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1
Is it as Simple as Picking a Performance Tool from
Manufacturing and Applying it in Healthcare?
Wendy M. Novicoff, Ph.D.Six Sigma Master Black Belt and Lean SenseiAssociate Partner, Creative Healthcare USA
Assistant Professor, Departments of Public Health Science and Department of Orthopedic Surgery, University of Virginia
Health System
2
Quality Improvement Process
• Problem identification• Team selection• Improvement model (PDCA, Six Sigma,
Lean, etc.)• Improvement tools• Implement solutions• Hold the gains
3
Making It Work
Q x A = E
BusinessResults
Quality of solution times its Acceptance = Effectiveness
4
What is Lean?
• Lean is a methodology that is used to accelerate the speed and reduce the cost of any process by removing waste (non-value-added activities)
5
What Is Lean Thinking?• Providing “a way to do more and more
with less and less – less human effort, less equipment, less time, and less space – while coming closer and closer to providing customers with exactly what they want.
JP Womack and DT JonesLean Thinking (1996)
Be “Lean,” Not “Mean”
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Types of Waste
MotionAny motion of the worker that does
not add value
WaitingWaiting on parts,
waiting on information
InventoryAny more than the minimum to get the
job done
Over ProductionProducing more than is needed
Defects/ReworkProduct or service not
meeting customer requirement
TransportationUnnecessary movement of
materials from one place to another
Over ProcessingAdding more value than the customer
is paying for
IntellectAny failure to fully utilize the time and talents of people
7
Signs of Non-Value Added StepsLarge file areas & frequent archiving
Multiple approvals
Waiting time and multiple hand offs
Process is seen as complex (mystical)
Frequentrework
Written correspondence required for the process
to complete
Procedures passed on by word of mouth, no SOP’s or SOP’s don’t reflect actual process
8
Five Principles of Lean Thinking
• Value• Value Stream• Flow• Pull• Perfection
9
Value• Value can only be defined by the ultimate
customer• Value is created by the producer• We must fundamentally rethink value from the
perspective of the customer – a conscious attempt to define value in terms of specific products with specific capabilities offered at specific prices through a dialogue with specific customers
What is REALLY needed by the customer? This does not equal what WE think the customer needs!
10
Viewpoint: Who is the Customer?
• Perception becomes reality and is therefore is a judgment of our service
Customerasks for
information
Customergets
answer
Long delay perceived by customer!
Our hard work at maximum efficiency –are All Steps Really Necessary?
11
Value Stream
• The value stream is the set of ALL actions required to bring a product (or process) from concept to finished product
• Value stream analysis shows the value of each process step– Steps that unambiguously create value– Steps that create no value but are currently
unavoidable (Type 1 Muda)– Steps that create no value and can be immediately
eliminated (Type 2 Muda)
12
Flow• All activities needed to design, order, and
provide a product or service occur in continuous flow – no stoppages, scrap, or backflow
• Batch-and-queue is the dominant set-up today; Flow thinking is counterintuitive to our culture of “departments”
The questions to ask (and hopefully answer) are: How does the entire process work together (or not)? How can we impact
the work of our suppliers to help with continuous flow?What if we don’t have control over all parts of the value stream?
13
Cycle Time
Process Time
Delay Time+
Flow of Work
14
Pull
• No supplier should produce a good or service until the customer downstream asks for it
• Make the customer tell you what they need instead of trying to “sell” something that you already have (Pull vs. Push)
• The demands of customers become much more stable when they know they can get what they want when they want it
15
Perfection
• Perfection is achieved with the complete elimination of muda so that all activities along the value stream create value
• Transparency in the entire value stream is needed before perfection can be obtained
1616
Stable vs. Capable
• In Lean, we strive for stable, standardized processes that can be replicated at any time by any worker and give roughly the same result
• In Six Sigma, we want a stable process that is also capable, that is – it satisfies the customer specifications every time
• The ultimate goal is a process that is stable and capable with as little variation as possible either in process or the ultimate product
17
DMAIC, DMADV, & LeanDefine
Measure
Analyze
DFSS ?
