Applying Toyota Lean Principles

in a Healthcare Supply Chain

Partnering between Supply Chain & Clinicians

WSHMMA Spokane 2006

Ken Fortune: Director of Purchasing & Distribution

Allen Caudle: VP Supply Chain Management

Swedish Health ServicesSeattle, Washington

Swedish Health ServicesSwedish Health Services

Largest Hospital System in the Pacific NorthwestLargest Hospital System in the Pacific Northwest 4 Acute Care Facilities4 Acute Care Facilities 25 City Blocks and 5.5 million Ft25 City Blocks and 5.5 million Ft22

1,286 Total Beds1,286 Total Beds Not for Profit – 501c3 OrganizationNot for Profit – 501c3 Organization Net Revenues - $1.1 billion (2006 budget)Net Revenues - $1.1 billion (2006 budget) 6,970 Employees6,970 Employees 1,744 Physicians1,744 Physicians 54 Operating Rooms54 Operating Rooms Approximately 40,000 Surgical ProceduresApproximately 40,000 Surgical Procedures $170M Total Supply Spending$170M Total Supply Spending

HospitalDivision

HospitalDivision

Home Health & Hospice

Home Health & Hospice

Physician Division

Physician Division

JointVenturesJoint

Ventures

FoundationsFoundations Research & Education

Research & Education MOBsMOBs

Supply Chain Vision Supply Chain Vision The Gold StandardThe Gold Standard

Supply Chain Vision Supply Chain Vision The Gold StandardThe Gold Standard

PatientCare

Med Surg SupplyImplementation RPI

Periop ServicesSupply Chain

Clin. Info System RPI Redesign

Nursing Unit Storeroom 5S

Bed Turnover RPIEnvironmental Services

Critical Use Equipment RPI

Pyxis

Treat the patient care constraint like Gold -- Align the organization and deliver The Gold Standard to our customers and clinical service partners!

Treat the patient care constraint like Gold -- Align the organization and deliver The Gold Standard to our customers and clinical service partners!

Forms Process Improvement RPI

What is the Toyota Production What is the Toyota Production System or “Lean Thinking?”System or “Lean Thinking?”

Request RevenueValue Stream Time Line

1. Value - define precisely what delights customers

2. Value Stream = Service Lines - identify all processes

3. Flow - make value steps flow by removing waste in every form

4. Just-in-Time - design & provide precisely what customers want precisely when they want it

5. Perfection - pursue through Daily Management

10 Leadership Practices for Managing 10 Leadership Practices for Managing & Sustaining Lean Operations& Sustaining Lean Operations

Establish a Good, Two-way Relationship

Goal Achievement

Set Context

Assign Tasks

Plan & Resource

Improve Work Continuously

Employee Development

Assess Judgment & Discretion

Coach & Develop Staff

Recognizing & Rewarding

Staff

Select & Orient Staff

Reassign, Correct

or Dismiss

•Quality•Patient

Satisfaction

•Lead-time

Success Requires 3 Stratum Success Requires 3 Stratum Leadership & Management Leadership & Management

Guidance TeamGuidance Team

DIR

Mgr

VP

COOCEO

VP

DIR

Mgr

DIR

Mgr

DIR

Mgr

Customer

Management Guidance Team• Epidemiology & Nursing• Cross-org. alignment -- BioMed, Envir. Services, Sterile Processing

3 Stratum Leadership• Authorizing manager• Process Manager• Experts in the Process

Our RPI Project Our RPI Project Management Process Process

ExecutiveCommitment

PLANRPI

Blueprint

60 DayReview

30 DayReview

WORKSHOPWEEK

DAILY MANAGEMENT(RPI Newspaper)

RPI

Hold the Gains

P

S

A

D

Sustainable Improvement

ASSESSMENTGo/No Go?

Activities of the Four Activities of the Four PhasesPhases

Initial Initial meetingmeeting

Process Process reviewreview

Site VisitSite VisitAssess Assess

managersmanagersFeedbackFeedback

- - OpportunitiesOpportunities- Risks- Risks- Scope- Scope

Go/No Go Go/No Go decisiondecision

Learn Learn toolstools

Analyze Analyze processprocess

Eliminate Eliminate wastewaste

ImplemenImplement short-t short-term term plansplans

Develop Develop follow-on follow-on plansplans

Complete Complete workshop workshop actionsactions

Implement Implement Daily Daily MgmtMgmt

Check Check results and results and hold gainshold gains

Spread to Spread to other areasother areas

Assessment

Workshop Workshop ObjectivesObjectives

Process Process boundariesboundaries

Timing setTiming setParticipant Participant

preparationpreparationManagemeManageme

nt nt preparationpreparation

Data Data collectioncollection

Agenda setAgenda set

Planning Workshop Daily Mgmt

Roles in the RPI Management Roles in the RPI Management Guidance TeamGuidance Team

Provide uninterrupted team member participation. Provide uninterrupted team member participation.

