Lean Guide

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Lean in Healthcare

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Lean Methods

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Lean Methods

Definition of Lean

Types of wasteKaizen

Value stream mapping

Tools

Takt time, throughput time, five Ss, spaghetti diagrams,kaizen events, standardized work, jidoka, andon, kanban,

SMED, flow and pull, heijunka, advanced access

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What Is Lean?

Elimination of waste

Toyota Production System (TPS)Philosophy

Produce only what is needed, when it is needed, with no

wasteMethodology

Determination of value added in the process

Tools

Five Ss, kaizen event, standardized work, etc.

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Lean Organization Inverted Pyramid

CEO

Senior

Administration

Directors & Managers

Front-line Staff

Support

Guidance

Implementation

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Types of Waste (Muda)

Overproduction

WaitingTransportation

Inventory

Motion

Overprocessing

Defects

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Seven Wastes of Healthcare

Overproduction

Producing more than

the customer needsright now

Working ahead ratherthan waiting

Justin

case thinking

Mixing drugs inanticipation of patient

needs Forcing admit to Critical

Care when not needed

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2. Transportation

Movement of productthat does not addvalue

Moving patients fortesting or treatment

Centralized storage

Transporting labspecimens

Transportingmedication andsupplies


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3. Motion

Movement of people that

does not add value

Searching for charts

Gathering supplies

Cross ward Nursing care


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4. Waiting

Idle time created when

material, information,people, or equipment is notready

Waiting for lab result Waiting for a bed

assignment

Waiting for discharge Waiting for treatment

Waiting for doctor, nurse


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5. Over Processing

Effort that adds no value fromthe patients viewpoint

Excessive paperwork

Redundant processes Unnecessary tests

Multiple bed moves

Requiring approval of surethings


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6. Inventory

More materials,

medications, or goods onhand than needed to servepatients right now

Lab specimen awaitinganalysis,

ED patients waiting forbed,

Excess pharmacy stock

Excess supplies


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7. Defects

Work that contains errors,

rework, mistakes or lackssomething necessary

Medication errors

Wrong patient wrongprocedure

Improper labeling of specimen

Multiple puncture for blooddraw

Failure to provide antibiotics in

time


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Kaizen Philosophy

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Kaizen Philosophy

Employeeled continuous improvement

Five steps Specify value

Map and improve the value stream

Flow

Pull

PerfectionEven if it isnt broken, it can be improved.

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Kaizen

Masaaki Imai coined the term in his book Kaizen : The key toJapans Competitive Success (1986)

Mindset in which all employees are responsible for makingcontinuous incremental improvements to the functions theyperform

The aggregate effect is the costeffective and practicalimprovements that have instant buyin by those who use

them

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Kaizen Blitz or Event

1. Determine and define theobjectives

2. Determine the current state of the

process

3. Determine the requirements of theprocess

4. Create a plan for implementation

5. Implement the improvements

6. Check the effectiveness of the

improvements7. Document and standardize the

improved process

8. Continue the cycle

Performed by

a team for

short periodof time

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Kaizen Blitz or Event

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Case Study Same day Surgery

Problem Statement

SameDay Surgery staff at this 230bed, forprofit hospital struggled toprocess patient information in a timely, organized fashion. Physicians

orders, preadmission test results, and patients medical histories were

often missing or incorrectly filed, leading to high patient wait timesand numerous procedure cancellations per week. These delays andcancellations caused increasing frustration among both patients andstaff.

Tools: Kaizen, Standardized work procedures, and Poka Yoke

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Case Study Same day Surgery

Issues

the team lacked of standardization for collecting, reviewing, anddistributing information.

there was no central repository for patients presurgery data, andstaff had lacked protocol for tracking patients who had been admitted.

staff were admitting patients with missing information such asphysicians orders, health and physical workups, or anesthesia reviews.

The Outcome

The hospital realized:

$75,000 annual tangible savings in payroll costs associated with stafftime spent searching for information

57% reduction in SameDay Surgery patient wait times resulting inimproved patient satisfaction.

Elimination of loose sheets of patient information, improveddocumentation accuracy and increased physician satisfaction.

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Case Study - Results of 175 Rapid Process Improvement

Weeks at Virginia Mason Medical Center

Source: Womack, J. P., A. P. Byrne, O. J. Fiume, G. S. Kaplan, and J.Toussaint. 2005. "Going Lean in Healthcare."

Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Online information available at:

http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm.

lV l S M i

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Value Stream MappingValue Stream Mapping

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Value Stream Mapping

Process map of the value stream

Includes information processing and transformationalprocessing

Valueadded steps: Would the patient and family be willing topay for this activity?

Nonvalueadded steps

Necessary

Unnecessary

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Value Stream Mapping Symbols

Supplier Database Sequence Kanban

Information InventoryImprovement

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VSM Exercise OPD Lab tests

Doctors

Office

Reception

Database

Laboratory

Reception

Takt time = 270 sec

Cycle Time = 240 sec

# of People = 2

Phlebotomy

Takt time = 270 sec


# of People = 1

Test Orders

Test Orders

Test Orders

Patient Info

Specimen

Label

0-15 0-20

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VSM Exercise OPD Lab tests

Doctors

Office

Reception

Database

Laboratory

Reception

Takt time = 270 sec


# of People = 2

Phlebotomy

Takt time = 270 sec


# of People = 1

Test Orders

Test Orders

Patient Info

Specimen

Label

0-15 0-20

SpecimenDelivered 2 Hourly

Report

DispatchReport Delivered

1X daily

Test Orders

Report Delivered

1X daily

Test Results

Test Results

Doctors

Office

90 15 10 05 120 300 Next Day

320 /

Next Day

Process Efficiency Percent

(22%) =

Value Added Time (320)

Lead Time (1440)

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Value Stream Mapping

Radiology Lab

House-

keeping PharmacySupplies

Anesthes-

iology

Social

Services

Porter

Stabilize

Incorrect

patient forms

Roomsunavailable

Long wait after

cleared to discharge

Education

late

Slow

turnaround

Patients

30-90 min

Admitting

1-3 hr

Triage

1-60 hr

Labor

and

Delivery

20-80 hr

Post

Partum

3 hr

Discharge

0-2 hr 1-3 hr 1-8 hr 1-5 hr

LOS

Rooms

not available

Nurses time spent on

non-patient care

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Lean Tools

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Tools

Takt time

Throughput time

Five Ss

Spaghetti diagram

Kaizen blitz or event

Jidoka

Andon

Standardized work

Kanban

Single minute exchange of die(SMED)

FlowPull

Heijunka

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Takt time

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Takt Time

The speed with which customers

must be served to satisfy demand for the service.

Cycle time is the time to accomplish a task in the system.

System cycle time is equal to the longest task cycle time in the

systemthe rate at which customers or products exit thesystem, or drip time.

demand/dayCustomer

/daywork timeAvailableTakt time =

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Calculating Takt Time

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Calculating Manning Levels

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Throughput Time

Time for an item to complete the entire process, whichincludes:

Waiting time

Transport time

Actual processing time

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Example - The OPD Clinic

Cycle, Throughput, and Takt Time

Move to examining room

2 minutes

Patient check-in

3 minutes

Nurse does

preliminary exam5 minutes

Physician exam

and consultation20 minutes

Visit complete

Wait 15

minutes

Wait 15

minutes

Wait 10

minutes

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Patient checkin cycle time = 3 minutes.

System cycle time = cycle time for longest task = physicianexam and consultation = 20 minutes.

Throughput time = 3 + 15 + 2 + 15 + 5 + 10 + 20 = 70 minutes.

tient.minutes/paphysician24

enthours/patiphysician0.4aypatients/d100

hours/day5physicians8Takt time

=

=

=


Cycle, Throughput, and Takt Time

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Valuedadded tasks:

Nurse preliminary exam

Physician exam and consultation

Nonvalueadded steps, necessary:

Patient checkin

Valueadded time = 5 minutes (nurse preliminary exam) + 20minutes (physician exam and consultation) = 25 minutes.

Percentage valueadded time = 25 minutes/70 minutes = 35percent.


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Case Study Central OPD Scheduling

Problem: This 180bed, notforprofit medical center faced thedaunting task of building efficient outpatient scheduling

procedures from the ground up. Although the center haddedicated significant resources to a new centralizedscheduling department, patients still faced a high number ofpostponed and cancelled procedures due to delayed, lost, or

mismatched paperwork.

