Leadership institute lean kaizen briefing 8 16 13 handout

Introduction to Lean

Leadership InstituteLeadership Institute&&

Performance ExcellencePerformance Excellence

AgendaAugust 16, 2013

• Welcome, Objectives, Expectations• Lean Background/ History• Kaizen Overview• Lean in Healthcare• Dot Simulation 1 Exercise

• Value & Waste Overview• Kaizen Process• Lean Tools: Circle of Work / Spaghetti Charts• Lean Tools: TAKT Time• Lean Tools: Push vs. Pull• Lean Tools; 5S and visual controls• Kaizen: Observing the Current Process• Dot Simulation 2 Exercise

• Lean Tools: Set up Reduction• Developing the future state• Kanban and Single Point• Dot Simulation 3 Exercise • Creating a new Standard Work• Error Proofing• Dot Simulation 4 Exercise

• Dot Exercise Debrief• Summary and Wrap up

Session Objectives• Provide an Introduction to Lean• Identify Lean Principles• Define Value, Non-Value Added work

and Waste• Identify Lean applications in

healthcare• Apply the Lean tools within the

Healthcare environment• Provide a description and

understanding of Kaizen events

Kaizen Definition

Thoughtful Acts of Continuous Thoughtful Acts of Continuous ImprovementImprovement

To take apart and make new

To think about so as to help others

Eliminate WasteEliminate Waste

Solve ProblemsSolve Problems

If the first fix doesn’t work, try againIf the first fix doesn’t work, try again

Lean is …..• A set of operation concepts• A set of tools used in a variety of

industries – including service & healthcare to improve business processes

• A philosophy that helps drive efficiency and speed through employee empowerment and change at the grass root level

Benefits of LeanLean attacks waste in any process or value stream

•Higher customer satisfaction•Reduced cycles•Better delivery•More capacity•Better quality and safety•Improved productivity

History of Lean

• Lean Manufacturing began as the Toyota Production System (TPS)

• Lean came to the US in late 1980’s• Healthcare Providers (Early Adopters)

in the US began to embrace Lean Enterprise concepts about a decade ago

• Insurance Companies and Insurance Providers demanding that Healthcare Providers embrace Lean Concepts

Kaizen

House of Kaizen

Kaizen Training

10

Do MORE with LESS

Waste Productivity

Staffing Productivity

Kaizen Training11

Standards

Enforce Inspect

.

Stabilize

IdentifyWaste

Improve

Problem Solve

Standardize

• Process requires ongoing inspection and enforcement to ensure “Standardized Work” is being followed

• Process does not improve automatically

- Following standards will only maintain, not improve, the process.- Improvement focuses on the entire process.

Why does Lean apply to healthcare?

• Tools easy to learn / teach• Learn by doing• Easier to apply at frontline where work

is really happening vs. other methodologies

• Improvement occurs with the first application

Lean Opportunities in Healthcare

Emergency Reducing Wait Times

Surgery OR Throughput

Radiology MRI/CT Throughput

Admission Bed Turnover

Understand flow of materials, information and people through the hospital, then identify tasks or activities (operations) that improve or

hinder flow

1. Understand who the customer is 2. Solve the customers problem completely3. Understand the value you provide4. Manage by observation facts...do not make

decisions based on reports5. Involve people closest to the problem…team-

based environment6. Drive to root cause7. Try storm, take action now!!8. Standardize – Discipline9. Sustain through customer focused cycle time &

process metrics

Lean Principles

Break-out

Simulation

The Dot SimulationDemonstrating Basic Lean

PrinciplesBackground InformationYou are workers in the Outpatient Radiology department of a hospital. Using colored dots on a sheet of paper, we will simulate the major steps in processing a patient through a radiological exam.

Red Dots = ReceptionGreen Dots = RegistrationOrange Dots = Patient PreparationBlue Dots = Exam Yellow Dots = Check films

We will run four round of the simulation. At each stage, you will have opportunities to improve the process, using some of the Lean principles we’ve studies.

As you participate in the simulation, think about other hospital processes where these principles might help you reduce waste and improve efficiency; admitting a patient to a nursing unit, coding, documenting a patient’s chart, etc.

Intro to Overall Simulation

Care Process Templates

Dots:

Reception

Registration

Patient Prep

Exam

Check Films

Red Green Orange Blue Yellow Red Green Orange Blue Yellow

Completed Care

Patient Care process

Roles and ResponsibilitiesMaterials manager•Record the time on the batch when the process is started. Move the batch to Reception (Red Operator). Only send one batch at a time to the Reception•Stock Room Management: Give out dots when the process workers come to you. You may only give out one sheet of dots at a time and only when the process worker has a signed requisition form from a VP.

