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Creating the Michigan Quality System
John E. Billi, M.D.Associate Dean for Clinical Affairs, University of Michigan Medical SchoolAssociate Vice President for Medical Affairs, University of [email protected]
Michigan Quality System:http://med.umich.edu/mqs
Michigan Quality System:
• Quality
• Safety
• Efficiency
• Appropriateness
Application of Lean Thinking to Health Care
Outline
• Introduction to UMHS
• Need for change
• Applying lean thinking to health care– Case examples
– Spear framework
– Lean tool examples
– Waste in health care
• UMHS lean journey– Decision to implement ‘lean thinking’
– Development of Michigan Quality System
– Learning projects and results
UMHS in a Slide
Integrated Academic Health System,
within major public research university:• UM Hospitals and Health Centers
– 817 beds– 1.6 million outpatient visits– 10,000 employees
• UM Medical School– 1500 faculty physicians– 995 resident physicians– 690 medical students
Mission Synergy
PatientCare
Research
Education
Good-to-Great in Health Care
“Greatness is not a function of circumstance. Greatness, it turns out, is largely a matter conscious choice and discipline”.
---Jim Collins, Author Good to Great
Burning Platform for Change?
Burning Platform for Change?
Traditional Health Care …or, the way I was trained
• Episodic• Requires patient initiation• Not well coordinated (patients & doctors)• Sporadic communication among clinicians• Sporadic patient education• Variable process of care• Clinicians’ opinions drive decisions• Systems do not prevent errors• Outcomes not measured• Expensive
Burning Platform for Change?
Gaps at UMHS:
• Quality: Not all diabetic patients on statins, aspirin
• Safety:- Wrong site surgery- Fatal medication errors- Preventable wound infections
• Efficiency: Days waiting for a CT scan
• Appropriateness: Generic drug rate around 55%
Burning Platform for Change?
• Bottlenecks– ORs– Inpatient beds
• Stress of overwork (muri):- Physicians, nurses, clerks running faster
- Nurse and physician shortage
• Financial pressures- Troubled State economy- Health care costs burden employers- The uninsured
HEALTHAFFAIRS
January/February 2001 – Volume 20, Number 1
Interview:A Founder of Quality AssessmentEncounters A Troubled System Firsthand
“At the University of Michigan, the outpatient and inpatient teams are entirely separate…There are areas where no one takes responsibility, where planning is weak, where I am left on my own…The system is the problem…Things won’t improve until something is done about the design of the system…The system is the responsibility of the doctors and the hospital leadership.
…….tell the committee that Donabedian said they have a problem.”
By Fitzhugh Mullan, p137-141
Transitional Care = Hand-offs Discharge Problems
Problem Example Consequence
AppointmentsTimely appointment not made
Patient unaware of appointment
Health deteriorates
Missed appointment
Contact Information
Discharge destination unknown Unable to contact patient
Dischargecounseling
Patient confused about medications Patient confused about tests
Does not take medicationsDoes not go to tests
SocialLacks transportation Cannot afford medications
Misses appointment
Does not take medications
Home care Visiting nurse not available Health deteriorates
Where Do We Want to Go?
Our future state vision:Based on Institute of Medicine Report“Crossing the Quality Chasm”
Care that is:• Safe• Effective• Patient-Centered• Timely• Efficient• Equitable
Crossing the Quality Chasm
• The IOM “Chasm” Report gives us a vision of where to go
• Lean Thinking gives us tools and methods to get there
• The IOM “Chasm” Report gives us a vision of where to go
• Lean Thinking gives us tools and methods to get there
Crossing the Quality Chasm
What is Lean Thinking?
“The endless transformation of waste into value from the customer’s perspective”.