Improve
Control
Design
Verify
NO YES
Familiarize
Define Work Elements
Time Study Work Elements
Develop New Process Maps
Overall Fixture Needs
# of Work Stations
Balance the Flow
Station Fixture / Tool Needs
Lay Out New Line
18
Getting Started – Guiding Principles
• The primary guiding principle should be that a quality process is safe, evidence-based, customer-focused, and efficient
19
Guiding Principle #1
• Incorporate Lean Thinking where possible– Define Value in terms of the customer. Always define
in terms of the patient being the greatest priority.– Identify all parts of the Value Stream for potential
impact on process– Change batch processes to continuous flow– Move to a “pull” model instead of “push”– Strive for a defect-free process– Employ rapid identification & abatement of errors– Apply mistake-proofing techniques– Consider cross training opportunities
20
Guiding Principle #2
• Use a selected data-driven methodology with measurable performance goals and objectives that is applicable and appropriate. – Six Sigma DMAIC or DMADV– Rapid Action Planning (RAP)– PDCA– FMEA
21
Guiding Principle #3
• Consider Human Factors– Reduce noise– Minimize interruptions– Minimize fatigue/boredom– Simplify– Use forcing factors– Employ recovery factors– Use affordances and natural mapping
22
Guiding Principle 4 and 5
4. Assure visibility– Know locations of customers, staff,
inventory, equipment– Involve customers in the process
5. Automate where possible– Bar coding, automated forms– Scheduling
23
Guiding Principles 6, 7, and 8
6. Standardize wherever possible7. Make it scalable, adaptable, flexible (for
new technology or systems)8. Assure accessibility of information, close
to point of service
24
Guiding Principles 9 and 10
9. Incorporate fiscal accountability– Define project as cost savings, revenue
increase, or “soft dollars” only– Take into account budget issues (ability to
add staff or equipment)10.Consider impact on current list of
precarious events/regulatory requirements
25
Stakeholder Analysis
Key Stakeholder
StronglyAgainst
Moderately Against Neutral Moderately
SupportiveStrongly
Supportive
26
Executives X
Administrators X O
Nurses X O
Physicians X O
Surgical Techs X O
Scheduling X O
Stakeholders StronglyAgainst
ModeratelyAgainst Neutral
ModeratelySupportive
StronglySupportive
Strategies to Improve Support and Reduce Resistance
Stakeholder & Resistance Analysis – Example
27
Three D’s MatrixApproach Examples
Data Charts, graphs, statistics
Demonstrate Show how project will positively impact people and processes
Demand Negative consequences if actions aren’t followed
28
Pay-Off Matrix
High payoff
Low payoff
Easy effort High effort
29
Common Tools & Underlying Principles
Tools• 5S• Kaizen “Blitz”
– Takt Time– Standard Work– Spaghetti Diagram– Load Leveling– Visual Controls– Mistake-Proofing
• Value Stream Map• Set-up Time Reduction
Principles• A bad process beats a good
employee nearly every time• Those closest to the problem
have the greatest knowledge• No excuses given or
accepted• Small, quick fixes add up
faster than than big, slow ones
• Improvement is the journey, not a destination
30
5S: Work Place Organization• Sort: separate locally
needed from unneeded items
• Simplify: establish a specific “home” for each item
• Sweep: throughout each day, constantly tidy the work place
• Standardize: ensure that processes are consistent among all
• Sustain: repeat the loop, always improving
2. Simplify
5. Sustain
1. Sort
3. Sweep
4. Standardize
31
Kaizen “Blitz”• Designated team attacks a specific “line of sight”
problem: throughput, cycle time, etc.• 2-3 days of learn-by-doing• Team sees tools and immediately applies them on the
specific problem• Report out with solutions
– Process managers attend– Solutions classified: immediate / medium term / long term– Every suggestion must receive response:
• Approval• Rejection with specific reason• Specific conditions needed before implementation
32
Takt Time• Lean strives to make each unit of work happen as identically as
possible• Takt time provides an ideal target for how often a unit of work should
be completed, using the formula below
• Available time: total minutes (or seconds) per day, during which workers are expected to be at their stations – leave out breaks, standard meetings, meals, etc.
• Demand: average number of times the process operates during a day
Takt Time =Available Time
Demand
33
Standard Work• If everyone does the “same” work his or her unique way, the
outcomes will experience unacceptable variation• Standard work identifies the best-current-knowledge way to
perform a process, and then ensures that everybody does it that way
• It works when those closest to the problem are given:– Accountability to develop and sustain standard processes– Guidelines to know what must never be changed (usually
outcomes, only occasionally procedures)– Tools & techniques to make it happen– Autonomy to implement changes that don’t require
additional resource– Support for changes requiring additional resources
• Standard work is developed by consensus, and then enforced strictly
• Improvements always permissible and encouraged, within the above guidelines
34
Spaghetti Diagram• Compelling map of movements
associated with a process– Can represent workers or the
“work” (samples, patients, etc.)– Be sure to show backtracking,
loops, etc.• Simple rearrangements can
lead to big improvements– Improved layout of work
stations– Identify where to keep physical
items• Example at right: fast food
35
Load Leveling• Try to ensure that work is spread out over a work period
to decrease overburdening, decrease fluctuations –balance is key!