Process Workers (1 person per color)•Apply colored dots on the paper as indicated by the customer when a batch is received•Deliver it to the next station. Send only one batch at a time.•Get additional dots from stock as needed. Only one sheet of dots per visit to the stock room is allowed. You must obtain a signed requisition form from a VP to get a new sheet of dots.•Any defective batches returned to your station take first priority. They must be fixed and sent back through the process

Roles and ResponsibilitiesPatient / Inspector•Receives batches from Yellow Operator and inspects for meeting quality requirements. If the batch passes, records the time that a completed batch passed through inspection, places them in the completed bin, and tell the patient it’s ok to leave. (Write the completion time on the unit, fold the unit in half and place it in a location indicating that it has been finished). If the batch does not pass, take it back to the work station responsible for the problem. Keep a record of batches that were sent back to be fixed and batches that were accepted using the inspection sheet.Recorder•On the flipchart, track the Inspection Sheet data and the Process metrics for each of the rounds

Simulation Round 1• Run for 5 minutes• Colors must be applied in sequence – first Red, then

Green, Orange, Blue, and Yellow• No process changes allowed during the round – we

want to understand and baseline the current process• If the process workers run out of dots, they must

complete a Materials Requisition Form and get it signed by a VP before requesting more dots from the Materials Manager

• When Reception (the Red Operator) finishes a batch, he / she must ask the Materials Manager for a new batch

Have Fun!!

Report Out

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SHIFT MINDSET

CURRENTTHINKING

REQUIRED

THINKING

WASTE NOT DEFINEDREACT TO LARGE EXAMPLESREACTIVE IMPROVEMENT

WASTE IS "TANGIBLE”IDENTIFY MANY SMALL OPPORTUNITIES -LEADS TO LARGE OVERALL CHANGECONTINUOUS IMPROVEMENT

WASTETYPES

OFWASTE

Correction

Processing

Motion

Waiting

Inventory

Transportation

Over- Production

Value and WasteValue

•An activity that the customer is willing to pay for•An activity that physically alters the existing state •Who are your customers•What is “Value” for YOUR customer

Waste (Muda)•An excessive or unwanted step, resource, motion, etc.•8 types of Muda

– Defects - Waiting– Overproduction - Transportation– Motion - Over processing– Resources (Inventory) - Under utilization

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Some examples NVA Activities:

WalkingWaiting on test results

Transporting parts

Generating useless reports

THE GOAL IS TO ELIMINATE THE THE GOAL IS TO ELIMINATE THE NON-VALUE ADDED ACTIVITIES.NON-VALUE ADDED ACTIVITIES.

Unnecessary motion

Unnecessary stock on hand

To determine if a process step or activity is VA, NVE or NVA….

Ask:If we stop doing _____task, would our end customer (patient) care?

If “YES”, then it is Value Added (VA)

If we stop doing ____task, would our internal customers or key stakeholders (Physicians, nurses, administration, regulatory agencies, etc.) care?If “YES”, then it is Non Value Added Essential

(NVE)

If the answer to both of these question is “No”, then it is Muda (Waste / NVA)

Kaizen Event Phases

PLAN

• Business Case Metrics

• Scope • Executive

Sponsor• Event

Owner• Team

Leader

PREP

• Observe Work / Flow

• Lean Tools• Team

Members• Support

Functions• Process

Metrics• Finalize

Business Case Metrics

• Approvals

EVENT

• Business Case• Training• Current State• Future State• Test /

Implement• Action Plan• Communicatio

n Plan• Metrics

FOLLOW-UP

• 30/60/90 Day Plan

• Daily Mgmt• Gemba

Walks• Measure

Impact

I II III IV

Kaizen Process • Selecting Projects• Setting Goals• The Team Leader and Team• Support and Infrastructure• The Kaizen Blitz Steps

– Set the scene (Document current reality)– Observe the current process (ID waste and

countermeasures)– Develop the future state process – Implement the new process (Make & Verify

changes)– Report and analyze (Measure results, Create

new standard work)• Potential Roadblocks

Scale for rating each criteria

0 if there is no impact 1 for low correlation 3 for medium correlation 9 for a high correlation






