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Introduction to Continuous Improvement

in HealthcareWhy Lean?

Why Lean in Healthcare?Lean PhilosophySeven Wastes

Reliable Methods as Countermeasures

• Hands-on consulting/training in Continuous Improvement

• Award winning Training Products• Lean practitioners with a passion for

Gemba-based learning• Promoting a culture of improvement• Not-for-Profit Organization

© Greater Boston Manufacturing Partnership

Our Mission Is Simple: to help companies become more productive and competitive through Continuous

Improvement education and implementation.

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www.gbmp.org617-287-7737

Home of the Old Lean Dude, lean blogger

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“I would recommend participation to all healthcare department heads and quality improvement practitioners. GBMP did a great job applying the material to healthcare, "going to the gemba" after learning lean concepts and tools in order to apply knowledge learned in the classroom.”

- Christine McMullan, Director of Continuous Quality Improvement, Stony Brook University Hospital

Introductions

• Pat Wardwell, GBMP• Chief Operating Officer

• 25+ years Operations and Improvement Roles

• Lean Gold Certified• Shingo Prize Recipient• Shingo Prize Examiner• AME Excellence Award Council

and Assessor

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Why Lean in Healthcare?“While technologies and treatments have made enormous strides during my career, nuts-and-bolts hospital operations haven't.” – Dr. Patricia Gabow.

National Healthcare

ReformInsurance Coverage

Desire to Improve Quality, Cost, Delivery and Safety of Care

Payment SystemsReporting

Requirements

Waste

Errors

Cost

Staff Frustration

Waiting

Work-Arounds

Silos4

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Lean in HealthcareAffinity Healthcare – A Healthcare Remedy

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What Is “Traditional”?

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What Is “Traditional Operating Methods”?

Customer requirements not known

Batch processing Pacing to “maximize”

resources Processes/Equipment

keep running despite defects

Lack of standardization Questionable quality

Operator’s work out of control

Operators not working together

Limited communication between operators and management.

Management occasionally present

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What Is “Traditional Healthcare”?

Patient requirements poorly communicated

Batch processing Unnecessary

procedures and tests Lack of standardization Long wait times

expected Questionable quality

Staff working out of control

Dr., nurse, and staff not working together

Limited communication between staff and management

Management occasionally present

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What is Continuous Improvement?

• An approach to healthcare which strives to maximize value to the patient by maximizing the value of employees.

Stability

Standardization

Autonomation

JIT

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What is Continuous Improvement?

Connects employees and patients.

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Concept of Value and Waste• Value Added

– Activities involved with the direct care of the patient– Activities the customer (Patient or Payer) is willing to

pay for

• Waste (Non-Value Added)– Activities that do not benefit the patient– Activities that fall under the 7 forms of waste– Activities not performed right the first time

• Necessary Non-Value Added (Incidental Work)– Activities causing no value to be created but which

cannot be eliminated based on current technology or regulations

What is Continuous Improvement? What is CI in Healthcare?

• The primary focus of lean or CI is in developing people as problem solvers and participants in process improvement.

• CI or lean is the creation of value for the customer through the relentless and iterative elimination of waste (muda), variation (mura) and strain (muri).

• Value is defined as any action or process for which the customer would be willing to pay.

• In Healthcare, value is defined as any action or process that directly contributes to the care of the patient.

“Care that is patient-focused, with less waste and cost and better medical outcomes” - John Toussaint, On the Mend 12

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Lean – The Big Picture10% Techniques & 90% People

Before strategy there is Philosophy.

Techniques are the means, not the ends

Management must lead.

At the center is Human Development.

Philosophy

Tech

niqu

es

Managem

ent

Human Development

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Lean PhilosophyPatient is First . . .

• Patients expect zero errors• At an affordable price• With no waiting.

Old Thinking New Thinking

Errors Expected

Profit = Price - Cost

Maximize for Physician

Price = Cost + Profit

Zero Defects

No Patient Waiting

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Lean PhilosophyEmployees are the most valuable resource.

• People want to make valuable contributions to the world.

• Dissatisfaction is a normal and necessary condition for improvement.

• 95% of objection is cautionary.• If employees truly understand

value, they will gladly provide it.• People have limitless capability.

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Lean Philosophy Direct Observation

• Direct observation on regular basis is critical to understanding.

• Best information for continuous improvement comes from direct observation and involvement with the people who do the work.

• Workplace is dynamic. • Go to Gemba often!

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Lean Philosophy Kaizen (continuous improvement) is for

everybody, everyday.

• Kaizen is small changes for the better that come from the common sense and experience of the people who do the work.

• The more employees learn and use CI the better they become at problem-solving (tacit learning.)

• Continuous improvement never ends.

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Toast Kaizen

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Toast KaizenEvent Metrics

Measure Current Target

Lead Time 4.2 min. 2.2 min.

