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7/29/2019 VlLean
1/27
1
C15: Think and Learn Lean
1
C15:Think and LearnLean:
Implications for an
ICU
2
When Problems are
Chronic or Reoccurring:
Find New Ways of
Thinking of Solutions
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C15: Think and Learn Lean
3
What Can We
Learn From
Toyota?
4
But Health Care
Is Different FromManufacturing
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C15: Think and Learn Lean
5
Toyotas Notion of Ideal
Are Defect Free
Can Be Delivered One Request At a Time
Can Be Supplied In The Version Requested
Can Be Delivered Immediately
Can Be Produced Without Waste
Can Be Produced In a Safe Work Environment
Goods and Services:
6
The IDEAL Health Care System
One in Which Patients Receive:
Correct therapy for the patient, safely & void of
complications (safe & defect free) (effective)
Appropriate therapy delivered upon request every
time (individualized) (patient focused)
Only therapy that is wanted and needed (as requested)
(equitable)
Delivered immediately (timely)
Therapy given efficiently & without waste at the
lowest possible cost (efficient)
Delivered in a safe working environment (safe)
Blue - the six goals from Crossing the Quality Chasm
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C15: Think and Learn Lean
7
Toyotas Success
Is Not in the Tools,
It Is in the Culture
8
The Toyota Paradox
Activities, Connections and
Production Flows Are Rigidly
Scripted
Yet
The Operations Are Enormously
Flexible and Adaptable.
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C15: Think and Learn Lean
9
What Are Some of the Principles
that Drive Toyotas Success?
Standardization of Processes - eliminatevariation on processes in order to identify problems andmeasure effects of change (Rule in Use #1)
Communication - person to person and withoutambiguity (Rule in Use #2)
Elimination of Waste - use only what you need butmake sure everything you need is there (Rule in Use #3)
Improvement - constantly look for and find ways to
improve. Improvement methods should be scientificallysound. (Rule in Use #4)
10
1st Rule In Use
How People Work
All Work Shall Be Highly
Specified As to Content,
Sequence, Timing, and
Outcome
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C15: Think and Learn Lean
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Pragmatic Scientific Method
Rule # 1 All Work Shall Be Highly Specified
Hypothesis
Sign of
Problem
Response
The Person can do the activity asspecified and
If the activity is done as specified the
service or outcome will be defect free
The activity is not done as specified or
The outcome is defective
Determine the true skill level of the
person and retrain as appropriate or
Modify the design
12
Before We Can
Improve a System We
First Have to StabilizeThat System
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C15: Think and Learn Lean
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Stabilization of theSystem Is
Accomplished By
Standardizing
Processes
Different Views of Reliability
110-10.9
10-60.999999
10-50.99999
410-40.9999
310-30.999
210-20.99
Sigmas
(approximate)
UnreliabilityReliability
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C15: Think and Learn Lean
STRICU & MICU - POTASSIUM ADMINISTRATION TABLESee table for more details on things which influence K+ needs.
Markedly Increased K+
NeedsNormal Renal Function AND 1)High
U.O.>250 cc/hr OR 2)Loop Diuretics with
high U.O. (>150 cc/hr for 2 hours) OR 3)GI
losses>2500 cc/day (NG or Diarrhea) OR4)on Corticosteroids or Amphotericin B
Normal K+ NeedsNo Diuretics or High U.O
No Excessive GI Losses
No Coritcosteroids
No Amphotericin
Markedly Decreased K+
NeedsU.O.3.0 OR
On K+ Blocking Diuretics
(Spironolactone or Triamterine)
**Replacement Table for Low Potassium. May be used in patients eating a diet
K+ = 3.0 - 3.7
Replenish Mg deficits if
present
Give 80mEq K+ via GI tract AND
check serum K+in 3 hrs. (If GI tract not
usable, infuse*** K+ IV @ 10mEq/hr
AND check K+ 30 min. after infusion.)
Replenish Mg deficits if present
Give 60mEq K+ via GI tract AND
check serum K+in 3 hrs. (If GI tract
not usable, infuse*** K+ IV @ 10
mEq/hrAND check K+ 30 min. after
infusion.) Replenish Mg deficits if
present
Give 20mEq K+ via GI tract AND check
serum K+in 3 hrs. (If GI tract not
usable, infuse K+ IV @ 10 mEq/hrAND
check K+ 30 min. after infusion.)
Replenish Mg deficits if present
K+ = 2.5 - 2.9
Replenish Mg deficits if
present
Give 100mEq K+ via GI tract AND
check serum K+in 3 hrs. May give in
Divided dose over 4 hours . (If GI tract
not usable, infuse*** K+ IV @ 15
mEq/hr***AND check K+ 30 min. after
infusion.) Replenish Mg deficits if
present
Give 80mEq K+ via GI tract AND check
serum K+in 3 hrs. (If GI tract nok
usable, infuse K+ IV @ 15 mEq/hr***
AND check K+ 30 min. after infusion.)