Pre-Event Preparation1.Describe the opportunity

A. Stakeholder analysisB. Define scopeC. Planning

2.Team selection and training3. Have your targets set4. Select Team leader5.Set event objectives tied to your

company’s goals6. Complete Kaizen Event Charter

Lean Six Sigma Project Charter

Title: Reduce Scrapped Cookies in NW Region BB/GB: B. Thornton

Business Gap

Defects & Metrics

Problem Statement

Team: B. Thornton (BB), A Yamoto (Process Owner), W. Houston (SME), P. Smith (SME), G. Hines (SME), L. David (SME)

Champion: T. Wong

Project Scope/Boundaries:

Process Start: Mix Ingredients Process Stop: Bake CookiesIn Scope: Chocolate Chip Cookies in all NW Bakeries Out of Scope: Packaging

Milestones/Timeline: Scheduled ActualDefine Tollgate Review: June 4, 2007 6-4-07Measure Tollgate Review: July 9, 2007Analyze Tollgate Review: August 13, 2007Improve Tollgate Review: September 10, 2007Control Tollgate Review: September 24, 2007

Customer

Objective Statement

Our bakeries scrap approximately 25% of all cookies baked. Scrapped cookies limit our ability to remain profitable while we are being pressured to reduce prices by our competitors. Scrapped cookies have always been an issue and it has become worse since new ovens were installed. Based on a Pareto Analysis we will focus initially on the NW Region.

External: Grocery Stores, Consumer

Internal: Regional General Manager

Defects: Scrapped CookiesPrimary: Scrap Rate for Cracked Chocolate Chip Cookies (CCCC)Secondary: Returns dues to CCCC’sConsequential: Taste, Chewiness

The scrap rate due to cracked chocolate chip cookies in the NW bakeries was 15% for the past 12 months based on daily scrap reports.

Reduce the scrap rate due to cracks from 15% to 8% by 11/12/07 as measured by the daily scrap report

Financial Impact$204,400 in direct savings based on current production rates

© BMGI. Except as may be expressly authorized by a written license agreement signed by BMGI, no portion may be altered, rewritten, edited, modified or used to create any derivative works.

Problem vs. Goal Statement

The purpose of the Problem Statement is to describe what is Wrong

The Goal Statement defines the Team’s Improvement Objective






Forming a Kaizen Team

Team member considerations:• Effective problem solvers• Team players• Open minded• Be aware of:

– CAVE

Kaizen TeamsSkeptics vs. Critics (CAVE)Skeptics vs. Critics (CAVE)

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Steps on Team Development

FormingForming This is the development of a multi-functional team with a variation of backgrounds and knowledge

NormingNorming Stage where the group agrees how to operate as a team

StormingStorming Open & honest discussion, also brainstorming

PerformingPerforming Agreement on solutions & taking action

AdjourningAdjourning Closing on the continuous improvement process after 30 days

Document Reality

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Kaizen NewspaperKaizen NewspaperAdd problem when you Add problem when you find themfind them

Responsibility listResponsibility list

Due dates for Due dates for completion completion

Use as a to-do list during eventUse as a to-do list during event






Go to the Gemba

ManagersMust Not Must Do

Give Up

Flex Muscle

sThrow Fits

Blame the

workers

Blame the

measuresShow boatCover

UpGame the measures

Throw people at problemsStress out

Hide in the

office

Create smoke screens

Grovel Be clueless

Think of at least 7 ways to do better

Kaizen your standard

work

Observe the process

Find the waste

Have a vision

Provide the right tools

Set goals

Communicate direction39






LEAN EXAMPLESTART

Document RealityVerify how are the processes done todayVerify how are the processes done today– What’s really happeningWhat’s really happening– See it for yourself (Walk the Gemba)See it for yourself (Walk the Gemba)– Target sheets, area profilesTarget sheets, area profiles– 5S Audits, Safety Audit5S Audits, Safety Audit

How does it work todayHow does it work today– Spaghetti Chart, Standard WorksheetSpaghetti Chart, Standard Worksheet– Layouts, DocumentsLayouts, Documents

What happens in this processWhat happens in this process– Photos, Time ObservationsPhotos, Time Observations

Document Reality

Circle of Work – Process Analysis

Circle of Work analysis is crucial1)to establish your baseline for the Lean project and 2)quantify improvements after change have been implemented.

Key points to remember

•Make sure all key elements of the process are included and a representative, reasonable time period observed

•Ensure the observer is familiar with the process and can identify all activities

•Use observation for single workers, work sampling for multiple workers and overall worker / equipment utilization

Spaghetti Chart

An important aspect of the Circle of Work analysis is to visually depict the flow of work from the perspective of the worker and / or product. The standard sequence of work chart, also know as the “Spaghetti” chart, accomplishes this objective.