---Womack and Jones, Lean Thinking
The 5 Steps of Lean ThinkingApplied to Healthcare
• Specify value from customer’s perspective• Identify the value stream for each product, and
remove the waste• Make value flow without interruptions from
beginning to end• Let the customer pull value from our process• Pursue perfection - continuous improvement
– Do this every day in all our activities
Source: Womack & Jones: Lean Thinking
The Clinic Appointment• You call the clinic, go through 3 voice prompts, are put
on hold, and leave a message.• The clerk calls you back and sets a date next week.• You arrive for the visit, check in, sit in waiting room.• You are called into the exam room, wait for doctor.• The doctor sees you, saying she’s been waiting for you
to arrive; diagnoses a URI, and BP is worse.• The doctor prints an antibiotic prescription, goes to the
staffroom to get it. You are allergic to that drug. • The doctor says to return in a week for the BP.• The medical assistant does an EKG.• At check out you ask the cost – clerk says they’ll bill you,
no appointment is available next week.• Pharmacist says your insurance prefers a different drug.• Is there a problem?
Using the 5 Steps in the Clinic Visit
• Specify value from customer’s perspective– A quick, effective clinic visit
• Identify the value stream for each product– Request > appointment > arrival > seeing doctor > check-out
…and remove the waste– Time on hold, callbacks, walking, wrong/unnecessary drug/test
• Make value flow without interruptions from beginning to end– Staff and patient move continuously from check-in to exit– No waiting room, no staff waiting– Errors surface immediately
• Let the customer pull value from the process– Pull the appointment or med refill when you want it
• Pursue perfection – continuous improvement– Every day, every clerk, doctor and nurse thinks about how to
redesign work to improve value to the customer
UMHS Example: Orthopaedic Outpatient Consults
Chronic problem:• Long delays just to get an appointment• Frustrated referring physicians/patients/orthopedists• Incomplete records, phone tag• Physician review records prior to scheduling• Lots of hidden processes, downstream consequences of
the way work was done• Patients/referring physicians seek care elsewhere
Project scope:
• Orthopaedic consult – from request to scheduling
Using the 5 Steps Orthopaedic Consults
1. Specify value from customer’s perspectivePatients/referring physicians: quickly
scheduled appointments
2. Identify the value stream for the serviceRequest > review> schedule appointment
…and remove the wasteVariation in request, time on hold,
callbacks, physician reviews
Orthopaedics MedSport Appts.Current State Map
Wednesday March 16, 2005 - Page 1
D R A F T - Orthopaedic Surgery MedSport - Current State Map
Summary
Total Processing Time : 11 31 minutes
Total Waiting Time: 1 - 36 days
% Complete and Accurate: %
Metrics
P/T: Processing Time
W/T: Wait Time
% C & A: % Complete and Accurate
Wait time (day)
Process Time (sec)
Mapping Icons
In
~~~ Service
Patient
Ref. Phys.Pt / ATC
Data Box
Information
OutsideSource
In Box(Queue)
ProcessStep
Wait Time
Phone
Fax
5 min 10 min
0 - 3 d0 - 1 d
P/T: 5 min
W/T: 0-3 days
C&A: 100%
Call Ctr.
In
~~~Receipt &InspectRequest
P/T: 1 min
W/T: 0 days
C&A: 98%
Physician
In
~~~ClinicalReview
P/T: 3 min
W/T:0-3 days
C&A: 100%
Call Ctr. Sctry.
In
~~~TransportAppointment
Request
P/T: 2 min
W/T: 0-3 days
C&A: 95%
Ref. Coord.
In
~~~Business/ClinicalReview
P/T: 10 min
W/T: 0-14 days
C&A: 5%
Call Ctr.
In
~~~Re-workRequest
P/T: 1 min
W/T: 0 days
C&A: 98%
Ref. Coord.
In
~~~Denial/PriorSetting
P/T: 3 min
W/T: 0 days
C&A: 100%
Sctry.
In
~~~TransportAppointment
Request
P/T: 1 min
W/T: 0-1 days
C&A: 100%
Front Desk
Mail Itinary
P/T: 5 min
W/T: 0-1 days
C&A: 100%
Call Ctr.
