Lean transformation; finding the balance between tools and people

Cellular Pathology, Royal Victoria InfirmaryCellular Pathology, Royal Victoria Infirmary

Terry Coaker, Terry Coaker, Histopathology Operations Manager

27th May 2011

Cellular Pathology, RVI, Newcastle 1981: RVI 9,700 requests per annum 1995: NGH acute services 1996: NGH histology 1997: Dental Hospital – oral pathology 2002: Freeman histology; muscle & nerve; cytology decant 2005: Histopathology decant – 42,000 pa 2007: Lean tools – examination phase2007: Lean tools – examination phase 2008: Neuropathology decant 2009: New building (planned 2004) – 47,000 pa 2009: Pre-examination phase2009: Pre-examination phase 2010: People2010: People

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Drivers for change

Lord Carter 20% reductionLord Carter 20% reduction Modernising Scientific CareersModernising Scientific Careers Private sectorPrivate sector NHS ModernisationNHS Modernisation Improve the serviceImprove the service

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Cytology Improvement Guidehttp://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?path=Cardiac%2FNational%2FWebsite%2FDiagnostics%2FCytology_14day_TAT.pdf

Cytology 14 day TATCytology 14 day TAT http://clinicalcytology.co.uk/resources/phttp://clinicalcytology.co.uk/resources/pdf/14dayturnaround.pdfdf/14dayturnaround.pdf

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HistopathologyImprovement Guidehttp://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?path=Diagnostics%2fNational%2fWebsite%2fHistology%20Guide%202.pdf

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Unconscious incompetenceUnconscious incompetence

Conscious incompetenceConscious incompetence

Conscious competenceConscious competence

Unconscious competenceUnconscious competence

Lean MethodsContinuous Improvement Toolbox

Value Stream Mapping

Pull Systems

5S System Layout

Setup Reduction

Teams

Visual Controls

POUSStandardized Work

Quality at the Source

Continuous Flow

Work CellsPerformance Measurement

TPM

Batch Size Reduction

Lea

n T

oo

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A lean transformation must keep an even balance…..

‘Tools’

TECHNICAL

‘People’

CULTURAL

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Too much emphasis on tools and methods….

Extensive use of “tools”Use of Japanese terms and conceptsSome processes made more efficientLean belongs to a few enthusiasts

TECHNICAL

Failure to embed or spreadResistance to changeResults not sustainedNo overall transformation

CULTURAL

27th May 2011

If Cultural concerns predominate….

Failure to establish flowLack of rigour in use of toolsLean “speak” without true understandingFull potential not realised

TECHNICAL Temporary feel good factor createdBetter teamworkIncreased levels of involvementBut hard to sustain without results

CULTURAL

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Peters and Waterman 1982““Managers themselves are the major barriers to Managers themselves are the major barriers to high levels of commitment on the part of staff.high levels of commitment on the part of staff.People come to work motivated and interested People come to work motivated and interested but they are soon alienated by the web of rules but they are soon alienated by the web of rules and constraints which govern their lives.and constraints which govern their lives.If only management could find ways to release If only management could find ways to release and tap employees creativity for example visa and tap employees creativity for example visa employee involvement, then their commitment to employee involvement, then their commitment to organisational goals would follow”organisational goals would follow”

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NHS Improvement

““We’re looking for exemplar sitesWe’re looking for exemplar sitesEr, no, not you !Er, no, not you !Q. What would make us an exemplar ?Q. What would make us an exemplar ?A. Staff engagement”A. Staff engagement”so…so…1.1. Visual Display Visual Display 2.2. Daily meetingsDaily meetings

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People Pitfalls

Managing from the officeManaging from the office Use all the brains in the DepartmentUse all the brains in the Department ““We are different”We are different” Not invented here Not invented here

e.g. COSHH, Quality and Leane.g. COSHH, Quality and Lean

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The Lean Leader

Go and SeeGo and See Ask WhyAsk Why Respect PeopleRespect People

Force ReflectionForce Reflection

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Re-organisation of meetings

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Weekly Huddle Review

Histology Performance

Spec Rec ICC General

Office

Cytology Slide

Production

? Medical specialty team ? Medical specialty team meetingsmeetings

Benefits

Daily ! Addresses issues immediatelyDaily ! Addresses issues immediately Clarifies dutiesClarifies duties Encourages feedbackEncourages feedback Staff know more about their roleStaff know more about their role OwnershipOwnership Motivating and enjoyable!Motivating and enjoyable!