Remove barriers for the workshop participants. Remove barriers for the workshop participants.

Empower and support the workshop participants to Empower and support the workshop participants to implement changes (i.e. provide resources).implement changes (i.e. provide resources).

Notify and coach workshop participants for their Notify and coach workshop participants for their role in the workshoprole in the workshop

Participate with team to resolve issues and mediate Participate with team to resolve issues and mediate differences.differences.

Advocate for the need of customers and “the whole” Advocate for the need of customers and “the whole” vs. a particular unit of people. vs. a particular unit of people.

Take risks and encourage workshop participants to Take risks and encourage workshop participants to do the same.do the same.

Celebrate and congratulate the team on success.Celebrate and congratulate the team on success.

3 Actuals Walk3 Actuals Walk

““The time that provides me with the most The time that provides me with the most vital information about management is vital information about management is the time I spend in the plant, not in the the time I spend in the plant, not in the vice president’s office.” -- Taiichi Ohnovice president’s office.” -- Taiichi Ohno

Go to the Go to the Actual PlaceActual Place Talk to the Talk to the Actual PeopleActual People Observe the Observe the Actual ProcessActual Process

The 5S’sThe 5S’s

Sustain Hold the gains & improve.

Standardize Develop common methods for consistency.

Sweep Sweep to clean and visual sweep to understand.

Simplify A place for everything & everything in its place, clean & ready to use.

Sort Separate the needed from the not needed (waste).

Pre-RPI SDS Case Cart ProcessPre-RPI SDS Case Cart Process

Window (10)

PL MSC

ORSuite

SPD

PDC

Rx Room

SDSCore

Suture Board

2 WKS PLs = $90kCore (30%) = $30k

4 Turns3+ months

40 Different Inventory Locations

Q

Q

Q

Q

QQ(136k) (65k)

Packs, Supplies

Pick Tickets

Instruments, Packs,

Soft Goods

Medications

Supplies, Equip,

Instruments

Supplies

Suture

Q

New Case Cart Building Process

Inventory Supply Room

Pull soft goods for 1st case next day

– Andrew (day before)

Packs, Solutions, Canisters

Meds, Suture, Equipment

Soft Goods

Linen

Instrument Set

PDC Items

DOSPull clean cart into

inventory room.Put on soft goods and PDC items.

Back Hallway

Take cart to back hallway

Put on instrument set, solutions, custom pack,

canisters, linens and bags

Laundry

Linen exchange cart -

daily

SPDSPD pulls

instrument set for next day.

Take to SDS, w/PL’s, to Kanban

spot

MSC

MSC restock soft goods, custom pack, solutions,

canisters – daily

PDC

DOSPDC pull items; put

on cart; place in inventory room for

Andrew

Core

Facilitator gets equipment and

positioning devices

Facilitator pulls meds, saturns and MD sterile

specials

OR Suite

Push cart into OR for 1st case – TF cases, push into kanban square

Case Cart Building Case Cart Building Process FlowProcess Flow

DOS

At 6amDay Before DOS Before 6am

§ SPD brings up cart with instrument sets for 1st unit (4 hrs) to designated spot in clean side of decontam with a list of what goes where

§ Specialty instrument (non-stored) for each procedure are combined with the instrument set by SPD

§ PDC pulls items needed for entire day and places on cart

§ Cart is moved to back hallway of Core to designated spot

§ Case Cart Builder (CCB) gets clean cart from back hallway designated spot and takes to clean decontam

§ CCB puts instrument set, peel pack and un-sterile specials; and pushes to inventory storage room

§ Add designated tote

§ Push cart to back hallway

§ In back hallway, CCB adds solutions, canisters, linens, PDC items and custom packs