Tools: Process mapping, Visual controls, Pull systems, Poka

Yoke, Spaghetti diagrams and Standardized work procedures

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Case Study Central OPD Scheduling

Issues Identified

Wide variances in the amount of time different employees took to

complete the same task Poor execution of critical tasks such as obtaining physicians orders or

scheduling imminent procedures.

The Outcome

With the solution in place, scheduling efficiency and effectivenessincreased dramatically.

Total work time for the scheduling process decreased 56%,Total work time for the scheduling process decreased 56%, accompanied

by a noticeable drop in the number of postponed or cancelled patientprocedures.

With backup staff assigned to scheduling, the department is able tomaintain this level of excellence even during peak workload hours.

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5S

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5S Principles

Elimination of wasteElimination of waste

Every body is involved, CoEvery body is involved, Co--operative effortoperative effort

Attack root causeAttack root cause

Human being is notHuman being is not infalliableinfalliable

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Objectives

Improve housekeepingImprove housekeeping

Make every individual responsible forMake every individual responsible forhousekeepinghousekeeping

Beautify by simple meansBeautify by simple meansProductivity improvement by saving time,Productivity improvement by saving time,

space etc.space etc.

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5Ss

SeiriSeiri -- SortingSorting

SeitonSeiton -- Systematic arrangementSystematic arrangement

SeisoSeiso -- CleaningCleaningInspection while cleaningInspection while cleaning

SeiketsuSeiketsu -- StandardizationStandardization

ShitsukeShitsuke -- Self DisciplineSelf Discipline

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5S

If we do not do 5S, we cant do anyother work efficiently.

They are features which are common to

all places and are the indicators of howwell an organization is functioning.

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Activity Establish a criteria for eliminating unwanted

items. Eliminate unwanted items either by disposingthem or by relocating them.

Success Area saved or percentage of space available

Indicator

Meaning Distinguish between necessary andunnecessary items and eliminate the unnecessary items

SEIRI = Sorting

SEIRI S tiSEIRI S ti

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SEIRI = SortingSEIRI = Sorting

Japanese Meaning : The Japanese meaning of Seiriis to straighten and contain. Get rid of waste and put it

in order according to rules

OTHER JAPANESE MEANINGS - farmland cultivation,

Make an orderly system and straighten

Wh t i

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Item is not needed

Item is needed however quantity in stock is more

than what is needed for consumption in near future

Contingency Parts

Critically decide the quantity of contingency parts to

be retained and criteria for such parts

What is unnecessary

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Frequency of use Storage Method

*Things you have not used

in the past one year

Throw them out

*Things you have used once

in the last 6-12 months

Store at distance OR

Keep in store

LOW

*Things you have used onlyonce in the last 2-6 months

Store it in central placein your zone

*Things used more than once

a month

Store it in central place

in your zone

AVERAGE

HIGH *Things used once a week Store near the workplace

*Things used daily or hourly Store near the workplace

Organization

Id tif i

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Identifying unnecessary

1. Parts & Work in Process (WIP)

Things fallen back behind the machine or rolled under it

Broken items inside the machine Things under the racks/ platform

Extra WIP

Stock of rejected items Items accumulated over period for rework

Material awaiting disposal decision

Material brought for some trial, still lying even after trial

Small qty of material no longer in use

Identifyin unnecessary

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2. Tools, Toolings, Measuring devices

Old jigs, tools not in use are lying

Modified tools, tooling for trial, are lying after trial Worn out items like bushes, liners, toggles etc. lying

Broken tools, bits, etc. may be lying

Measuring equipment not required for the operationbeing performed, is lying

3. Contingency Parts

Many times storage place for contingency parts become

a last refuge for broken parts, surplus items and things

nobody is likely to use


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4. Shelves and Lockers Shelves and lockers tends to collect things that nobody

ever uses, like surplus, broken items etc.

5. Passages and Corners Dust, material not required seem to gather in corner

6. Besides Pillars and under the stairs These places tends to collect junk, spittoon etc.

7. Walls and Bulletin Boards Old out dated notices which have lost their relevance Posters or bulletins on wall Dust, remains of torn notices, cell tape pieces


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8.Floor, Pits, Partitions

Defective parts

Protection caps, covers Packing material

Hardware items , small items

Even tools, toolingItems dropped on the floor are never picked

9.Computer Hard Disk Many unwanted, outdated, temporary files pile up

Improvement methods

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Improvement methods

1. Flow Process Chart (Procedural Analysis)

Drawing a process flow chart for the system

eg. How to make and use category wise grouping

2. Operational Analysis

Preparing the sequence of operations for systemeg. How to perform Seiri (sorting)

3. Check ListA check sheet is used to decide what sort of main system

and sub system are necessary.