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Visual Display

Slide Delivery

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Average number of cases delivered to Dr's Res. 25.10.10-20.11.11

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50

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70

80

90

100

09:00 11:00 13:30 15:30 16:45

Delivery time

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Monday

Tuesday

Wednesday

Thursday

Friday

Average number of cases delivered to Dr's Res. 07.03.11-08.04.11

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10

20

30

40

50

60

70

80

90

100

09:00 11:00 12:30 13:30 15:30 16:45

Delivery time

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Tuesday

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A3

One side of A3One side of A3 Pencil and eraserPencil and eraser Root cause analysisRoot cause analysis 5 Whys?5 Whys? Plan, Do, Check, ActPlan, Do, Check, Act 66σσ (Sigma) 3.4 defects per million opportunities (Sigma) 3.4 defects per million opportunities

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Six sigma

3.4 defects per million opportunities3.4 defects per million opportunities One SUI in 47 000One SUI in 47 000 One in 470 000 (10 years)One in 470 000 (10 years) One in 940 000 (20 years)One in 940 000 (20 years)

A3 PROBLEM SOLVING PROCESS – GO SEE, ASK WHY ?, RESPECT PEOPLE TITLE:WHAT IS THE PERCEIVED PROBLEM?IDEALLY FROM A CUSTOMER VIEWPOINT

1. BACKGROUND

WHY ARE WE TALKING ABOUT THIS PROBLEM? FOCUS ON THE CUSTOMER (Internal or External) BRIEFLY STATE HOW THIS PROBLEM IMPACTS ON THE PURPOSE

OF THE ORGANISATION & THE PROCESS GIVE RELEVANT BACKGROUND INFORMATION WHO ARE THE STAKEHOLDERS?

2. CURRENT CONDITION

WHERE DO THINGS STAND TODAY? USE DIRECT OBSERVATIONS & MEASUREMENTS GO SEE (where activity actually occurs e.g. laboratory, office etc.) REPRESENT VISUALLY – USE CHARTS, GRAPHS, DRAWINGS, VALUE

STREAM MAPS etc. BE OBJECTIVE,THOROUGH & SUMMARISE CONCISELY

3. GOALS & TARGETS

WHAT SPECIFIC OUTCOMES ARE REQUIRED?

4. ANALYSIS – WHAT IS THE ROOT CAUSE OF THE PROBLEM?

ASK 5 WHYS ?

AUTHOR:NAME:DATE:

Understand how the work is done‘GO SEE’

PRESENTING PROBLEM

CLARIFY PROBLEM

WHY? CAUSEWHY? CAUSEWHY? CAUSEWHY? CAUSE

WHY? ROOT CAUSE

Grasp the situation• Actual vs standard• Actual vs ideal

Establish ‘Point of Cause’Time and place where events cause

abnormality

5. PROPOSED COUNTERMEASURES

WHAT ARE THE POSSIBLE MEASURES THAT WILL ACHIEVE THE TARGET CONDITION?

