5 Keys to Lean Success: Avoiding Common Lean Pitfalls

Tony Gorski BSIE, MBA Tuesday, June 25th, 2013

• Tony Gorski is CEO of Safer Healthcare. Mr. Gorski is an award-

winning speaker, published author and recognized subject matter

expert in helping hospital boards, CEOs and management teams

transform operational performance and creating High Reliability

Organizations (HROs). Mr. Gorski is also driving the launch of

www.MyRounding.com, an iPad Leadership Rounding application

for directors, managers and frontline staff. Mr. Gorski holds a

Bachelor of Science in Engineering from Marquette University and

a Masters of Business Administration from the University of North

Carolina in Chapel Hill. Mr. Gorski currently resides in Denver,

CO.

Tony Gorski, BSIE, MBA

Disclosure Information

Speaker:

Tony Gorski, BSIE, MBA

No Conflict

Accreditation Statement

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on

Accreditation.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.

AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS

EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY

REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.

Planning Committee:

Susan D. Root, MSN, RN, CNOR

Manager Perioperative Education, AORN

No conflict

AORN’s policy is that the subject matter experts for this product must disclose any financial relationship

in a company providing grant funds and/or a company whose product(s) may be discussed or used

during the educational activity. Financial disclosure will include the name of the company and/or

product and the type of financial relationship, and includes relationships that are in place at the time of

the activity or were in place in the 12 months preceding the activity. Disclosures for this activity are

indicated according to the following numeric categories:

1. Consultant/Speaker’s Bureau 2. Employee

3. Stockholder 4. Product Designer

5. Grant/Research Support 6. Other relationship (specify)

7. No conflict of interest

Discuss 5 keys to making Lean work

and improving your probability of

success.

Objective

Quality is today’s health care mandate. Yet, there is a dark cloud blurring the

vision of many nurse executives today because Lean has had some false

starts and stops in days gone by.

Ask 10 staff members what the definition of Lean is—chances are you will

get 10 different definitions.

Today we work in broken processes that require excellent people to

achieve average results. Many nursing processes are inherently setup to fail.

Lean running hospitals think differently – focused on building excellent

processes. The key is applying Lean in the right way. While 90% of hospitals

are doing Lean, less than 10% are “running” Lean.

The Lean Dilemma

In this webinar, we will discuss 5 keys to making Lean work and improving your probability

of success:

1. Focus on throughput – this is one of the most powerful metrics for Lean, and you get

a lot of other things for free, such as patient satisfaction, error rates, etc.

2. Avoid focusing on clinical tasks – Instead, focus on the things that get in the way of

performing clinical tasks.

3. Don’t make every nurse a Lean expert – not every member of your staff needs to be

a Lean expert.

4. Leading 3-steps ahead – Lean work must be facilitated by someone can think three

steps ahead at all times to guide the transformation.

5. Educate yourself and then educate your team members – we must be able to think

both from a process perspective and a clinical perspective.

5 Keys to Driving Success

Six Aims for Improvement

“Health care should be: • Safe • Effective • Patient-centered • Timely • Efficient • Equitable

These aims are not new….Yet American health care fails far too often with respect to these aims, despite enormous cost and dedication and good efforts of millions of American healthcare workers”

Six Aims for Improvement

The IOM “Chasm” Report

gives us a vision of where

to go

Lean Thinking gives us a path to get there

– Process Improvement Framework

– Tools and Problem-Solving Skills

Lean Calibration

• What is it?