Key aspects of the Spaghetti Chart are:

•A diagram that shows the motion of the patient / family / caregiver / supplies throughout the course of care.

•A visual representation of the amount of travel involved for an activity to be completed and the number of locations involved

•A Spaghetti chart will include the total distance traveled (in feet)

•Spaghetti charts are created BEFORE and AFTER improvements are made in order to document success.

Document Reality

Standard Work SheetStandard Work Sheet

(Spaghetti Chart)(Spaghetti Chart)• Operator path in RED• Material path in BLUE• Safety YELLOW• Quality GREEN

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Be consistent with colors and symbolsBe consistent with colors and symbols

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What is TAKT Time?

TAKT is used to “set the pace” of the operation such that it takes place at the rate at which the customer “PULLS” from you.

By determining TAKT, you can adjust your offerings so as to add or reduce capacity.

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Single Piece Flow

Single piece flow is the basis of TAKT time

Single piece flow: Completing the process from start to finish continuously

Batch Process Single Piece Flow

How many do you have? You have only one.

Where are they in the process? You know where it occurred.

What is the root cause? Resolve the root cause immediately.

The next process step is the customer……. …..never send defects!!

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TAKT Time CalculationAvailable Time (seconds) / Period

Total Units of Customer Demand / PeriodTAKTTAKT

Available Time / Period (one shift):

Breaks - 2 @ 15 minutesShift Time ( 8 hrs. )

Total Time Available:

- 30 mins.480 mins.

450 mins.

Units Required / Period (one shift):10,500 Units Sold Monthly

21 Working shifts / month

or 27,000 secs.

500 Required units / shift

TAKT Time:TAKT Time: 27,000 secs / shift500 units / shift

54 secs.

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Line BalancingBy redistributing some of the tasksin Step D to A, B, and C…

…we can easily identify our target for Improvement. If we reduce the cumulativecycle times for all the steps by 12seconds, we can potentially reduce fromfour steps to three.

Takt Time

FlowMovement of patients / products, services and information down the value stream.

Objective is a continuous flow as patient / product, service and information is transformed by continuously adding value.

Flow is created by eliminating queues and stops, and improving process flexibility and reliability.

Pull

End customer pulls product / transaction through the value stream.

Each step pulls the product / transaction when needed from the preceding step.

Only the amount required is taken.

No action is taken until the downstream process initiates it.

Push vs. Pull

A Fundamental Lean PrinciplePush Principle – Admitting or feeder units

say: “We have a patient and need a bed”

Pull Principle – Floor Nurse says:“We have a bed and we need a patient”

We always seek to eliminate waste, establish flow and create a pull system

5S System and Visual Management

Maintain and improve sort, set-in-order, shine, and standardize

SortSort Separate the needed items from the un-needed items which are then removed to a "red-tagged" location

Set InSet InOrderOrder

Arrange remaining items in the way in which they will be used

ShineShineMaintain the work area for the already sorted and set-in-order items

StandardizeStandardizeEnsure sort, set-in-order, and shine are consistently followed across all users

SustainSustain

5S5S

SortWhen in doubt, remove it!• Segregate what is needed and what is not needed, discard what

is not needed.

• Use “Red Tags” to make it easy to reduce clutter.

• Note that “remove” does not mean dispose of. Unneeded items that may have some value are moved to a holding area for disposition.

STEP 1: Clarify what is needed.STEP 2: Dispose of things that are not

needed.STEP 3: With items that are needed,

segregate according to frequency of use.

Set in OrderA place for everything, and everything in its place.

• Clearly mark and arrange everything neatly so what is needed can be easily found.

• With unnecessary clutter removed, the team determines appropriate locations for items that are needed to “add value”.

• After repositioning items and tools, the team applies temporary labels, signboards, and positions.

STEP 1: Decide place for storageSTEP 2: Set up markings (Boundary Lines)

for storage locationsSTEP 3: Mark items to be placed for storageSTEP 4: Use ingenuity to make maintenance

easy

ShineClean to inspect, inspect to detect, and detect to correct.

• Clean up personal and working environment so there are no areas untidy with dirt or other clutter.

• Top to bottom cleaning and inspection.

• By touching and observing equipment as they clean, team members can spot early signs of trouble before they cause break downs, accidents, and defects.

