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by David Brunt of Lean Enterprise Academy shown at the 2nd Lean Healthcare Forum on 6th June 2006 ran by the Lean Enterprise Academy www.leanuk.org
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Lean Enterprise Academy www.leanuk.org
David BruntJune 6th 2006
Mapping the End-to-End Process
Lean in Healthcare
Lean Enterprise Academy www.leanuk.org
Objectives
To give an overview of Value Stream Mapping
Lean Enterprise Academy www.leanuk.org
The Essence of Lean Thinking
Where is the time in your value stream?
The physical patient flow?The information flows – patient lists & notes?
“All we are doing is looking at the time line - from the moment the customer gives us an order to the point where we collect the
cash. And we are reducing that time line by removing the non-value-added wastes”
Ohno (1988-ix)
Lean Enterprise Academy www.leanuk.org
Value Stream Improvement & Process Improvement
Out Patients Pre-OpAssessment Procedure
CUSTOMER
RawMaterial
FinishedProduct
PROCESS PROCESS PROCESS
VALUE STREAM: All the steps, VA & NVA, required to bring the product from raw material to customer
Necessary but non value adding35%
Value adding5%
Non value adding60%
Lean Enterprise Academy www.leanuk.org
Out Patients Pre-OpAssessment Procedure
Value Stream Improvement & Process Improvement
CUSTOMER
RawMaterial
FinishedProduct
PROCESS PROCESS PROCESS
VALUE STREAM: All the steps, VA & NVA, required to bring the product from raw material to customer
Necessary but non value adding35%
Value adding5%
Non value adding60%
Focus of “traditional”efficiency improvements
Lean Enterprise Academy www.leanuk.org
Out Patients Pre-OpAssessment Procedure
Value Stream Improvement & Process Improvement
CUSTOMER
RawMaterial
FinishedProduct
PROCESS PROCESS PROCESS
VALUE STREAM: All the steps, VA & NVA, required to bring the product from raw material to customer
Necessary but non value adding35%
Value adding5%
Non value adding60%
Focus of LEANimprovement
Lean Enterprise Academy www.leanuk.org
Value Stream Mapping
Follow a product’s path from beginning to end and draw a visual representation of every process in the material & information flowsThen draw (using icons) a “future state” map of how value should flow
Helps us see flow
Hernia Current StateGP Practice
Lead Time = 65.5 daysProcess Time = 193 Min
5 Min 22 Min 32 Min
5 Min
7 Min
3 Weeks
70 Min
90 Min
20 Min
60 Min
12 Min
6 Weeks4 Weeks
Referral
OutPatient
Appoint-ment
Pre OpAssess-
ment
Admission(Day Case) Procedure Discharge Follow Up
National Choose & Book
Local BookingService
List 2 wksBefore
Appointment
18 Week target
Max 6 MonthsMax 13 Months
Patient
GetDate
Consultant Secretary
Letter to PatientLetter to GP &
Patient &Consultant
Letter to GP
Follow upDate
Daily List
Come In List
List 2 WeeksBefore
Appointment
Letter to GP
I I I I I I
ProcessBox
DataBox
Inventory
“Push”
C/T = 7 MinC/O = 0 min.Uptime = 100%2 Shifts27,000 sec av.
Lean Enterprise Academy www.leanuk.org
Using the Value StreamMapping Tool
Product Family
Current State Drawing
Future State Drawing
Work Plan
Understanding how the processes currently operate
Designing a lean flow
Deciding what to map
Lean Enterprise Academy www.leanuk.org
Deciding What to Map
The Glenday Sieve - A tool to helpImplement Every Product Every CycleIdentify product familiesRemove waste
Lean Enterprise Academy www.leanuk.org
The Glenday Sieve- first analysis
99%
95%
50%
Cumulative % Product Range
Cumulative % of Sales
Last 1%
Lean Enterprise Academy www.leanuk.org
The Glenday Sieve – second analysis
99%
95%
50%
Cumulative % Product Range
Cumulative % of Sales
Last 1%
Blue
Yellow
Green
ColourCode
Red
Lean Enterprise Academy www.leanuk.org
The Glenday Sieve & Value Stream MappingMap the “greens” because you want to make these flowWhich removes non value added wasteAsk questions about yellow, blue & red products
Can anything be done to include these in the “green stream?”