– The word “Lean” – only 1 word, but 100 definitions

– Toyota Production System – not a Panacea

– Bunch of tools or a fundamental shift in mindset

– Cost-focused (common interpretations):

• Reduce waste, Operational efficiency, Cost reduction

• Customer-focused…….or Patient-focused

– Speed and safe response to customer demand

Random Acts of Lean

Value-Stream Mapping

Workplace Organization (5S), (6S), (7S)

Six Sigma

Visual Management

Total Preventive Maintenance

Balanced Scorecard / Lean Scorecard

Kaizen Events

Theory of Constraints

Workouts

Kanban

Reduce Waste – 7 Wastes, 8 Wastes, etc

Improve Efficiency

Hejunka Scheduling

Standard Work

Rapid Improvement Events

Operational Method Sheets

Changeover Optimization (SMED)

Case Sequencing

DMAIC

Production Preparation Process (3P)

Process Balancing Tools

Electronic Kanban Methods

Benchmarking Practices

Health Care Execution Systems

Green Belts, Black Belts

Mixed-Model Designs

Drum/Buffer/Rope

RFID/Bar Code Strategies

Flow Rate Management

Cellular Concepts

Rationalization Practices

Demand-Driven Metrics

Flexibility Practices

Process Mapping

Velocity Analysis

Mistake-Proofing (Poka-Yoke)

Common problem…

– Pockets of improvement are not tied or affect bottom line

– Primarily focused on micro areas with micro results

Common answer…

– Many organizations end up creating their own Excellence System or Operating System

Excerpt from U.S. News and World Report…

“…During the visit, a team led by Virginia Mason's chief of medicine met with a Toyota guru, a sensei who absorbed the Toyota approach into his very marrow. Examining a layout of the hospital, the sensei learned that there were waiting rooms scattered across the campus.

"Who waits there?" the sensei had asked.

"Patients," said the chief of medicine.

"What are they waiting for?"

"The doctor."

The sensei was told there might be a hundred or so such waiting rooms and that patients wait about 45 minutes on average.

"You have a hundred waiting areas where patients wait an average of 45 minutes for a doctor?" He paused and let the question hang in the air.

"Aren't you ashamed?“

What Medicine Can Learn From Business

(U.S. News & World Report, June 17, 2008)

Push Facility

Originally Built to Push/Batch Product

Traditional Push & Power of Pull

vs.

Push Facility Pull Facility

Originally Built to Push/Batch Product Originally Built to Pull to Customer Demand

vs.

Traditional Push & Power of Pull

• Consider the process of patient care

– from a cross-functional viewpoint instead of individual

functional departments

– Get past the trees to see the forest

• Both outcomes and patient satisfaction

– depend on a healthcare experience that is a smoothly

flowing series of connected steps

• HCAHPS and Jiffy Lube…

Outcomes vs Patient Satisfaction

Where to focus efforts?

• The 90/10 Rule of Value

– Often, the same amount of effort applied to

the non-value added activity (the 90%) as

the value-added activity (the 10%) yields

significantly greater results

– However, most improvements focus

solely on the 10%

• In health care, this applies to both paper

process(ing) and patient process(ing)

10%90%Time

Non-value added activity Value added activity

Typical NVA Activities: Counting Handling Waiting Stocking/Storing Signoffs Multiple Order

Entry/Processing Moving

Where to focus efforts?

Value Added Non-Value Added

1. Defects

2. Overproduction

3. Waiting

4. Transportation

5. Inventory

6. Motion

7. Excess

Processing

Typically 90+% of all cycle

time is non-value added

Throughput - Definition

The time it takes to flow all the way through a process or value

stream, from start to finish including waiting time, process

time, queue and non-value added time.

• What are your significant value streams?

• What are throughput times?

• Are they measured in seconds, minutes, days, weeks, etc.?

• Use Value Stream Mapping to help identify a future state

with improved Throughput

Time Start Finish

Waiting Wait Move Wait Move/Wait = Value Added Time

(VA)

= Non-Value Added

Time

(NVA)

Tests Treat Triage

Traditional Focus Improve the VA processes

Lean focus Eliminate the NVA processes

Separating Waste from Value

It’s Affect on 7 Wastes

• The seven types of waste

– Over-production

– Waiting

– Transportation

– Over-processing

– Inventory

– Motion

– Defects

Throughput

Throughput - Examples

• Admission to discharge

• Invoice process

• Filling medications

• Length of stay

• Lead times on purchased items

• Room turnovers

• Time to fill employee requisition

• IT help desk – problem resolution process

• Reduce waiting time

• Reduce non-value added activities (orange vs blue)