In
~~~Scheduleand/or Notify
6 Requests28 Requests 6 Requests 6 Requests 28 Requests 30 Requests 29 Requests
1 - 14 d0 - 1 d
2 min
0 - 1 d0 - 3 d
3 min
0 - 1 d1 - 7 d
1 min
0 - 1 d
3 min
0 - 1 d
1 min
0 - 1 d
5 min
0 - 1 d0 - 1 d
1 min
0 - 1 d
Appeals
2 Rqsts2 Rqsts
Requests 30/Day
OPNotes
PhysicianNotes
Imaging
2 Rqsts
Lost Req1 Req
Orthopaedics Taubman Appts.Current State Map
Wednesday March 16, 2005 - Page 1
D R A F T - Orthopaedic Surgery Taubman Center (Adult) - Current State Map
Summary
Total Processing Time : 10 - 58 min (Avg. 34 min)
Total Waiting Time: 4 - 60 days (Avg. 32 days)
% Complete and Accurate: 44%
Fax
Phone
Email fromPatient
Referral SnailMail
Email fromPhysician
Walk-in
5%
10%
20%
53%
5%
7%
In
~~~
Receipt EachPhysician’sSecretary
ReceiptMedSport
Receipt S.Main
ReceiptTaubman
Receipt of Request
P/T: 3 sec - 2 min
W/T: 1 - 7 days
C&A: 95%
65/Day
InspectionRole
P/T: 5 min
W/T: 1 - 5 days
C&A: 80% RequestsCompleted
Metrics
P/T: Processing Time
W/T: Wait Time
% C & A: % Complete and Accurate
Wait time (day)
4
62
3
Process Time (sec)
Mapping Icons
In
~~~
Payer
Imaging
Other AuxlServices
Inspection of Requestfor Completeness,
Payer Appropriateness,Demographics, Clinical
Info.
Triage toServices
P/T: 1 min
W/T: 1 day
C&A: 100%Distributed toServices
PhysicianReview &
Decision toSee
In
~~~In
~~~
15% re-triaged
Tumor
Trauma
Spine
MedSportNon-Op
MedSport
Joints
Hand/Arm
Foot/Ankle
P/T: 1 - 40 min
W/T: 0 - 21 day
C&A: 85%AppropriatelyDistributed
AppointmentScheduling w/
Discourse
AppointmentScheduling
Input
P/T: 1 - 5 min
W/T: 1 - 21 day
C&A: 95% ActuallyScheduled
Service
85% of Peds &10% of Adults
YES 90%Who
WhereWhen
NotificationEmail
NotificationPhone
UMHSPhyisician
Patient
ExternalPhysician
Intra-Dpt.
OutsideOrtho
E D
UMHSPhyisician
Patient
ExternalPhysician
Intra-Dpt.
OutsideOrtho
E D
NotificationMail
P/T: 2 - 5 min
W/T: 0 - 5 day
C&A: 80%Satisfaction w/Time& Date
In
~~~
Denial to See10%
Data Box
Information
OutsideSource
In Box(Queue)
ProcessStep
Wait Time
300
1
60
10.5
1,230
11
180
2.5
210
20% of scheduledappointments areunaccepable to
patient. Rescheduled
Using the 5 Steps Orthopaedic Consults
3. Make value flow without interruptions from beginning to endStaff scheduling appointments on first
phone call
Uniform intake process
No waiting for appointments; errors surface immediately
Orthopaedics Appts.Future State Map
Thursday March 17, 2005 - Page 1
D R A F T - Orthopaedic Surgery - Future State Map
Summary
Fast Track Slow Track
Total Processing Time : 6- 11 min 8 - 13 min
Total Waiting Time: 0 - 1 min 1 - 7 days
Lead Time: 6 - 12 min 1 - 7 days
% Complete and Accurate: 95% 85%
Metrics
P/T: Processing Time
W/T: Wait Time
% C & A: % Complete and Accurate
ConsultRequest
Guidelines onthe Web
BusinessReview
Ref. Phys.