Replenish Mg deficits if present
Give 40mEq K+ via GI tract AND check
serum K+in 3 hrs. (If GI tract not
usable, infuse K+ IV @ 10 mEq/hrAND
check K+ 30 min. after infusion.)
Replenish Mg deficits if present
K+ = < 2.4
Replenish Mg deficits if
present
Give 120mEq K+ via GI tract AND
check serum K+in 3 hrs. May give in
Divided dose over 4 hours . (If GI tract
not usable, infuse*** K+ IV @ 20
mEq/hr***AND check K+ 30 min. after
infusion.) Replenish Mg deficits if
present
Give 100mEq K+ via GI tract AND
check serum K+in 3 hrs. (If GI tract not
usable, infuse K+ IV @ 15 mEq/hr***
AND check K+ 30 min. after infusion.)
Replenish Mg deficits if present
Give 60mEq K+ via GI tract AND check
serum K+in 3 hrs. (If GI tract not
usable, infuse K+ IV @ 15 mEq/hr***
AND check K+ 30 min. after infusion.)
Replenish Mg deficits if present
K+ = 3.8 - 4.4
ANDCardiac
Arrhythmiapresent or feared (e.g.
digoxin levels high)
Give 40mEq K+ via GI tract AND check
serum K+in 3 hrs. (If GI tract not
usable, infuse*** K+ IV @ 10mEq/hr
AND check K+ 30 min. after infusion.)
Replenish Mg deficits if present
Give 30mEq K+ via GI tract AND check
serum K+in 3 hrs. (If GI tract not
usable, infuse K+ IV @ 10 mEq/hrAND
check K+ 30 min. after infusion.)
Replenish Mg deficits if present
Give 10mEq K+ via GI tract AND check
serum K+in 3 hrs. (If GI tract not
usable, infuse K+ IV @ 10 mEq/hrAND
check K+ 30 min. after infusion.)
Replenish Mg deficits if present
16
Give 60 mEq K+ via GI tract AND
check serum K+in 3 hrs. (If GI
tract not usable, infuse*** K+ IV
@ 10 mEq/hrAND check K+ 30
min. after infusion.) Replenish
Mg deficits if present using Mg
replacement protocol
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C15: Think and Learn Lean
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Potassium ProjectPercent of Unsafe Values In Critical Range
Critical is < 3.0 mEq/L or >6.0 mEq/L
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
< Critical > Critical
1996 1997 1998 1999 2000 2001 2002
10-2
10-3
Glucose Control All TEN Pts.Percent of Unsafe Values in Critical Range
Critical is < 60 mg% or >350 mg%
0
0.5
1
1.5
2
2.5
< Critical > Critical
Pre-Prot/94 Post-Prot/95 1997 1998 1999 2000 2001 2002
10-3
10-3
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C15: Think and Learn Lean
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2nd Rule In Use
How People ConnectEvery Customer-SupplierConnection Must Be Direct,
and There Must Be An
Unambiguous Yes-or-No Way
To Send Requests andReceive Responses
20
Step 1 -
A Group of
Processesor
Procedures
Value Stream Map30,000 foot level
Requester
Intermediaries
Step 1 -
A Group of
Processesor
Procedures
Step 1 -
A Group of
Processesor
Procedures
Step 1 -
A Group of
Processesor
Procedures
Step 1 -
A Group of
Processesor
Procedures
Represents a Delay
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C15: Think and Learn Lean
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New Order
Set Needed
Work Group
Experts and
Knowledge
Engineers
Review by
Dev.
Team
(assigned)
Review by
IHC
Clinicians
Approval by
Dev. Team
Leaders
Activation
Trial in
Clinical
Arena and
Problems
found
CP Guidance Council:
Set Priorities
Value Stream Map Current Condition
30,000 foot level
M.D. R.N.
IHC Health Plans:
Define Specific Needs
22
30,000 foot level
Value Stream Map Current Condition
Work Group
Experts and
Knowledge
Engineers
Review by
Dev. Team
(assigned)
Review by
IHC
Clinicians
Approval by
Dev. Team
Leaders
Activation
Trial in
Clinical
Arena and
Problems
found
New Order
Set Needed
MD RN
New Order
Set Needed
MD RN
Work Group
Experts and
Knowledge
Engineers
(Dev. Team)
Trial in
Clinical
Arena and
Problems
found
Value Stream Map Target Condition
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C15: Think and Learn Lean
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3rd Rule In Use
How Pathways AreConstructed
The Pathway for Every Care
Process and Service Must Be
Simple and Direct
24
Can You Imagine How Long
Toyota Would Tolerate Not
Having The Correct Part
Immediately Available When
Needed On the Assembly Line?