Floor Space 24 sq. ft. 4 sq. ft.

Steps 25 4

Customer Happy? No Yes

Job Easier? No Yes

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Lean Summary• Everybody, everyday!• Patient focused.• 10% techniques &

90% people.• Is taken in small

steps. • Produces orders of

magnitude benefits.• Is not consistent with

traditional approach.

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Benefits of Lean

• Highest Quality• Lowest Cost• Shortest Time• Safer for Patient• Least Strain for Caregiver• Greatest Productivity• Better use of Space• Greatest Margin Flexibility• There are no limits to

improvement!

Connects Patient to Staff

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Process - Operation Model

Process

Operation

Admissions

Screening

Reading

Feedback

Patient A Patient B Patient C

Main Reception

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Process - Operation ModelMain Reception

Admissions

Screening ReadingFeedback

Waste

95% of process is waste.

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Seven Wastes

3. WaitingTo get inTo get outFor resultsFor medication, for food

Searching, walking, backtracking, reaching, bending, climbing, taking eyes off of work

4. Motion

Patients and providersInformation

Supplies

2. Transportation

In patient roomsIn stockroomsBetween departments

In hallways1. Inventory

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Seven Wastes Patient being asked the same questions, unsafe or strain producing, Unnecessary, irrational

5. Processing

Infections, wrong site surgeries, medication errors

6. Defects

Excessive tests, unnecessary treatment

7. Over-production

Worst Waste

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Reliable Methods• 5S - Workplace Organization • Problem Solving for CI Teams• Value Stream Mapping• Continuous Flow• Standardized Work• Kanban/ Pull Systems• Visual Control Systems• Set up Reduction• Poka-yoke/ Error Proofing• Heijunka/ Level Scheduling

Identify reliable methods.

Keep all employees practiced.

Create a favorable environment.

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S1 – Sort Out

S2 – Set Locations

S3 – Shine

S4 – Standardize

S5 – Sustain

5S - The First Improvement

5S Video Essay

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CEDACTeam Based Problem Solving Technique

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Value Stream MappingGood Process Good Result

Continuous Flow (Cells)• Reorganizing physically

and organizationally for improved flow.

• All steps used to complete a prcess are placed in sequence of production. No space between steps.

• No material build-up between operations.

• One piece flow.

31Spaghetti Diagram

Lab Flow

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Standardized Work• Best (current) combination of people,

machines and material to complete process for patient demand. • Takt Time – time allowed by customer to complete

the process• Cycle time - time to perform the process, including

machine and manual time• Work Sequence - order of operations to complete

the process • Stock on Hand – inventory required to maintain flow• Key safety and inspection points

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Kanban• Kanban eliminates

overproduction.• Kanban re-integrates

inventory data with material.

• Number of kanban cards controls level of inventory.

• Delays (unavailable kanban) are highlighted immediately.

• Kanban is like money, always try for less money in system.

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Visual Control SystemsLetting the Process Speak

Visual Indicator

Visual Signal

Visual Control

Visual Guarantee

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Reducing Interruptions and Improving Patient Safety

• A study involving nine San Francisco Bay Area hospitals focused on improving accuracy in administering drugs - with particular emphasis on reducing interruptions that often lead to mistakes - resulted in a nearly 88 percent drop in errors over 36 months at those hospitals.

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Set-up Reduction

• Reduce every set-up by “59/60th’s”

• Separation of external from internal tasks• external = process running

internal = process stopped • Convert internal to external

tasks• Minimize adjustments• Improve overall set up• Focus on waste, not operation

Patient Room

Operating Room

Equipment

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Poka-yoke

• Poka-yoke means to avoid (yokeru) inadvertent errors (poka).

• “Preventing the act of forgetting what you have forgotten” -- Shigeo Shingo.

• Respect the intelligence of staff by taking the judgment out of repetitive tasks where errors are likely to occur.

Defects = 0

Cannot connect to the wrong tank!

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Continuous Improvement Summary

• Develop from Need• 90% People (Patients

and Employees)• Focus on Workplace • Create Kaizen Way• Incremental use of

reliable methods to counter 7 wastes

5S and VSM

Continuous Flow

Standardized Work

Pull Systems

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Key Points• Three aspects to TPS

• Technical – tools like 5S, Kanban, Set Up Reduction

• Philosophy (see below)• Management – new strategy,

policy and organization• TPS (Lean) Philosophy:

• Patient First• Employees most important

resource• Direct observation. (Go see!)• Kaizen – small changes for

the better, everybody, everyday

• 7 Wastes• Storage• Transportation• Overproduction• Processing• Motion• Defects• Waiting

• Basic hierarchy of improvement• JIT• Autonomation• Standardization• Stability

Create a favorable environment: 90% people,10% methods!

Thank you!Questions

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