Dealing with papers

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Dealing with papers

How to reduce papers on

your table ?

1. Make a single pile of papers2. Go through them and sort in

following categories

a) Immediate action

b) Low priority

c) Pending

d) Reading materiale) For information

Dealing with papers

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Dealing with papers

How to reduce papers on

your table ?

4 D Principle4 D Principle

DODELEGATE

DELAY

DUMP

SEITION S t ti A tSEITION S t ti A t

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Activity - Functional storage

- Creating place for everything and putting

everything in its place

Success - Time saved in searchingIndicator - Time saved in material handling

SEITION = Systematic ArrangementSEITION = Systematic Arrangement

Meaning To determine type of storage and layout thatwill ensure easy accessibility for everyone .

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SEITION S stematic ArrangementSEITION = Systematic Arrangement

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How to achieve Systematic Arrangement ?

Decide where things belongDecide where things belong

Decide how things should be put awayDecide how things should be put away

Obey the Put away rulesObey the Put away rules



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Decide where things belong-- Standardize Nomenclature

- Determine an analytical method of storage

Decide how things should be put away-- Name & locations to everything. Label both item

and location

- Store material functionally- Prevent mistakes with coding by shapes & colour

contd..contd..



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Decide how things should be put away-- Follow first in first out rule

- If two identical items are to be located, then store

them separately, colour code them.

Obey the rules

-- Put the things back to their location aftertheir use



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USE :USE :

1 ) Signboards1 ) Signboards

2)2) ColourColourcodescodes

3) Outline markings3) Outline markings

4) Labels4) Labels



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FunctionalFunctional

StorageStorage


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Category Same category of material may be

stored in one location.

Eg. Allen Screws, Oil Seals

Operation

Wise

All items required for an

operation may be stored in onelocation.

Eg. Allen key, spanner etc hand

tools required for setting m/c

Functional Storage



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Outlining and Placement Marks

-- Mark boundaries of dept., aisles, Machines

- Follow straight line, right angle rule- Nothing shall be kept outside the boundaries

Stands and shelves-- Keep only required number of stands and shelves

- Standardize height, size

- Provide casters where necessary so that it can bemoved



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Wires and Ducts

-- Colour code

- When there are multiple connections - bundle thewires, label them and make sure that they are in

straight line /right angle and firmly anchored

Machine-tools & Tools-- Put the tools in the order you need them

- Location of the tool should be such that it can be

put away with one hand- Try to eliminate some hand tools by permanently

attaching it to the bolt head



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Blades, Dies, Other important consumables

-- Store them in the protected place

- Maintain these things regularly by applying rustpreventive, oiling etc.

WIP- Work In Process-- Designate a place for each component/part- Decide on how much quantity to be stored

- Ensure that there is no damage to good part

during transit, they do not get rusty and they are

not mislabeled


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SEISO = CleaningSEISO = Cleaning

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Meaning Cleaning trash, filth, dust and otherforeign matter. Cleaning as a form ofInspection

Meaning Cleaning trash, filth, dust and otherforeign matter. Cleaning as a form ofInspection

Activity - Keep workplace spotlessly clean

- Inspection while cleaning

- Finding minor problems with cleaninginspection

Success - Reduction in machine down timeIndicator - Reduction in no. of accidents



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Japanese Meaning :

Dictionary meaning to clean up and getting rid of dirt

and unclean items

While cleaning potential defects such as abrasion,damage, loose parts, deformities, leaks temp., vibration,

abnormal sound etc. are revealed hence Seiso is

Inspection



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Here cleaning means more than just keepingHere cleaning means more than just keeping

things clean. Cleaning should be viewed as athings clean. Cleaning should be viewed as a

form of Visual Inspectionform of Visual Inspection

Preventive measures should be taken to tacklePreventive measures should be taken to tackleproblems of dust, grim, burrs, leakage etc.problems of dust, grim, burrs, leakage etc.

