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Bringing Sanity to Clinical Work Life

Lean in HealthcareMichael Nelson, MDBlue Corn Professional Services, LLC

SO How did they do that?

LeanAbout removing waste for clinical care processesImportance of tools and culture5S, Kanban, Single piece flow, etc.Transformational change for leads, supervisors, managers and senior leaders (oh and by the way clinicians)Shingo methodProcessOperators

Definitions Value AddedValue AddedPhysically or Emotionally Changes the PatientPatient is Willing to Pay for itDone right the first time

Required Work Non Value AddedIt must be done based on our current regulatory processes TODAY, but does not meet all three (3) criteria above

66The product in this case is the patient. So physical changes might include cure of sinus infection, repair of laceration, etc. But may also include changes in the patients emotional state as a result of the visit.

While prevention activities will not usually create a physical or emotional change in a patient, they are willing to pay for it, provided it is done right the first time.

Regulatory processes include not only external agency regulations but our own internal rules and policies that govern how we work today.

On the quote: Time waste (delays) are the easiest to create but when done cant be recovered.Leading with LeanThe Possibilities

8Shingo Lean Implementation Primary Care ClinicEight primary care physicians4 internal medicine2 family practice2 pediatricsLean Implementation Jan 08 April 08

Standard Work Area???Solution = 5SSort (remove infrequently used items)Set (Everything has a place and everything in its place)Shine (clean)StandardizeSustain

9Is this a standard work area? :>)

No organization. Coffee cups, vials of medicine, charts scattered everywhere

So what do you do about that? Answer: 5S (which will appear on the next mouse click on this slide)

Standard Work Area!!!!

11Here is an example of a standard work area. Dr Nelsons officeCreating the Value Stream MapDirect observationPeople flow: patients, providers, staffMaterials flow: medical records, equipmentInformation flow: messages, test results

Cycle time measurementMinutes count but seconds rule

Full work analysisVideotape providers / staffAnalyze each step of work with the staff person

Determine demand

Determine resources

12Describe what we did. Walking around with data sheets to record times, comments and observations. Used stop watches so Minutes count but seconds rule applies.

Determine demand is how many patients, messages, charts pulled, telephone calls etc.Determine resources is how many people are there to do the work.

All eventually put into a formula that tells you how many patients, records, phone calls, etc you need to do an hour (or other period of time) to not have delays. That measure is called Takt time.13Future State Value Stream Map(where we need to focus improvement efforts to reach desired state)

13Future state map as indicated before is really a map that identifies all the improvement opportunities (Kaizan bursts) that need to be identified as part of the work to create a better future state.Taiichi Ohno was the Toyota executive largely responsible for structuring and implementing the system known today as the Toyota Production System over four decades after World War II. Ohno was known for drawing a chalk circle around managers and making them stand in the circle until they had seen and documented all of the problems in a particular area.

Ohno Circle

1415Creating Well Child Check PacketsLOCATION: Registration DeskPackets:Created by Registration StaffGiven to Patients Seen For Well Child ChecksContains a Variety of Forms & Documents47,424 packets created per year

Eight Deadly WastesExcess InventoryExcess raw material, WIP, or finished goods. This hides problems such as process imbalances, late deliveries from suppliers, defects, equipment downtime and long setup times.MotionAny wasted motion employees make to perform the course of their work. Actions such as looking for, reaching for, stacking, picking up or putting down and walking.CorrectionProducing products that need correction or are defective. Repair, rework, scrap, replacement and inspection are all defect costs.Employee ParticipationLosing time, ideas, skills, improvements and learning opportunities by not engaging or listening to employees.

Eight Deadly WastesOverproductionProducts being produced in excess of whats required. Products being made too early. This generates other costs such as overstaffing, storage and transportation.Waiting (time on hand)Workers that are standing around waiting on a machine, someone to bring them materials, equipment downtime and no work available.TransportationCarrying work in process (WIP) long distances, moving materials more than once, moving parts in and out of storage.Over processingTaking unneeded steps to process the work. Inefficient processing due to poor tool or product design and. Producing a higher quality product than necessary.

18Initial Batch ProcessCYCLES: 5TOTAL TIME: 3:36 minCYCLE TIME: 0:43 secOBSERVATIONS?

19Improved Batch ProcessCYCLES: 5TOTAL TIME: 1:40 minCYCLE TIME: 0:20 sec (53% Improvement)

IMPROVEMENTS:Forms Organized by Packet TypeEliminated Wasted MovementError Proofing

1920Single Piece Flow ProcessIMPROVEMENT:Build Packets While Waiting For PrinterEliminated Non-Value Added TimeNo Added Time To The Process

Primary Care Clinic (FP, IM, Peds)

Primary Care Clinic (FP, IM, Peds)

Primary Care Clinics (FP, IM, Peds)

Lean Culture consider culture in a work organization to be the sum of peoples habits related to how they get their work done

David MannCreating a Lean Culture

Lean Culture That is, our idea of culture of a place or organization is a result of what we experience there. In this way a companys culture is a result of its management systemculture is critical, and to change it, you have to change your management system.

David MannCreating a Lean Culture

Questions