OutsideOrtho
OPNotesED
Patient
Phone
Input byphone only.Faxes and
emails will befunneled to
phoneprocess
Clinic ReviewSchedule
AppointmentAppointment
Requirements
ItineraryPrinted &
Mailed
Entry Criteria
||||||||||||||||||||||||||||
Call Center Staff
Contact Schedule ReminderScheduling Patient Appointment:
StandardWork
3-5 Days Pre-Arrival Call
StandardWork
PatientRef. Phys.Pt / ATC
90%
LL
FailedRequests
areRedirected
Fast Track
2nd ReviewRotatingDesignee
10%
Slow Track - Exception Process
P/T: 6 - 11 min
W/T: 0 -1 min
C&A: 95%
P/T: 8 - 13 min
W/T: 1 - 7 days
C&A: 85%
Fast Track Slow Track
Mapping Icons
In
~~~ Service
Data Box
Information
OutsideSource
In Box(Queue)
ProcessStep
Wait Time LLLearningLoop
Using the 5 Steps Orthopaedic Consults
4. Let the customer pull value from the processSame day appointments
After school sports, till 7PM
5. Pursue perfection – continuous improvementEvery day, every clerk, doctor, and nurse
thinks about how to redesign work to improve value to the customer
Orthopaedic ConsultsProject Results
• Orthopaedic consult – from request to scheduling – Results:
• Pre project: – process time = 27 min– wait time = 23 days
• Post project: – MedSport = 91% of appointments made on first
call (2.5 min) – Still true a year later!
• Attending and staff freed to create more value:
– After school, same day appointments till 7PM
How To Get It “Right Every Time”
Steven Spear’s 4 Part Process:1. Design work to surface problems
– “Generous processes” tell us where problem is– Embed testing in work: immediate signals – Tell normal from abnormal right now (Mr. Cho)
2. Fix the problem now– For this case and for future– Improve work as close as possible to problem
» in time, person, place, and process
– Learn and correct the root causes– No workarounds, lots of small steps
3. Disseminate learning (the problem and the fix)4. Management must support 1-3
Steven Spear. Fixing Healthcare from the Inside, Today.
“The leader must know everything that went wrong, every day”.
---Paul O’Neill
How To Get It “Right Every Time”
• Catheter-related sepsis – a lot of little things:– No sink, no soap, no sanitizer, no doormat reminder or
buzzer– Gloves missing, wrong size, old and rip, on other side of
patient, at bottom of kit– 92% of nurses faced with impediments constructed ad
hoc workarounds
• Laryngoscope detects misplaced tube– signals the operator– downloads to QI lead
Steven Spear. Fixing Healthcare from the Inside, Today
How to Get It “Right Every Time”
• ICU bed automatically adjusts to 30° (vent)– signals when not at 30°
• “CPR disc” signals the defibrillator to speak: – hand position, depth, ventilation rate and depth,– stores for QI
• Manufacturing corollary: “Do not accept, build, or ship a defect”
– General Motors
Fixing Health Care from the Inside, Today – Steven Spear
• Americans think of a plan as a prediction of what will happen. Toyota thinks of a plan as an experiment whose result will improve understanding of the work.
– Paraphrase of Steven Spear
Fixing Health Care From the Inside, Today – Steven Spear
• Work is designed as a series of ongoing experiments that immediately reveal problems
• Problems are addressed immediately through rapid experimentation
• Solutions are disseminated adaptively through collaborative experimentation
• People at all levels of the organization are taught to become experimentalists
Fixing Health Care From the Inside, Today – Steven Spear
• Short on Time???• Can’t find time to fix root cause??? • Rather fix the problem every day for the rest of
your life? • Steven Spear: Just take 5 minutes a day to fix
root cause of one problem – Frees up time, so tomorrow it will be 10 min.– Next time it will be 15 minutes…
Find it, Fix it
“Cultivate a ‘Find it, Fix it’ mentality for overcoming challenges in your area”.