Root cause of the problem should be identifiedRoot cause of the problem should be identified

and it should be eliminatedand it should be eliminated



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Various Minor DefectsVarious Minor Defects= Trash = Dirt =Knocking

= Loose parts = Leaks =Scattering

=Skips =Curvature =Abrasion

=Rust =Scratches =Eccentricity

=Lurching =Abnormal =VibrationMovements

=Abnormal =Heat =AbnormalSounds & smells

=Faded colour =Hisses


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CleaningCleaning--Inspection points for most equipmentInspection points for most equipment


TighteningLoose bolts, welding detachment,

loose parts, vibration or bumping

noise, friction

Heat Oil tanks, motors, heater, axles, control

panels, washing/ cleaning water,bearing, wiring etc.


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CleaningCleaning--Inspection points for most equipmentInspection points for most equipment


Breakage, cracks, dent on sliding

parts, handle has come off, broken

switches, wire joints come off, wiresare broken or crack, crack dial of

various pre. gauges, meters etc.

Breakage,

Cracks


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Function wise Cleaning check list of equipmentFunction wise Cleaning check list of equipment

Pneumatics

Hydraulics

Compressed Air lines, air valves,

connections, meters, filters,

reservoirs etc.

Hydraulic oil tank, oil valves,

filters, pumps, hoses, gauges,cylinders etc.

SEISO = CleaningSEISO Cleaning


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Function wise Cleaning check list of equipmentFunction wise Cleaning check list of equipment

Mech &

Power Train

Electrical

Motor fan, fan belt, couplings,

Joints, pulleys, chains, pump

bearings etc.

Control panel, lamps, light, switch,

sensors, wiring, ducts, fuses etc.

SEISO = CleaningSEISO Cleaning

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SEIKETSU = StandardizationSEIKETSU = Standardization

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Meaning Setting up standards / Norms for a neat,clean, workplace and details of how to

maintain the norm (Procedure)

Meaning Setting up standards / Norms for a neat,clean, workplace and details of how to

maintain the norm (Procedure)

Activity - Innovative visual management

- Colour coding- Early detection of problem and early action

Success Increase in 5S indicatorIndicator

SEIKETSU StandardizationSEIKETSU Standardization


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Japanese Meaning :

Dictionary meaning

unsoiled things, purity and cleanliness

Clean manners ,

Clean cloths, clean politician

It is the proof that 3 Ss are being faithfully carried out.


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Tools used for analysis :MTTR

MTBF

OEE


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Regularizing 5S activities so that abnormalitiesare revealed

Make it easy for everyone to identify the state of

normal or abnormal condition

For maintaining previous 3S, deploy visual

management


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Some methods for visual communicationSome methods for visual communication

Colour coding Use of Labels

Danger alerts

Indication where things should be put

Directional arrows/ marks Transparent covers

Performance indicators



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Some methods for visual communicationSome methods for visual communication

LabelsLabels Precision management labels

Inspection labels

Temperature labels

Responsibility labels

SEIKETSU StandardizationS SU Sta da d at o


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Points to remember in making visual control toolsPoints to remember in making visual control tools

1. Make them easy to see from distance2. Put the display on the things

3. Everyone can tell what is right and what is wrong

4. Anybody can follow them and make necessary

corrections easily5. Work place should look brighter & orderly

SEIKETSU Standardization


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Some everyday visual management examplesSome everyday visual management examples

Traffic signal Zebra crossing

In car - Petrol indicator

- Speed indicator

Direction arrows

Electric danger sign etc.

SEIKETSU Standardization


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Some visual communication signsSome visual communication signs

SHITSUKE = Self DisciplineSHITSUKE = Self Discipline

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Meaning Every one sticks to the rule and makes it

a habit

Meaning Every one sticks to the rule and makes it

a habit

Activity - Participation of everyone in developing

good habits

- Regular audits and aiming for higherlevel

Success High employee moraleIndicator Involvement of all people

S SU Se sc p ep


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Japanese Meaning :

Dictionary meaning is

learning of the manners

having manners, dressing neatly ORtraining children for good customs

Japanese Meaning :

Dictionary meaning is

learning of the manners

having manners, dressing neatly OR

training children for good customs

pp


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Activities :

5S Committee

5S Training

5S Competition / evaluation5S Month

Posters , Literature etc.

