controls
D
E
T
R
P
N
Actions
Recommended
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
What
is the
input?
What
can go
wrong
with the
input?
What can
be done?
What is
the effect
on the
outputs?
What are
the
causes?
How can
these be
found or
prevented
?
How
bad?How
often?
How
well?
Risk Priority Number (RPN): Severity X Occurrence X Detect ability = RPN #
Severity of Effect (1=Not Severe, 10=Very Severe)
Occurrence of Cause (1=Not Often, 10=Very Often)
Detection of Current Controls (1=Likely to Detect, 10=Never able to Detect)© 2016 International Business Machines Corporation
Example from our LEAN workshop:
FMEA with paper and sticky notes
© 2016 International Business Machines Corporation
Waste elimination strategies
Once Waste (NVA) is identified:
1.First Priority: Eliminate (do not improve an activity that should be
eliminated)
2.Second Priority: Automate
• Poka Yoke
• Auto populate
3.Third Priority: Simplify
• Reduce handoffs
• Eliminate redundancy
• Co-locate and sequence tasks
• Reduce approvals
• Standardize
• Reduce motion
• Prioritize efforts
• Balance resources
• One piece flow
• 5S
© 2016 International Business Machines Corporation
Poka Yoke Ideas
• Reduce NVA by eliminating rework loops, auto populating data entry
– Drop down menus for data entry
– Color coding items that go together
– Manual processes automated (not manumated)
– Electronic sensors for danger areas
– Bar coding
– Collision detection systems
– Correct position setting tape so item is always placed in the correct
location
– Barriers to electronic files
– Computerized Physician Ordering Systems
– Plug protections for children
http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/mistakeproof/mistake8.html
© 2016 International Business Machines Corporation
5S Detail Steps
1. Sort: Keep only what is needed, discard
everything else. Sort the remaining into
categories
2. Store: A place for everything and
everything in its place. Store and label all
items in an area that is easily visible and
accessible to the group.
3. Shine: Keep the workplace tidy and
organized and labels obvious.
4. Standardize: All areas must be set up
exactly the same way.
5. Sustain: Maintain, plan, schedule, train,
track and audit all areas periodically.
© 2016 International Business Machines Corporation
Examples of 5S
http://www.moreeffective.com/products/5shandbook.html
http://totalqualitymanagement.wordpress.com/2010/03/23/some-
images-of-5s-houskeeping-in-factories-and-offices/
http://5sbestpractices.ning.com/photo/tool-shadow-
boards-before-and-after?context=user
http://runningahospital.blogspot.com/2009/10/5s-projects-are-spreading.html
Labels Styrofoam Inserts
Clear Visuals
Archived Obsolete Files
Set in Order
© 2016 International Business Machines Corporation
Finally: Map the “to be” process
As-Is
To-Be
Map the “To Be” with
all combined ideas
and create an action
item list to start
implementing them!
© 2016 International Business Machines Corporation
4. IMPLEMENT THE SOLUTION
AND LET THE PATIENT PULL
VALUE THROUGH THE WORK
FLOW.
Up to this point, everything is still on paper
© 2016 International Business Machines Corporation
• Kanban is literally a “signal” that something needs to be ordered or that
the next step in the process is now ready for the entity flowing through
• No one from an upstream step moves the entity to the next step until
the next step is ready for it
• Only reorder when signaled (the Kanban card is on top)
A Kanban can help with Pull
Pull
Step 1 Step 3 Step 4 Step 5Step 2
“I’m ready!”
© 2016 International Business Machines Corporation
Now, it’s all about Change Management
http://aurorasblog.com/2013/05/15/im-not-too-busy-part-2/
Let the fun begin
© 2016 International Business Machines Corporation
It’s now all about Change Management
• The easy part is done
• Now, the real hard part begins
Change is individual not organizational
© 2016 International Business Machines Corporation
16% 16%68%
PioneersWill embrace and support
the change early. Won’t
understand why it took so
long
DinosaursWill never accept the change
and will fight any efforts to
get them on-board
SettlersWill go along with the
change once it has been
proven ‘safe’ for them
Get the Pioneers to help you pull up Settlers
This group is already on
board and will pull
others to join
This group, the majority,
is watching to see
what happens
This group is afraid
of losing its value
Early Adopters
Majority
Laggards
The Adoption Curve
© 2016 International Business Machines Corporation
Kotter’s 8-Steps for Managing Change
1. Create a sense of urgency
2. Form a guiding coalition– Those who can help move the project forward
– Up and down the organizational hierarchy
3. Create a vision of the future
4. Communicate the vision
5. Empower action
6. Create short term wins
7. Don’t let up
8. Make change stick
Kotter’s 8-Steps can help with change management
© 2016 International Business Machines Corporation
5. MAINTAIN THE GAIN AND
PURSUE PERFECTION.
© 2016 International Business Machines Corporation
Compare before and after measures
• Measure Before VS After and report on improvement
Before
After
© 2016 International Business Machines Corporation
Monitor and Close: Pursue Perfection
• Go back and review the Charter and patient values from the KANO
• Redefine new and tougher targets
• Find additional waste to remove using the LEAN Criteria
• It takes about 90 days for a change to stick
• Only the Champion can close the project
• Must insist on evidence that the project was successful and when
doing more is not worth the cost to continue
• Monitoring and measuring the key measures must
continue…FOREVER
© 2016 International Business Machines Corporation
IN CONCLUSION
© 2016 International Business Machines Corporation
End toend
ProcessingApprovalsRework
© 2016 International Business Machines Corporation
TechnologyIBM WH
EMRPeopleSoft
Etc…
PeopleKnowledge,
Skills,Abilities
ProcessWays of Working
Why LEAN? To Optimize all three bubbles
Training & ExperienceProcesses
© 2016 International Business Machines Corporation
Systems
Tools
If you want more, we have our LEAN
Fundamentals Workshop for Healthcare coming
up in July
For more information email: [email protected]
Or visit the LEAN Fundamentals Workshop website
https://www.ibm.com/events/ast/lean/16leanhealth.nsf.
© 2016 International Business Machines Corporation
Q&A
© 2016 International Business Machines Corporation
THANK YOU!
The recording and handouts will be sent to you
via email within 2 business days
© 2016 International Business Machines Corporation