---G. Richard Wagoner, Jr. Chairman and CEO
New Way of Thinking
• Cultivate– Accountability– Collaboration– Teamwork
• Weed out– Silos– Tribalism
“Act your way to a new way of thinking”.
---John Shook, Ph.D.
Senior Advisor, Lean Enterprise Institute
Author, Learning to See
Lean Tools in Health Care
• Standard work – 4 ways lab results get to me• Pull systems – no signal when OR ready• One piece flow – 36 steps to make an ortho appointment
– Process Time = 27 min., Lead Time = 23 days;• Visual workplace – each exam room has forms in
different colored, opaque folders – common ones gone• Cellular layout – Mirror image ORs – half not optimal• Multi-process (cross-trained) operators – RN clean OR• Iterative questions (5 “whys”) – The ER patient…
-left without being seen because of a long wait,-because of a long stay patient
-because of the lack of an inpatient bed-because of a gap in discharge planning…
• Andon cord – “Stop the Line” in surgery or meds
Eight Forms of Waste in Healthcare
Overproduction and Production of Unwanted Products:
Material Movement:
Worker Motion:
Waiting:
Over-processing:
Inventory:
Correction of defects:
Wasted creativity of employees:
Not All Waste Is Equal
Production of Goods and Services Not of Value to the Customer:
• Most important form of waste:– Worsens all the others
• Appropriateness – key dimension of quality in health care!– Eliminate tests, treatments, steps, processes that do
not add value• Better to eliminate work than to improve how it’s done
– Hard to beat the efficiency or safety of a cardiac cath that’s not done because it wasn’t needed
– If its not worth doing, its not worth doing well.-Donald O. Hebb
Eight Forms of Waste in Healthcare
Overproduction and Production of Unwanted Products: The most important form of waste – worsens all the others.
• Any health care service that does not add value to the patient • Antibiotics for respiratory infections• CT screening for coronary disease• Medication given early, testing and treatment done ahead of
time to suit staff schedules and equipment use• Appropriateness – key dimension of QI in health care!Material Movement: • Moving patients, meds, specimens, samples, equipmentWorker Motion: • Searching for patients, meds, charts, supplies, paperwork• Long clinic halls• No printer in exam room for prescriptions, patient education
Adapted From Long, Mersereau, Billi
Eight Forms of Waste of Healthcare
Waiting:• ER staff waiting for admission, can’t see next patient• Waiting for test results, records, information • Nurse waits for med, blood draw, transport, OR cleaningOver-processing: • Bed moves, retesting, repeat paperwork, repeat registration,
multiple consent forms, logging requests Inventory: • Bed assignments, pharmacy stock, lab supplies, specimens
awaiting analysis• Patient waiting for anything – tests, visits, discharge, phone
cuesCorrection of defects: • Medication errors, wrong patient, wrong procedure, missing or
incomplete information, blood re-draws, misdirected results, wrong bills
Wasted creativity of employees:• Resident trying to find a Livonia infusion center
Lean Thinking at UM Health System
1. Why Lean Thinking?
2. “Michigan Quality System” concept
3. Learning projects: seeking a Model Line
Why Lean Thinking?
Why do we believe Lean Thinking is best way to:– Reduce errors?
– Address quality problems?– Eliminate stress?
– Increase efficiency?
• It is a learning approach– Empowers workers to redesign their work– Uses “Work as Learning”
• It is a research-based approach– Uses study of work to discover new knowledge
• Can be used to align the organization from top to bottom
Why Lean Thinking?
• Can healthcare use the lessons of Toyota and GM to transform waste into value?
• Can a health system use:- fewer inputs (time, human effort, materials) - than traditional care process - to produce a wide variety of “products” - with fewer “defects” more quickly - with less stress?