STEP 1: Conduct overall ‘Shining’STEP 2: Maintain cleanlinessSTEP 3: Improvement plans to prevent dirtinessSTEP 4: Efficiency plan for sustained improvement

StandardizeYou can see the perfection !

• Maintain the conditions of Sort, Set-in-Order, and Shine

• Turn proven temporary methods for keeping the work place uncluttered into permanent “VISUAL” methods that make new standards obvious to everyone.

SustainSustain the Gain. Pride of ownership!

• Adhere faithfully to the decisions that have been made.

• Communicate and maintain practical approaches for improved workplace conditions.

• Spread the activities and pride of ownership to all levels and areas of the company.

What is Visual Control?

• The visual control method is based on the 5-S System

• Order is established with visual control• Because it impacts us directly, a visual

control is considered aggressive in its approach to adherence

• Visual controls can be very important as a tool for error proofing and should always be considered in a brainstorming effort

Examples of Visuals

Status Board

Work GroupDisplay Boards

OR in Use

Prep Next Patient

OR Ready

Indicator Lights

Direction of Flow Indicators

Gages showing Normal

Operating Range

Fluid Markings

Process Control Boards

Color Coding of Patients

Standards not followed are not standards.

the lean proverbs






Waste can multiply itself like rabbits.

the lean proverbs

Identify Waste

• Remember the 8 Wastes– Anything that doesn’t add value to the

customer

• Once identified make sure event scope is correct

– Ok to change, make sure everyone knows

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5 Whys• When problems are found

– Find the root cause by using the 5 whys

Asking why opens the mind to new causes.

the lean proverbs

Countermeasures• Solutions need to be

implemented during the week

• Try it out – action versus analysis

• Creativity before capital

• Continuous strive to reduce waste, no matter how small it is

• Attack items that impact– Process flow– Material flow– Information flow

• Solutions strive for– Takt– Flow– Pull– Lower Inventory

Kaizen• Just do it!

– Action over analysis

• Improving specific piece – The Value Stream– Company goal

• Manage to completion

Spirit of Creativity - A “McGyver” Capability

Symptoms to solve is little to resolve.

the lean proverbs

Section Review• Value• 8 types of Waste• Kaizen Process• Problem Statement• Selecting Team• Process Mapping – Spaghetti Map• Takt Time• Single Piece Flow• Push vs. Pull• 5S• 5 Why’s

Break-out

Simulation

Simulation Round 2• Run for 5 minutes• Colors must be applied in sequence – first

Red, then Green, Orange, Blue, and Yellow• You may redesign the work layout – you

will have 10 minutes to do this. Work layout changes must be approved by a VP. Flipchart your changes to facilitate approval by a VP

• You may not change the job descriptions of any of the process workers

Report Out

Examples of Set-up / Changeover Activities

There are numerous examples of set-up / changeover activity in healthcare, primarily for procedures and treatments:

•Starting / Removing IVs for patients•Transporting patients in and out of rooms•Verifying MD orders•Staff understanding what procedure needs to be done and how to do it•Placing/securing/aligning patients on a table/bed and then removing them•Ensuring supplies and instruments are available and ready before procedure or treatment begins•Equipment readiness•Interviewing patients regarding H&P information

Reducing Set-up TimeSet-ups are categorized in four phases•Preparation•Change / loading or unloading•Adjustment / Alignment•Inspecting and / or securing

Set-up reduction minimizes the amount NVA time devoted to these activities

Set-Up Reduction

As previously indicated, the set-up / changeover would include:

•Any preparation•Tearing down or cleanup of previous job, patient, procedure, etc.•Searching for equipment, supplies, information•Moving/transporting•Testing/calibrating equipment•Performing trial runs•Making further adjustments

Setup

Finish “A”

- - - - - - - “A”

Begin “B”- - - - - - - “B”

Set-up time is the time from the last step of the previous item, service or run to the first step of the next.

Process for Set-up Reduction Analysis

The process for analyzing set-up (or changeover) reduction analysis is as follows:

1.Identify all tasks associated with the set-up or changeover

2.Classify activities as happening while a process

3.Record the time associated with set-up activities

4.Associate all tasks with the four categories previously stated – preparation, changeover (loading/unloading), adjustment/alignment, inspection or securing

5.Brainstorm ideas to eliminate NVA time (i.e., maximize room or equipment utilization) and minimize overall set-up activity

6.Quantify the improvements

7.Develop new standard work (SOPs) for the implemented changes

Set-up / Changeover Improvement Ideas

When examining the categories of set-up / changeover (preparation, changing, adjusting, secure/inspect), there are several common flags or opportunities to look for:

•Alignment / Adjustment time: any type of alignment or adjustment of patients or equipment should automatically be considered a flag for evaluation, since they are typically non-valued added tasks. Analysis of equipment options (e.g. guide pins, blocks, scales) or some 5S type controls for patients could provide viable solutions.