Lean Enterprise Academy www.leanuk.org
Focus on One Product Family
High volume low variety manufacturingDetermine product families via similar downstream “assembly” steps & equipment
“Every job is different” processesSieve & focus on tasks
Process Steps & Equipment
LH Steering Bracket
RH Steering Bracket
InstrumentPanel Brace
SeatRail
BumperBrackets
Electronic TestFixtures
AssyRobot Weld Flash Remove Paint Manual AssySpot Weld
X X XX
X X XX
XXX X
XX
XXX
Prod
ucts
Lean Enterprise Academy www.leanuk.org
Current State Drawing
Material & information flowsDraw using iconsStart with the “door to door” flowHave to walk the flow & get actuals
No standard timesDraw by hand, in pencil
Foundation for the Future State
Product Family
Current State Drawing
Future State Drawing
Work Plan
Understanding how the shopfloor & offices currently operate
Lean Enterprise Academy www.leanuk.org
“Healthcare” Data Set 1
Demand (Green Stream)
Local Anesthetic Cystoscopy = 15%
General Anesthetic Cystoscopy = 11%
Hips/Knees Arthroscopy = 9%
Hernia & VVS = 7%
LA Lumps & Bumps = 4%
Lower GI Endoscopy = 3%
Carpal Tunnel = 3%
Process Steps: Following referral from a GP the patient goes through
the following steps:Out patient appointment
Pre-Operation Assessment
Admission
The Procedure
Discharge
Follow Up
Acme Healthcare Trust has a number of sites. The case concerns an Elective only site. Analysis of the Green Stream shows that 5% of procedures account for 50% of demand.
Hernia Current StateGP Practice
Lead Time = 65.5 daysProcess Time = 193 Min
5 Min 22 Min 32 Min
5 Min
7 Min
3 Weeks
70 Min
90 Min
20 Min
60 Min
12 Min
6 Weeks4 Weeks
Referral
OutPatient
Appoint-ment
Pre OpAssess-
ment
Admission(Day Case) Procedure Discharge Follow Up
National Choose & Book
Local BookingService
List 2 wksBefore
Appointment
18 Week target
Max 6 MonthsMax 13 Months
Patient
GetDate
Consultant Secretary
Letter to PatientLetter to GP &
Patient &Consultant
Letter to GP
Follow upDate
Daily List
Come In List
List 2 WeeksBefore
Appointment
Letter to GP
Lean Enterprise Academy www.leanuk.org
Lean Enterprise Academy www.leanuk.org
Analysis
Workshop Theme:Lean Workshop
Workshop No. Team Date:
Slide: Of:
Team Members: Dept:Process:
Lean Enterprise Academy www.leanuk.org
Future State Questions
What is the Takt Time?Will we build to shipping or to a supermarket?Where can we use continuous flowWhere do we have to use supermarket pull systems?At what single point in the production chain do we trigger production?How do we level the production mix at the pacemaker process?What increment of work will we release and take away at the pacemaker process? (levelling the volume)
Supporting ImprovementsWhat process improvements will be necessary?(e.g. uptime, changeover & training)
Hernia Current StateGP Practice
Lead Time = 65.5 daysProcess Time = 193 Min
5 Min 22 Min 32 Min
5 Min
7 Min
3 Weeks
70 Min
90 Min
20 Min
60 Min
12 Min
6 Weeks4 Weeks
Referral
OutPatient
Appoint-ment
Pre OpAssess-
ment
Admission(Day Case) Procedure Discharge Follow Up
National Choose & Book
Local BookingService
List 2 wksBefore
Appointment
18 Week target
Max 6 MonthsMax 13 Months
Patient
GetDate
Consultant Secretary
Letter to PatientLetter to GP &
Patient &Consultant
Letter to GP
Follow upDate
Daily List
Come In List
List 2 WeeksBefore
Appointment
Letter to GP
I I I I I I
??
?
?
Green Stream Future StateGP Practice
Referral
OutPatient
Appoint-ment
Admission(Day Case) Procedure Discharge Follow Up
National Choose & Book
Local BookingService
List 2 wksBefore
Appointment
Patient
GetDate
Letter to GP &Patient &
ConsultantLetter to GP
X Days
F I F OX Mins
F I F OX Mins
F I F OX Days
F I F O
VisualUpfront Plan
ReduceVisits
BookFollow Up
BookAdmission
Green StreamFixed Plan
FilterPatients
Lean Enterprise Academy www.leanuk.org
A Plan to Get There
Don’t wait!To “manage the exceptions” you need a plan!
Tie it to your business objectivesBreak your Future State into “loops”Make a VS Plan: What to do by whenNow relate the Future State Map to your layoutValue Stream manager completes VS Review form in advanceConduct Value Stream reviews walking the flow
Implementation
Lean Enterprise Academy www.leanuk.org
Implementation via Point Kaizen
Process
PointKaizen
Eraser
Future State Map
Lean Enterprise Academy www.leanuk.org
David BruntJune 6th 2006
Mapping the End-to-End Process
Lean in Healthcare