• Lean is not about working harder or faster, it is about finding waste and transforming it into value our customers want.
Why UMHS Chose Lean as the Best Uniform Approach
Key Attributes:
• Builds on traditional Continuous Quality Improvement• Uses first-hand knowledge of the work• Analyzes root causes of problems (5 whys)
• Starts with value as defined by the customer
• Uses “one piece flow” to surface problems
• Creates new future state value stream map, not just a better current state map
• Value stream maps useful for invisible work of health
“Michigan Quality System” Concept
• Create– a health system-wide
consistent approach
to quality and process improvement
adapting the principles of the Toyota Way
building on CQI base
• Incorporate 4 goals of Michigan Value :– Quality – Safety– Efficiency– Appropriateness
Michigan Quality System: The Value Proposition
• Uniform process improvement across UMHS – Across missions: education, research, clinical/service
Example: Medical students in clinic flow
– Across goals: - Quality - Efficiency- Safety - Appropriateness Example: Map created to improve “efficiency” can be used to improve
“safety” (root cause analysis following an adverse event)
– Spread to adjacent areas: merging projects• ED => Radiology => OR
– Training synergy:• Transferability of training received for one project when working on
other projects• Teach residents and medical students to think lean
Learning Projects
• What are they? Why use them? – Institutional examples of lean in healthcare– Proof of concept at UMHS– Can expand upstream, downstream and
laterally
• Why not train all managers first?– We Learn Lean By Doing– Training long before use is less valuable– “Learn-do-reflect-discuss” cycle of a learning
organization
MQS ProjectSelection Process
• Areas:– Prioritization Committee
(COO, CFO, CMO, Chief of Nursing, Ambulatory Director, Group Practice Director)
• Project leads: – Determine scope, participants and timing
• Leadership panel: – All the leaders who need to approve the Future
State Value Stream Map and the plan to get there
– They support the implementation
MQS Project Selection Criteria
• Institutional priority
• Opportunity for improvement – large gaps between optimal and current practice
• Opportunity to expand upstream and downstream; and to translate sideways
• Existence of a ‘clinical champion’
• Visibility - potential for creating an exemplar
Quality of CarePatient SafetyEfficiencyAppropriateness
UMHS Learning Projects
• Faculty appointment, credentialing, insurance enrollment– 72 signatures
• Care transition
– Right drugs, appointments at discharge– Management until the first follow-up appointment
• Emergency Department – Patient flow– Series of projects for patient journey:– Discharge of patients to home:
• Nurses prioritize sickest, never get to discharges– Admission to an inpatient bed
UMHS Learning Projects
• Wound care• Timed blood drawing• CT scheduling and throughput
– Physicians “protocol” (review) every request
• Orders Management Project (CPOE) – Medication management end-to-end– New IT - Redesign new workflow – High institutional visibility and impact
• Institutional Review Board
Selected Project Results
• Vascular Access:Increased PICC lines placed within 12 hours by nurses from 35% to 71%; reduced by 46% cases needing to be place by interventional radiology.
VAS Supply Cart 5S
Drawer: Pre-5S
Drawer: Post- 5SSaved nurses an hour a day
Selected Project Results
• OR ENT Cases “decision to incision”:99% of history and physicals are now complete at pre-op visit compared to 75% prior to workshop.
• EKG leads left on: pre-op, OR, post-op• Adopted at new ambulatory surgery center
Selected Project Results
• Radiation Oncology:
Delays in scheduling and treatment planning Now treating 61% of brain metastases patients on the first day of call.
• Applying to the rest of their referrals
Selected Project Results
• Results Reporting: Pre-workshop, ~ 99,000 lab results had no ordering physician identifiable after extensive rework, implementation now 80% complete.
Selected Project Results
• Orthopaedics Project:Reduced time to schedule MedSport appointment from 23 days to 2-1/2 minutes.