Activities :

5S Committee

5S Training

5S Competition / evaluation

5S Month

Posters , Literature etc.

pp


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We need everyone to maintain 5S guidelines.We need everyone to maintain 5S guidelines.

To maintain DISCIPLINE, we need to practice andTo maintain DISCIPLINE, we need to practice andrepeat until it becomes a way of life.repeat until it becomes a way of life.

Discipline is the Core of 5SDiscipline is the Core of 5S

pp


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Discipline means making a steady habit of properlyDiscipline means making a steady habit of properly

maintaining correct proceduremaintaining correct procedure.

Time and effort involved in establishing properTime and effort involved in establishing proper

arrangement and orderliness will be in vain if we doarrangement and orderliness will be in vain if we donot have discipline to maintain it.not have discipline to maintain it.

pp


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PledgePledge

It shall be my constant effort to maintain my workplaceIt shall be my constant effort to maintain my workplace

in good order byin good order by

Assigning a place for everything & keepingAssigning a place for everything & keeping

everything in its placeeverything in its place

Sorting out unwanted material periodically &Sorting out unwanted material periodically &

discarding themdiscarding them

Keeping my work area neat & clean everydayKeeping my work area neat & clean everyday

pp

Organization

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g

Departments into areas

Coordinators at department level

Coordinator at each area level

Training for all

Audit each area and make action check listImplement actions

Audit and evaluation on continuous basis

Five Ss

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Sort

Separate and remove clutter and items unneeded in theworkspace.

Extraneous items impede the flow of work.

Set in Order

Organize what is left to minimize movement and make things clear.

Shine (and inspect)

Clean area, storage, equipment, etc. and inspect for warning signsof breakdowns.

Standardize

Set up an area with 5

S supplies (cleaning supplies, labels, coloredtape, other organizational items) and schedule time andresponsibility for restoring work area to its proper conditionregularly.

Sustain

Audit area regularly, expand 5S to other areas.

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Spaghetti Diagrams

Spaghetti Diagram

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Medication

Call Bell &

Bedpan

Educating

Discharge

Process

Rounds

With

Doctor

BookingInvestigation

Instruction for Spaghetti Diagram

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1. Select the process to be mapped. It is generally goodto start with work processes that are executed

repeatedly and frequently. These processes will givethe best returns on time invested.

2. Follow a person through the current state workprocess. If desired, have the person wear a

pedometer to know distance traveled (this can also beapproximated if the floor layout is to scale). As youfollow, draw the person's motion on the floor layout(you should not lift your pencil off of the paper, itshould be 1 continuous line).

*Also note any safety or ergonomic hazards while you observe*

Instruction for Spaghetti Diagram (Continued)

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3. Discuss the current state.

Talk about the total distancetraveled and discuss ways that it could be reduced bymoving equipment, bringing materials closer to theworkplace, eliminating rework steps, or changing the order

of steps.4. Draw a map of the future state and implement. Draw a

map that anticipates the future state workflow based onthe brainstormed ideas. Develop an action plan toimplement the future state.

5. Verify the future state by following a person through it.Verify that the future state works as you expected. Makecorrections where necessary

6. Communicate and make permanent.

Communicate andtrain all users of the area on the new process. Show themthe current state and future state spaghetti maps. Changestandard work so that the new process becomes standard.Ask for feedback to continuously improve the process.

Case Study Nursing Team Redesign

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Problem Statement

The Nursing Staff at this 230 bed for profit (Point of Use) hospitalstruggled with processes and systems that impacted their ability to

spend time at the patients bed side. A study performed on onenursing unit revealed that approximately 32% of a nurses day wasdedicated to activities that were considered nonvalue added or waste.In total, 46% of nursing time was spent on tasks related to patient carewhile the remaining 54% was directed towards regulatory tasks and

waste.