How Often Does That Occur In
Medicine?
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C15: Think and Learn Lean
25
Patients Condition
Requires a Med.
Nurse
Alerts
Phys
Phys
Writes
Order
Clerk
Takes
Order
Off
Order
Sent
To
Pharm
Pharm
Verifies
Order
Tech
Prepares
Order
& Sends
To ICU
Request Made
Value Stream Map Current Condition
30,000 foot level
4.5 h
26
Patients Condition
Requires a Med.
Nurse
Alerts
Phys
Phys
Writes
Order
Clerk
Takes
Order
Off
Order
Sent
To
Pharm
Pharm
Verifies
Order
Tech
Prepares
Order
& Sends
To ICU
Nurse
Alerts
Phys
Phys
Writes
Order
With
Pharm
Pharm
Verifies
&
Sends
Order
Tech
Prepares
Order
& Sends
To ICU
Request Made
Value Stream Map Current Condition
Value Stream Map Target Condition
30,000 foot level
Multidisciplinary Rounds
Communications
4.5 h
47 min.
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C15: Think and Learn Lean
27
The Toyota Method
of Evaluating
Problems
28
Tools Used to Support the
Culture at Toyota
Formal observation
A3 process Value stream mapping
Kanban Cards
Andon cords
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C15: Think and Learn Lean
29
Define the Issue
Understand the Issue inDepth Background
Do a Detail Observation
Draw Current Condition:
Confirm It by Asking Others
Identify Areas of Waste
Identify Problems With CurrentCondition (Storm Clouds)
Analysis of Problems: 6-Whys
for Each Problem
Define the Issue
Toyota A3 Process QI - Rapid Cycle Process
Left Side
30
Patient Flow From
MSICU to Acute Care
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C15: Think and Learn Lean
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Issue: The waste and delays
in care associated with
inappropriate stays in the ICU
environment.
32
Background: For years we have
struggled with the problems of
patient flow through the ICUs.
This causes a lot of waste,
difficulty admitting patient who
need ICU and enormous
frustration for physicians and
nurses.
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C15: Think and Learn Lean
33
Observation Method
Go and Observe The EnvironmentAround the Issue
Record Observation Carefully, Minute
by Minute
Study the Observation and Represent It
As a Picture
34
Dr. Clemmers
Observation
Sheet
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C15: Think and Learn Lean
35
Patients Condition
Meets
Discharge Criteria.
Current Condition
Physician
Writes D/C
Order and
Specifies
Receiving
Unit
Physician
Consults
with Others
About D/C
Pt. Continues to
Occupy ICU Bed
Inappropriately
Specified
Receiving
Unit Is Full
Patient
Transferredto New Unit
No
Disagrees
YES
Request Made
To Physician
Specified
Receiving
Unit Has
or Opensa Bed
Non-specified
Unit Is
Open
Undecided
Agrees
Physician
Agrees,
Disagrees or
Is Undecided
About D/C
Physician
Wants
More Data
Before
Deciding
= a Delay
36
Agrees
Current Condition
Physician
Writes D/C
Order and
Specifies
Receiving Unit
Physician
Consults
with Others
About D/C
Pt. Continues to
Occupy ICU Bed
Inappropriately
Specified
ReceivingUnit Is Full
Physician
Wants
More Data
Before
DecidingPatient
Transferredto New Unit
No
Disagrees
YES
Request Made
To Physician
Specified
Receiving
Unit Has or
Opens aBed
Non-
specified
Unit Is Open
Undecided
Problem 5
Problem 1
Problem 3
Problem 4
Patients Condition
Meets
Discharge Criteria.
Physician
Agrees,
Disagrees or
Is Undecided
About D/C
Problem 6
Problem 2
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C15: Think and Learn Lean
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Why Do Physicians Need to Consult withOthers Before Discharging?
Attendings are not confident in the H.O. ability to make
such decisions or fail to communicate clearly with them
H.O. fear the attending will disagree because attending
sometimes rewrite their orders and fail to communicate
with them clearly
Attending afraid the consultant might disagree and do
not want conflict
Insecurity in their own decision making capabilities
Problem 1 Analysis
38
Why Do Physicians Disagree with
Discharge Criteria?
Non-functional discharge criteria
They do not know what they are
Have not had input and therefore disagree with them They feel their gestalt is better than the rules
They use other non-definable criteria in making the
decision such as what is the staffing and care like on
the receiving unit, my work load today, H.O. coverage
Personal bias
Problem 2 Analysis
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C15: Think and Learn Lean
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Problem 3 Analysis
Why Do Physicians Need MoreInformation?