ClinicED Radiology OR Admitting Transition Planning
PICC
A UMHS Patient
Patient Journey
ClinicED Radiology OR Admitting Discharge Planning
PICC
Orders Management Project
UMHS Lean Learning Projects
IdealPatientFlow
CT Scheduling
OrthoScheduling
OR ENTCases
Vascular Access
Patient Journey
Care Transition
Wound Care
Misdirected Results
Sched.Admits
ReferencesBooks:• Keyte B and Locher D. The Complete Enterprise: Value Stream
Mapping for Administrative and Office Processes• Liker J. The Toyota Way.• Liker J and Meier D. The Toyota Way Fieldbook• Rother M and Shook J. Learning to See.• Marchwinski C and Shook J, eds. Lean Lexicon.• Womack J and Jones D. Lean Thinking.Articles:• Spear S. Fixing Health Care from the Inside, Today. Harvard
Business Review. Sept 2005• Spear S. Learning to Lead at Toyota. Harvard Business Review.
May 2004 • Spear S, et al. Decoding the DNA of the Toyota Production System.
Harvard Business Review. Sept 1999• Institute for Healthcare Improvement Whitepaper:
“Going Lean in Health Care”http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm
Additional Materials
• Health Care is not Manufacturing
• Waste categories
• Barriers to using Lean Thinking in healthcare
• Value Stream Mapping slide
Can Lean Thinking Work In Healthcare?
• How is it Harder to Use Lean Thinking in Health Care than Manufacturing?
• How is Health Care Similar to Manufacturing?
• What Advantages Does Lean in Health Care Have Over Manufacturing?
What do you think?
How is it Harder to Use Lean Thinking in Health Care
than Manufacturing? • Who is “customer” and what do they value?
– Patient/family vs. Employer, Payer, Government– But patient and doctor insulated from cost of choices
• A “distortion of value”• As if the driver didn’t pay for the car
• Lots of invisible work– Patient encounter often involves a process or decision
as the outcome -- not a tangible “product”– Examples: decision to operate, clinic scheduling, lab
results ordering & reporting
• More privacy issues
How Does Health Care Differ from Manufacturing?
• Organizational and professional culture issues– Physicians, some world renowned– Nurses, many irreplaceable – Other health professionals
• Professional autonomy – vs. teamwork and systems thinking
• Mission-driven (at least some)– Non-profit orientation– Production of social goods
How is Health Care Similar to Manufacturing?
• Process dependence• Huge variability, often unjustified
– Aversion to standardization• Pressure to innovate and use new technology• Need for high reliability systems
(patient safety leaders learn from airlines, nuclear power industry)
• Lack of embedded testing– No “instant awareness of every error”
• Trillion dollar industry• Continuous Quality Improvement orientation
What Advantages Does Lean in Health Care Have
Over Manufacturing?• We expect change: new treatments, drugs, devices • We have scientific literature to guide us • We accept standardization in research protocols • We (mostly) accept standardizing treatment of
common conditions:– “evidence-based medicine” and practice guidelines
• We accept standardization to improve patient safety • We use root cause analysis in safety and quality• We are working on transparency to improve safety• We have external pressures for efficiency, safety and
quality– Pay for performance– Public reporting
Eight Types of Waste in Heath Care
Waste Category
Definition Heath Care Examples
Correction Rework because of defects, low quality, errors.
Requisition form incomplete/inaccurate/illegible.Order entry error.
Overproduction Producing more, sooner, or faster than required by the next process.Inappropriate production.
Unused printed results/reports.Unnecessary labs/visit.
Motion Unnecessary staff movement (travel, searching, walking).
Walking to and from copier/office/ exam room. Searching for misplaced form/ equipment/chart.
Material Movement
Unnecessary patient or material movement.
Multiple patient/paperwork transfers.Temporary locations for supplies.
Waiting People, machine, and information idle time.
Patient in waiting room. Wait for lab results.
Inventory Information, material, or patient in queue or stock.
Patient waiting in exam room. Excess stored supplies.