ALWAYS CONSIDER A RANGE (OR SET) OF COUNTERMEASURES HOW WILL EACH COUNTERMEASURE AFFECT THE ROOT CAUSE? SELECT A COUNTERMEASURE (S) THAT BEST ADDRESSES THE ROOT

CAUSE

6. PLAN

IMPLEMENTATION OF CHOSEN COUNTERMEASURE(S) WHAT ACTIVITIES ARE REQUIRED FOR IMPLEMENTATION? WHO IS RESPONSIBLE & WHEN WILL THEY HAPPEN? DEFINE SPECIFIC PERFORMANCE INDICATORS & MILESTONES BE VISUAL – USE TABLES OR GANTT CHARTS

WHAT? WHO? WHEN? OUTCOME

7. FOLLOW UP

WHAT ISSUES CAN BE ANTICIPATED? CHECK OUTCOMES ARE BEING ACHIEVED. IF NOT, THEN CHECK TO

SEE IF CURRENT CONDITION [2] & ROOT CAUSE ANALYSIS [4] WERE CORRECT

CAPTURE & SHARE LEARNING – COMMUNICATE STANDARDISE TO MAKE CHANGE TO CURRENT CONDITION

– AMEND POLICY, PROCEDURES, SIGNAGE, TRAINING etc REPEAT THE CYCLE - PLAN DO

CHECK ACT

SPONSOR / MANAGER:NAME:DATE FINAL A3 APPROVED:

COMMUNICATECOLLABORATE

MENTOR & RESPECT

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People - Attitude curve

20

30 30

20Resistant

to changeRange of attitudes “Wait and see” “Show me”

Ready for change

“Lets get started!”

Innovators

Early adopters Early

Majority

Late Majority

Laggards

Rogers diffusion curve

18th June 2007

Kegan and Lahey

20

30 30

20Resistant

to changeRange of attitudes “Wait and see” “Show me”

Ready for change

“Lets get started!”

Dogs Horses Sheep Goats

The Lean Champion is a Farmer

18th June 2007

Lemmings

Jackals

Issues

‘‘No problems’ – is a problem!No problems’ – is a problem! DisciplineDiscipline Poor performance – must be addressed – Poor performance – must be addressed –

outside the huddle.outside the huddle.

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Gemba audits – What is the problem? Issues remain unresolvedIssues remain unresolved Not seen as the number one priorityNot seen as the number one priority Lack of time to investigate and fixLack of time to investigate and fix Superficial solutions – ‘sticking plasters are not ‘root Superficial solutions – ‘sticking plasters are not ‘root

cause’cause’ No clear ownershipNo clear ownership Med / tech barrier blocks communicationMed / tech barrier blocks communication Performance not reviewed (no huddle)Performance not reviewed (no huddle) What defines a good days work?What defines a good days work?

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Gemba audits - Actions

Open issues and outstanding CAPA’s Open issues and outstanding CAPA’s discuss at histo performance meetingdiscuss at histo performance meeting

Add “waste walks” to PI’sAdd “waste walks” to PI’s Define checklist of Gemba auditsDefine checklist of Gemba audits Define dashboard for auditDefine dashboard for audit Audit visual display boardsAudit visual display boards

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Gemba audits – The Future

Robust gathering of problemsRobust gathering of problems Speedy and binding resolution of issuesSpeedy and binding resolution of issues

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TAT February

0

5

10

15

20

25

30

Team

Day

s

95% 7.00 18.15 12.95 13.00 22.60 20.10 13.00 21.10 11.00 6.95 24.00 8.00 17.95 13.00 21.25

50% 3.00 3.00 4.00 5.00 7.25 7.00 5.00 9.00 5.00 3.00 7.00 3.00 5.00 4.00 7.00

BR CT GI GYN HPB LymphNeuro

MNOA OR Paed RE SK UR Histo

Total

Histo referral

3

75

27th May 2011

‘‘Not everything that counts Not everything that counts can be counted, can be counted,

and not everything that can and not everything that can be counted counts.’be counted counts.’

EinsteinEinstein

Cellular Pathology, Royal Victoria InfirmaryCellular Pathology, Royal Victoria Infirmary

Terry CoakerTerry Coaker

Thankyou

27th May 2011

…any questions ?

Also known as… Process improvement Re-engineering Continuous improvement Total Quality Management Six Sigma 3.4 DPMO– Motorola - DMAIC Lean – Toyota Common sense?!

27th May 2011