• Reduce total amount of work-in-process

• Accelerate value added processes

• Improve linkages between processes

• Implement “pull” techniques

• Focus on flexibility

Throughput – How to Improve

Chase Variation, not Averages

• Variability recognizes that processes do not produce

identical results every time (inherent in nature)

– Variability may be caused by identifiable forces acting on the process or by

minute fluctuations in the process itself

– Range (low to high spread), standard deviation (relative dispersion from the

mean), and variance (how far a set of numbers is spread out) are common

measures of variability

μ = average

σ = variation

The Normal

Distribution Curve

Leading 3-steps Ahead

• Presents a clear path moving forward

• Must have a clear sense of where they are currently, as

well as the ideal state to which they are heading

• A leader is a change agent, not a magician

– The leader doesn’t assume all tasks/actions

• Lean leaders create a ‘creative tension’ for progress

“Too many times, Lean Leaders are ‘forced’ into the roles and are setup to fail. Lean work must be facilitated by someone can think three steps

ahead at all times to guide the transformation.”

“Rely on someone who has ‘been there, done that’ versus struggling alone.”

Shared

Vision

Skills /

Training Incentives Resources

Action

Required

Successful

Change

Skills /

Training Incentives Resources

Action

Required Confusion

Shared

Vision Incentives Resources

Action

Required Anxiety

Shared

Vision

Skills /

Training Resources

Action

Required

Gradual

Change

Shared

Vision

Skills /

Training Incentives

Action

Required Frustration

Shared

Vision

Skills /

Training Incentives Resources

False

Starts

Leaders Identify the Missing Link

Nurses and Lean Experts

not every member of your staff needs to be a Lean expert...

but every Lean tool should be very well known by at least one person

on your staff…

“I just don’t process things that way” “It’s too much and can all be so intimidating” “I spend more time trying to understand the proper use of Lean language than I do getting anything done”

“One person is the Value Stream Mapping leader, another is the Standard Work leader, another the workplace organization leader” “I’m very comfortable with identifying Standard Work, but the rest frankly confuses me” “Now I can focus on being great on one thing versus a laggard at everything”

Educate Not Just on Tools…

• Educate yourself

– to ensure you can identify the roadblocks and know how to

address them

• Then educate your team members – properly

– not a one-size fits all mentality

“we must be able to think both from a process perspective and a clinical

perspective”

In this webinar, we will discuss 5 keys to making Lean work and improving your probability

of success:

1. Focus on throughput – this is one of the most powerful metrics for Lean, and you get

a lot of other things for free, such as patient satisfaction, error rates, etc.

2. Avoid focusing on clinical tasks – Instead, focus on the things that get in the way of

performing clinical tasks.

3. Don’t make every nurse a Lean expert – not every member of your staff needs to be

a Lean expert.

4. Leading 3-steps ahead – Lean work must be facilitated by someone can think three

steps ahead at all times to guide the transformation.

5. Educate yourself and then educate your team members – we must be able to think

both from a process perspective and a clinical perspective.

5 Keys to Driving Success

Your Takeaways…

• Feel

– What do patient waiting times trigger in me?

– Have I felt the “Missing Links” managing change?

• Think

– Are we more like McDonald’s years ago or like Subway today?

– Are we doing “Random Acts of Lean”?

– Am I focused on the ”ORANGE” or the “BLUE”?

– Are we chasing Averages or reducing Variation?

• Do

– Eliminate something ”ORANGE”

This highly-concentrated three day, hands-on workshop teaches

critical thinking, problem solving, and leadership skills that are

fundamental to creating and sustaining actual change using LEAN

strategies. Work teams highly recommended as this course “explains

by doing.”

August 20-22

September 18-20

Denver, CO – AORN Headquarters

www.aorn.org/LeanLeadership

Know what counts. Measure what matters. Deliver results.