Processing Redundant or unnecessary processing. Reentry of patient demographics. Repeat collection of data.
Underutilization Underutilized abilities of people. Nurses refilling Rx or making appointments.Doctors doing simple patient education.
From Elsa Mersereau
TYPES TYPES OFOF
WASTEWASTE
II
CC
OO
MMWW
PP
MM
CURRENTTHINKING
WASTE NOT DEFINEDREACT TO LARGE EXAMPLES
REACTIVE IMPROVEMENT
REQUIRED THINKING
CONTINUOUS IMPROVEMENT
CorrectionCorrection
OverProduction
OverProduction
MotionMotion
MaterialMovementMaterial
Movement
WaitingWaiting
InventoryInventory
ProcessingProcessing
WASTE IS "TANGIBLE"IDENTIFY MANY SMALL OPPORTUNITIES
LEADS TO LARGE OVERALL CHANGE
GM’s Categorization of Waste
WASTEWASTE
Unreasonable-ness
Unreasonable-ness
UnevennessUnevenness
Source: GMS Training
Waste in the Current State: Causes and Countermeasures
Type of Waste Cause(s) Countermeasure
Correction of defects and rework
Procedure information incomplete or inaccurate; 20% of scheduled, authorized procedures cancelled or rescheduled
Reduce lead-time to eliminate rescheduled or cancelled procedure (no-shows only)
Inventory Backlog of schedule, authorized procedures
Reduce wait-time.
Over-processing
Process time too long; scheduling and authorization not coupled
One-piece flow
Over-production
Procedures scheduled weeks or months in advance
Reduce lead-time to 3 days or less.
Waiting Payer authorization too slow and days after scheduling
Reduce process and wait time for pending process; 24 hr. in-patient insurance information
From John Long
Perceived (and Real) Barriers to Application of Lean in Health Care
• “Just the Management Flavor of the Month – this too shall pass.”– Must show it is a learning approach, not just some projects
• “We’ve done well, why change?” “The autos had to do it”– Lack of a burning platform/overriding reason to change
(national v. personal)• “Let each unit choose QI process it finds most useful.”
– Some see no value in uniform QI approach; miss the synergy• “Who can lead this?”
– Lack of expertise/clinical champions • “I’ll join when I see that the leaders are on board.”
– If not led from the top, many will not engage• “How much are we spending on this new program?”
– Will the “return on time invested” be there?• “A 3 day workshop??!!”
– They’ll spend 3 days over 3 years and not change anything
Perceived (and Real) Barriers to Application of Lean in Health Care
• “Is this cost cutting disguised as QI?”– The term Lean is misunderstood– 1990s CEP (Cost Effectiveness Program) = lay offs
• “I can’t do this on top of my day job.”– Isolated projects will not change the corporate culture – it will
never become management’s job• I can’t risk my area’s performance to optimize the whole
product line throughput– Accountability, teams, and incentives must cross silos and levels
of the organization– Evaluation of middle management must match corporate goals – The Peace Health example
• “Creativity is our most important asset – standard work will stifle creativity.”– Can you innovate if you have not first standardized???– Do you want your cardiologist innovating or giving you statin and
aspirin?
Perceived (and Some Real?) Barriers to Application of Lean in Health Care
OR,
People are not automobiles…
Using the Value Stream Mapping Tool
Understanding how things currently operate. This is the foundation for the future state
Value Stream Scope
Designing a lean flow through the application of lean principles
Current State Drawing
Implementation Plan
Determine the Value Stream to be improved
The goal of mapping! 30, 60, 90 day follow-up
Implementation of Improved Plan
Future State Drawing
Developing a detailed plan of implementation to support objectives (what, who, when)
Sta
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From John Long
![Billi Kay Khuwab Main Chechrey [Urdu]](https://img.pdfslide.us/doc/110x75/577ca59a1a28abea748b99dd/billi-kay-khuwab-main-chechrey-urdu.jpg)