• Example: Products B and C take longer to make/process than Product A
Product 1 2 3 4 5 6 7 8
A X X X X X X X X
B O O O O
C OO OO OO OO
36
Visual Controls
• Visual displays can make people’s jobs easier
• Images, not words• Simple is better
37
Mistake-Proofing• Simple tools to minimize
likelihood of errors– Usually < $100– Wait until root cause of
problem is known• Hierarchy of solutions
1. Eliminate step altogether2. Replace step with error-
proof one3. Design step to prevent error
from happening4. Detect error before it moves
on5. Mitigate impact of error
38
Value Stream Map (VSM)• Straightforward to create, a little complex to interpret• Includes process steps and much more:
– Queues– Times (value-added & NVA)– Usage rates– Shipment quantities & frequencies– Flow of information (orders, forecasts, etc.)
• Current State map exposes primary areas of waste• Future State map provides plan of attack for
improvement– Immediate / medium term / long term– Shows where further evaluation is needed
39
VSM Example: Insurance Claims
Future State
Current State
4040
Total Productive Maintenance
• Each operator is charged with maintaining their supplies and equipment
• Key issues in TPM– Preventive maintenance– Corrective maintenance– Breakdown maintenance– Maintenance prevention
• Six big “losses” in TPM: Equipment breakdowns, set-up and adjustment delays, minor stoppages, reduced machine speed, process defects, reduced yield
41
Quick Change-Over• Objective: minimize NVA time that customers,
equipment, or facilities are in transition between tasks
• Basic concept: classify setup tasks as “internal” or “external”– Internal setup: activities that happen when equipment
is out of service: cleaning rooms– External setup: activities that can be done while
equipment is actively in use: delivering or replenishing supplies
– Objective is to convert as much internal to external as feasible, and then to speed up remaining internal time
• Example: NASCAR pit stops
42
Productivity• Quick Change-Over• TPM• Spaghetti Diagram
Inventory Control• Just-in-Time• Load Leveling• Flow Processing• Kanban
Where to Start With LeanEnterprise Wide:Work Place Management:• 5S• Value Stream Map
Localized:Standard Work• 5S• Kaizen• Visual Controls• Mistake-Proofing
43
Elements for Successful Projects
• High frequency events (hourly, daily, weekly)
• Established measures and data collection• Narrow scope• Jurisdiction – authority to make changes• Significant business impact ($$,
satisfaction, growth etc…)
44
But What Is Really Needed?
• Support from Management
• Sponsor• Owner• The “right” team
45
Problems In Project Identification • Having a predetermined solution • Trying to make “everything” a project
instead of making reasonable or necessary changes (Just Do It)
• Projects that focus on improving inputs exterior to the department or company– Increases complexity and time for project– Great likelihood that solution may not be
implemented unless project partnering exists
46
Questions to Ask (and Answer)
• What concerns you the most about the current process?
• Why should we do this project NOW instead of later?
• How do we prioritize multiple projects?
47
Project Selection & Rating ToolDirections: rate each category on a 1 to 5 scale (see below for definitions). Add the category scores to get a final rating. The goal is to
get a project with the highest score.
Category Project #1 Project #2 Project #3 Project #4
Current performance gap (1 = gap is small; 5 = large gap with ideal performance)
Cost to business if NO changes made (1 = low cost; 5 = high cost)
Impact on customer satisfaction (1 = low impact; 5 = high impact)
Degree of waste (1 = little or no waste; 5 = lots of waste)
Customers can be defined (1 = not easily defined; 5 = easy to define)
Inputs can be identified (1 = hard to identify; 5 = easy to identify)
Outputs can be identified (1 = hard to identify; 5 = easy to identify)
Data is available (1 = difficult to collect or manual; 5 = easy to obtain, electronic)
Team needed to understand / identify solutions (1 = team NOT needed; 5 = team definitely needed)
Team has authority to implement solutions (1 = little or no authority; 5 = has authority to implement)
Manageable project scope (1 = very large scope; 5 = contained, narrow scope)
Alignment with Strategic Plan ( = not aligned; 5 = good alignment)
Total Score
48
Discussion• What is the process of project and
student selection at your institution? • How does project selection tie to the
strategic plan/business goals of your institution?
• What is the Executive Team’s role in project development?
• How are Sponsors/Champions selected, supported, and held accountable?
49
The Good, the Bad, and the Ugly
(Names have been removed to protect the guilty)
50
The Bad and the Ugly
• Not preparing the organization for change• Switching priorities (customer satisfaction
vs. saving/generating money)• Lack of accountability• “Flavor of the month” approach
51
The Good (to Great)• CEO and leadership engaged in rollout, project
selection, and accountable for follow-up• All leadership (managers and above) required to have at
least two-hour training session• All leaders required to participate in one project per year
as either Project Champion or “support” person• All employees required to attend at least 20-minute
introductory session• Core group of employees trained as project leaders• Broad-based, multi-modal communication plan• Semi-annual project fairs in public areas
52
Presentation Summary
• Much potential for a combined Lean and Six Sigma approach to projects – don’t forget to consider a “retooling” of previous projects
• Keys to success: manageable projects, the “right” people, management support
• Leadership support is critical no matter what the improvement methodology – are your leaders willing to ask and answer the tough questions?