They feel the D/C criteria does not consider the
time component to describe stability
They feel a likely complication will result in
immediate death or disability
They feel the receiving unit cannot monitor
closely enough or handle the situation Lack of confidence in their early judgment
40
Why Are There Big Delays in Getting
Discharge Orders on the Chart?
Physicians responsible for writing order not
available
With busy physician schedule writing the
discharge order is not a priority
Delays in communicating desire with H.O. or
other physician responsible to write the orders
Problem 4 Analysis
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C15: Think and Learn Lean
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Why Do Physicians Insist on a SpecificReceiving Unit?
They feel the care for their patients is inadequate
in other units
They like the efficiency of having all their patients
on one unit.
They know the procedures and processes on one
unit better than the other units and communicatebetter there
Problem 5 Analysis
42
Why are the Specified Units
Frequently Full?
Inefficient early discharging practices
Poor planning and control of the surgery
schedule
No or nonfunctional discharge criteria
Problem 6 Analysis
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C15: Think and Learn Lean
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Barriers to Creating New Condition No agreed upon discharge criteria
Physicians refusal to abide by discharge criteria
Fear that patients condition may change despite
meeting discharge criteria
Insecure H.O. and controlling Attendings
Inadequate care on some units
Physicians perception that only one unit can
adequately care for their patients
Physician inefficiency when having patients on
multiple units
Desired unit frequently full
44
Patient Transferred
to New UnitPhysician
Writes D/C
Order
An Appropriate
Unit Is Open
All Appropriate
Units Are Full
Pt. Continues to
Occupy ICU Bed
Inappropriately
Target Condition
Request Made To Physician
Patients Condition
Meets
Discharge Criteria.
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C15: Think and Learn Lean
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Agrees
Current Condition
Physician
Agrees,
Disagrees orUndecidedAbout D/C
Physician
Writes D/C
Order andSpecifies
Receiving Unit
Physician
Consults
with Others
About D/C Pt. Continues to
Occupy ICU BedInappropriately
Specified
Receiving
Unit Is Full
Physician
Wants
More DataBeforeDeciding
Patient Transferredto New Unit
Disagrees
YES
Request Made
To Physician
Specified
Receiving
Unit Has or
Opens a
Bed
Non-
specified
Unit Is
Open
Undecided
Physician
Writes D/C
Order
Patient
Transferred
to New Unit
An AppropriateUnit Is Open
All Appropriate
Units Are Full
Pt. Continues to
Occupy ICU Bed
InappropriatelyTarget Condition
Request Made To Physician
No
Patients Condition
Meets
Discharge Criteria.
Patients Condition
Meets
Discharge Criteria.
Combined
46
4th Rule In UseHow to Improve
Any Improvement Must Be Made
In Accordance With a Pragmatic
Scientific Method, Under theGuidance of a Teacher, At the
Lowest Possible Level In the
Organization
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C15: Think and Learn Lean
47
Toyotas Pragmatic
Scientific MethodThe Toyota System Creates a
Community of Scientists By
Defining Specifications,
Establishing Hypotheses and
Continually Testing Them and
Measuring the Outcomes.
48
Learning Line ConceptProblems are used to improve the system
Problems are recognized immediately and help
sought. (Problem solving is a team sport)
Help is immediately available
A counter-measure will be instituted immediately
to get to the patient their needed care
The Socratic method is used (the 6 whys) to find the
root cause and a final solution
A permanent solution will be instituted
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C15: Think and Learn Lean
49
The Scientific Methodof Improvement
All Changes Are Discussed With
Immediate Supervisor, Documented
and Outcomes Measured
50
Draw a Target Condition
Measure the Current Condition
Counter Measures:
Plan the Counter Measures
Test the Countermeasure
Measure the Results
Follow up:
Set the AIM
Set Up a Measurement System
Develop a Change Concepts
Plan
Do
Study
Act
Toyota A3 Process QI - Rapid Cycle Process
Right Side
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C15: Think and Learn Lean
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Redo Counter Measures:
Plan the Counter Measures:
Test the Countermeasure
Measure the Results
Follow up:
Develop a New Change Concept
Plan
Do
Study
Act
Toyota A3 Process QI - Rapid Cycle Process
Right Side
52
The Toyota System Discourages
Command and Control
Environments.
It Stimulates Workers and
Managers to Engage InExperimentation That Is the
Cornerstone of a Learning
Organization
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C15: Think and Learn Lean
53
How to Create a Learning
Environment That Thinks Lean Push the Processes Down to the Front Line
Recognize Problems
Do Observations
Approach All Problems As a Team, No More
Workarounds
Stabilize Your Processes
Use Toyotas Four Rules in Use