§ Case cart pushed into designated OR

§ 1st case only

§ Facilitator pulls sutures, meds, and sterile MD specials and peel pack items

§ Facilitator gets equipment and positioning devices

§ Pushes cart into OR when complete

§ Repeat steps 4-6 for next case

§ CCB places TF case cart in designated spot in back hallway or outside OR

Inventory Supply Room

§ Case cart builder pulls soft goods for 1st case of next day

§Places soft good in tote designated for specific OR

§ Stages for next day

Data SummaryData Summary # Steps# Steps 111111 4545 ↓ 59%↓ 59%

# VA Steps# VA Steps 6 6 6 6

# NVA Steps# NVA Steps 105105 3939 ↓ 63% ↓ 63%

# Queues# Queues 4 4 3 3 ↓ 25% ↓ 25%

# Handoffs# Handoffs 23 23 3 3 ↓ 87% ↓ 87%

# Feet Traveled# Feet Traveled 10,23410,234 378378 ↓ 96% ↓ 96%

# In Queue (WIP)# In Queue (WIP) HundredsHundreds

Lead TimeLead Time 58 Hrs58 Hrs 17 Hrs17 Hrs ↓71%↓71%

Cycle TimeCycle Time 8 Hrs8 Hrs 15 min15 min ↓ 97%↓ 97%

SpaceSpace C FloorC Floor

B FloorB Floor

A FloorA Floor

Inventory ReductionInventory Reduction Patient ChargeablesPatient Chargeables BeforeBefore FutureFuture ChangeChange SDS CoreSDS Core 7,944 7,944 7,378 7,378 SPDSPD 5,394 5,394 0 0

$ 13,338$ 13,338 $ 7,378$ 7,378$ 5,960$ 5,960

Non-ChargeablesNon-Chargeables SDS Core & Inventory SDS Core & Inventory

RoomRoom 19,498 19,498 2,765 2,765 SPDSPD 2,169 2,169 0 0

$21,667$21,667 $ 2,765$ 2,765$18,902$18,902

Returns to MSCReturns to MSC $ 2,000$ 2,000

SutureSuture SDS CoreSDS Core $ 65,119$ 65,119 Marked boxesMarked boxes $ $

9,896 9,896

TotalTotal $36,758$36,758

Percent of SDS Average Weekly Stockouts

0.45%

0.27%

0.22%

0.72%

1.08%

0.81%

0.36%

0.60%

0.36%

0.65%0.58%0.58%0.72%

0.00%0.00%

0.22%

0.00%

0.29%0.45%

0.14%

0.58%

1.01%

1.22%

0.58%

JULY – DECEMBER 2005PERCENT OF SDS AVERAGE WEEKLY STOCKOUTS

Percent of MSC Average Weekly Stockouts

3.29%

2.97%

2.39%

2.71%

3.57%

3.19%

3.07%2.99%

2.90%

3.17%3.08%

3.03%2.95%2.94%

2.64%2.57%

2.50%

1.89%

2.15%

1.85%

2.39%

2.65%

2.57%

3.21%

2.64%

JULY – DECEMBER 2005 PERCENT OF MSC AVERAGE WEEKLY STOCKOUTS

Communications & Instrument Delivery ProtocolCommunications & Instrument Delivery Protocol

Pick instruments and record missing instruments

(Blue Sheet)

2nd Shift

2nd Shift prints pick tickets after 5p

Sort pick tickets intotwo piles

1st Shift

7:30a – 12:30p1st run pick tickets

No front sheet

Copy Missing Instrument Sheet

Send copy w/instruments

Place original w/1st shift pick tickets

Deliver instruments for the day to SDS by 11:30p

SPD calls SDS for Missing Instrument Needs #66042 at

6:00a

12:31p – 5:31p1st Shift

Pick instruments and record missing instruments

(Blue Sheet)

Copy Missing Instrument Sheet

Send copy w/instruments

Deliver instruments to SDS 10:00a

Dispose used PL’s

Call SDS for Missing Instruments #66042 by 11a

Dispose used PL’s

Rapid Instrument Turnover Flow SDSRapid Instrument Turnover Flow SDS Circulating RN calls for

instruments to be picked up in OR

Instrument suitable for auto wash?

Hand wash

Initial cleaning by hand

Run in washer

Deliver to room

Deliver back to room

Sterilize

Time available to auto wash

Sterilize

Hand washDeliver back

to roomSterilize

No

No

Yes

Yes

Forms “System”

Form content is developed

Someone wants to generate or revise clinical protocol, careplan, clinical guideline or other clinical

form

Stakeholder Approval

Process for Implementati

on

Print Process

Forms Committee and Standards

Committee Approval

Processes

NO

Approved?