Tools: JIT, Spaghetti diagrams and Standardized work

procedures

Case Study Nursing Team Redesign

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Issues encountered

Reduce Waste in the Process

Improve Flow for Caregivers and Increase Patient Care

Decrease Wasted Motion Document Equipment/Maintenance Issues

Standardize Nursing Floor Processes

The Outcome

Standardized Patient Room Layout/Equipment

Patient Supplies Stocked at the Point of Use

43% Overall Waste Reduction

30% Increase in Care Related Activities

27% Increase in Bedside Time

12% Decrease in Wasted Motion (Steps)

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Standardized Work

Standardized Work

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Written documentation of the way in which each step in aprocess should be performed

Not a rigid system of compliance, but a means ofcommunicating and codifying current best practices

Apollo Gleneagles Hospitals care pathways

Standardized Work

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Standardized Work - Definition

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Standardized work is A TOOL FOR MAINTAINING

PRODUCTIVITY, QUALITY, AND SAFETY, at high levels

Standardized work is defined as work in which the

sequence of job elements has been efficiently organized,and is repeatedly followed by a team member

Standardized work is a process whose goal is kaizen. If

standardized work doesnt change, we are regressing

Why Standardized Work

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Provides a basis for employee training.

Establishes process stability.Reveals clear stop and start points for each process.

Assists audit and problem solving.

Creates baseline for kaizen.

Enables effective employee involvement and

pokayoke.

Maintains organizational knowledge

Elements of Standardized Work

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Takt Time and Cycle Time

1. Takt Time = Daily operating time / Required quantity per day

2. Cycle Time = Actual time for process

3. Goal is to synchronize takt time and cycle time

Work Sequence

1. The order in which the work is done in a given process.2. Can be a powerful tool to define safety and ergonomic issues

InProcess Stock

1. Minimum number of unfinished work pieces required for the

operator to complete the process

Implementing Standardized Work

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Implement new

standard work

Substantiate

and enumerate

improvements

Modify the

existing process

Identify areas of

opportunity

Evaluate the

current

situation

LeanTransformation

process

VSM Current state

Standard work sheet

Observation sheet

Combination sheet

Percent load charts

Implement standard work

Conduct training

Communicate changes

Share information

ID Constraints

Non Value Add

Muda

5S, Leveling, Quick

Changeover, Kanban,

Visual Controls, Andon,

Poka Yoke, DMAIC

Conduct Pilots

Money Saved

Enhanced Revenue

Floor Space & Time Savings

Human Resources

Misconceptions of Standardized Work

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Standardized work is sometimes mistaken to be a static work

process.

Workers may feel threatened that their jobs are at risk and

therefore may not participate fully in optimizing the

process.

Standardized work may not show immediate results due to

other factors:

worker attrition additional training requirement

improvement cycle just beginning

Tools of Standardized Work

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Case Study Operating Room Turnover

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Problem Statement

The O.R. staff of this 250 bed community not for profitmajor medical center wanted to reduce the changeoverand setup between surgical cases in this eleven O.R. suiteinpatient surgery department. The staff recognized thatimproved overall efficiency in this process would result inimproved patient care, improved physician satisfaction andgreater O.R. capacity without increasing staff.

Tools: SMED, Kaizen, Value Stream Mapping, and Poka Yoke


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Outcomes

The O.R. staff realized an initial reduction of 46% of timededicated to the O.R. turnover process. Since inception of

lean management, efficiency has grown to a 60% reductionof time needed in the O.R. changeover process.


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Jidoka and Andon

Jidoka and Andon

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Jidoka is the ability to stop the process in the eventof a problem.

Prevents defects from passing from one stepin the system to the next

Enables swift detection and correction of

errors

Andon is a visual or audible signalingdevice used to indicate there is a problem

in the process.

What is Jidoka?

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Automation with a human touch

Practice of stopping a manual line or process whensomething goes amiss

Also known as Autonomation

Healthcare example Detection of drug drug interaction

and medication error through software

What is Jidoka?

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Quality builtin to the process

First used by Sakichi Toyoda at the beginning of the 20thcentury

A pillar of the Toyota Production System

Healthcare example 30 degree Head Elevation as a primarytool for prevention of Ventilator Associated Pneumonia

Role of Jidoka

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Autonomation is an important component of LeanManufacturing Strategy for highproduction, low varietyoperations, particularly where product life cycles aremeasured in years or decades.