YES

Track form

Track form

Track form

Track form

Track form

Printed Forms

Storage/Inventory(Merrill, MSC, 1 SE)

Department/Unit

Sort & PurgeOld Forms

To DepartmentsTo Inventory/Storage

Swedish On-line forms and orders

Sort & PurgeOld Forms

Track form

Management and Storage of Forms and Forms Inventory In The Units and In All Storage Locations

Goals:Ø Reduce staff “search time” for forms

Ø Identify and inventory most current forms

Ø Find opportunities for standardizing forms process on units

Ø Eliminate forms that are problematic for patient safety

Ø Reduce forms inventory on units, MSC, Merrill

Ø Identify responsible person to manage forms inventory on unit

Ø Design staff education format for new/improved forms process in units

Ø Design process so that nursing units are aware of when a new or revised form is in house and how to obtain it on the unit

Ø Design process so that prior to distribution of new or revised forms, staff have received notification and or education as appropriate

Ø Identify who pays for purged/discarded forms

Ø Standardize process to notify MSC and Merrill when form has been discontinued

Ø Standardize process to notify MSC and Merrill for just-in-time delivery of forms to unit

Storage/Inventory

Storage/Inventory(Merrill, MSC, 1 SE)

Department/Unit

Department/Unit

Sort & PurgeOld Forms

Sort & PurgeOld Forms

Printed Forms

Forms Development Process

Form content is developed

Someone wants to generate or revise clinical protocol, careplan, clinical guideline or other

clinical form

Stakeholder Approval Process for Implementation

Print Process

Forms Committee and Standards Committee Approval Processes

PDSATeam meetingsStakeholder inputEvidence-based researchPilot/Test in daily workMake recommended revisionsPut into standardized formatBegin form education plan Prepare to submit to Forms and Standards CommitteesTrack through Committees’ processesRevise as Committees requireResubmit to Committees for approval

Submit to key stakeholder committees and councilsMake revisions if necessaryResubmit to project team for rework if necessaryResubmit to Forms and Standards if necessarySubmit to Print process when final

NO

Approved?

YES

Track form

Track form

Track form

Track form

Track form

Forms have been printed

To Management After Printing Process

GOALS

· Reduce lead time for forms development and printing

· Streamline and standardize forms development process

· Design staff education format for new/revised forms

· Reduce cost of forms development and printing

· Link Forms and Standards committees to the Forms Development Process

· Identify single point accountability for Forms Development Process

· User can track forms development process

· Prepare for the transition of forms to CIS

Swedish On-line forms and orders

Track form

Becoming PartnersBecoming Partners

The week-long Rapid The week-long Rapid Improvement Process Workshop Improvement Process Workshop helped to break down long-helped to break down long-standing barriers between standing barriers between departments…departments…

Surgery was unaware of the Surgery was unaware of the services Supply Chain could services Supply Chain could provide to them…provide to them…

Communications opened up Communications opened up during the workshop with many during the workshop with many opportunitiesopportunities

Becoming PartnersBecoming Partners

The RPI was a strong success…The RPI was a strong success…85% reduction in “Go-Gets” by 85% reduction in “Go-Gets” by moving supplies closer to point moving supplies closer to point of use and case cart accuracy of use and case cart accuracy improved to 99% because cases improved to 99% because cases picked within core and on a just-picked within core and on a just-in-time basis.in-time basis.

Right people, doing right job, at Right people, doing right job, at the right timethe right time

SummarySummaryHOW HAVE OUR ROLES CHANGED?HOW HAVE OUR ROLES CHANGED?

• Better partners between Supply Chain Better partners between Supply Chain and cliniciansand clinicians

• Supply Chain viewed as professionals Supply Chain viewed as professionals in supply management and leaders of in supply management and leaders of sustained process improvementsustained process improvement

• Supply problems eased in the OR with Supply problems eased in the OR with better supply management process better supply management process (fewer stock outs and “go-gets” from (fewer stock outs and “go-gets” from the rooms)the rooms)

• Nurses can be nurses – focusing on Nurses can be nurses – focusing on patient carepatient care

HOW HAVE OUR ROLES CHANGED?HOW HAVE OUR ROLES CHANGED?

• Supply chain professionals Supply chain professionals manage the process with data manage the process with data and continued “Roundings” and continued “Roundings” with clinicians, OR managers, with clinicians, OR managers, and physiciansand physicians

• Supply chain professionals Supply chain professionals are now relied upon to solve are now relied upon to solve other problems in the ORother problems in the OR