How Organization Can Benefit From Jidoka

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Jidoka helps to detect aproblem earlier

Jidoka avoids the spread of

bad practices

A level of human intelligence

is transferred intoautomated machinery

Kanban

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Task 1

Workstation

1

Task 2

Workstation

2

FullKanban

Customer

Order

FullKanban

Empty

Kanban

Empty

Kanban

Kanban

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Single Minute Exchange of Die (SMED)

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Used to reduce changeover or setup time, which is the timeneeded between the completion of one procedure andthe start of the next procedure

Pioneered by Shigeo Shingo

Steps

1. Identify and classify internal and external activities2. Separate internal activities from external activities

3. Convert internal setup activities to external activities

4. Apply changes to convert remaining internal activitiesto external activities

5. Streamline all setup activities

Single Minute Exchange of Die (SMED)

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Healthcare examples

1. The changeover times in Operation Theaters, i.e.,

the time between the surgeries typically accountfor high valued OT utilization time. These alsoaccount for variations in OT scheduling effectingoverall utilization, increasing cancellation and

reducing revenue generation

2. The higher room arrangement and bedmakingturn around times account for increased waiting

times for the patients waiting for admission

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Advanced Access

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Patients are unable to obtain timely primary careappointments.

Advanced access scheduling reduces the time betweenscheduling an appointment for care and the actualappointment.

The goal is swift, even patient flow through the system.

Advanced Access - Advantages

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Decreases noshow rates

Improves patient satisfaction

Improves staff satisfaction

Increases revenue

Higher patient volumes Increased staff and clinician productivity

Promotes greater continuity of care

Increased quality of care

More positive outcomes for patients

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Lean Templates

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Lean Templates

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Lean Templates

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Lean Templates

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Lean Templates

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Lean Templates

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Lean Templates

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Lean Templates

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Mistake Proofing

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One description divides the process into two distinct steps:

determining the intent of the action, and

executing the action based on that intention.

Failure in either step can cause an error.

Mistakes are errors resulting from deliberations that lead to

the wrong intention. Slips occur when the intent is correct,but the execution of the action does not occur as intended.

Generally, mistakeproofing requires that the correct

intention be known well before the action actually occurs.

Mistake Proofing Approaches

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The approaches to error reduction are diverse and evolving.More innovative approaches will evolve, and more categorieswill follow as more organizations and individuals thinkcarefully about mistake

proofing their processes.

Tsuda lists four approaches to mistakeproofing:

Mistake prevention in the work environment. Mistake detection (Shingo's informative inspection).

Mistake prevention (Shingo's source inspection).

Preventing the influence of mistakes.

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Mistake Detection

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Mistake detection identifies process errors found byinspecting the process after actions have been taken.Immediate notification that a mistake has occurred is

sufficient to allow remedial actions to be taken in order toavoid harm.

Shingo called this type of inspection informative inspection.The outcome or effect of the problem is inspected after an

incorrect action or an omission has occurred.

Informative inspection can also be used to reduce theoccurrence of incorrect actions. This can be accomplished byusing data acquired from the inspection to control theprocess and inform mistake prevention efforts.

Statistical Process Control (SPC) is a set of methods that usesstatistical tools to detect if the observed process is being

adequately controlled.

Mistake Detection

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Mistake detection identifies process errors found byinspecting the process after actions have been taken.Immediate notification that a mistake has occurred is

sufficient to allow remedial actions to be taken in order toavoid harm.

Shingo called this type of inspection informative inspection.

The outcome or effect of the problem is inspected after anincorrect action or an omission has occurred.

Informative inspections are

Statistical Process Control statistical tool to assess the processcontrol

Successive Checks inspections of previous steps

Self Checks devices to allow the users to assess their own quality

Mistake Detection Setting functions

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A setting function is the mechanism for determining that an error is aboutto occur (prevention) or has occurred (detection).

It differentiates between safe, accurate conditions and unsafe, inaccurateones.

Determines and ensures that informationrequired in the process is available at the correct timeand place and that it stands out against a noisy

background.

Information enhancement

Facilitates checking that matched sets ofresources are available when needed or that the correct

number of repetitions has occurred.

Grouping or counting

(Shingo's fixed value methods)

Checks the precedence relationship of theprocess to ensure that steps are conducted in thecorrect order.

Sequencing(Shingo's motion step)

Checks to ensure the physical attributes of theproduct or process are correct and errorfree.

Physical

(Shingo's contact)

DescriptionSetting Function

Mistake Detection Control functions

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Mistake Detection

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Mistake Detection Fall from Wheelchair

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Documents

Lean Guide