•Securing / Inspection time: regarding equipment, consider available options (e.g. Velcro vs. screw type restraints), while with patients evaluate repeatable or duplicative tasks (tests, vital signs, etc.). Multiple approvals or assessments should also be evaluated.

The goal should be to maximize room and/or equipment utilization.






Make Changes• Make the changes – NOW!

– Don’t get stuck waiting for a better time– Make the changes then observe them

• Pre-plan for large moves before the event

• Everyone needs to contribute– Don’t dictate, build teamwork

• Make sure you update the newspaper

Verify Changes• Verify with new observations• If it’s not easier, make more changes• Goal is to put new process in place

and verify it– Do this early in event to allow time for

more changes– Make sure a better process is working

at end of event






Kanban DefinitionA Japanese work that means “signboard”

•In a Lean enterprise, it’s a signal authorizing production or delivery of required materials. The signal is initiated by consumption from an upstream process

•Allows a just-in-time (JIT) environment to be set up but it requires:

– Level Production

– Pull

– Defect Free Products

•A Kanban is a high-level tool that is implemented after solving many problems

Kanbans route information in a pull systemSupermarkets provide material for a pull system

Measure Results• Compare results with baseline data

– Did we make it better?– Was waste removed?

• Did we achieve what we wanted to?

Not all changes are successful.Not all changes are successful.

Don’t worry.Don’t worry.

Learn from what we’ve done!Learn from what we’ve done!

Improvement IdeaDate: __________

Kaizen Title:____________________ Team #: ____________ Completed By: __________________________

Description of Problem: Description of steps taken: Results:

Before Kaizen After Kaizen

Remarks:

The lift truck cords were continually being left on the floor causing delays and damage.

A cord retractor was installed at each rechargestation.

Prevents damage to plugs

Eliminated trip hazard

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Single Point Lesson

Water cooling lines• Mistake proofed fittings• Hoses can only be hooked up one way

– Simple fix, no money spent, just switched fitting from hose to fixture

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Mistake proofed is mistake’s pain missed.

the lean proverbs

Section Review

• Reducing Set up Times• Making Changes• Verifying Changes• Kanban• Measuring data

Break-out

Simulation

Simulation Round 3• Run for 5 minutes• Colors must be applied in sequence –

first Red, then Green, Orange, Blue, and Yellow

• You may not change the job descriptions of any of the process workers

• The Department Director has decided to institute a Kanban system. The VP or facilitator will explain Kanban

• In your group, apply the concepts of Set-Up Reductions

Report Out

Create New Standard

• Put new visual standard work in place– Maintain progress made during event– Training tool– Should be understood by anyone observing the process

• Post all open action item on the Kaizen Newspaper– Make sure all items have a name attached to them– Follow up to make sure they get completed

• Visually display what has happened in the area• New process must be repeatable and sustainable

– Try it out during the week!!!

Celebrate

Standard WorkWhat is “Standard Work”?

•For a given process, it is having every activity done in the same sequence and manner every time with the least possible amount of time in order to meet customer specifications. It is the most effective combination of activities that will minimize non-value-added activities while providing the highest quality of care.

•For the process workers, it is knowing what to do, how to do it, and when to do it every time the process cycle occurs

•For the process non-labor, it is having the right supplies and equipment available when they are needed and in the right quantity (Just-In-Time).

Without standard work, there can be no continuous improvement - it is the basis for Lean

transformation

Standard Work – Healthcare Examples

• Clinical pathways, protocols, practice guidelines for disease state or DRG management

• Standard Operating Procedures(s) for a treatment or case, including patient prep and discharge

• Organizational Policy and Procedures – departmental or hospital wide

While we can see from the above that standard work has existed to some degree in healthcare (but not necessarily successfully), it is not even remotely close to where it needs to be for us to meet the challenges in the years ahead

Standard Work – Critical Components

Implementation of Standard Work involves five steps, all of which incorporate numerous lean tools. The five steps are:

•Evaluate the current situation•Identify areas of opportunity•Modify the existing process•Substantiate and enumerate improvements•Implement the new standard work

Standard Work - Evaluation

Evaluating the current situation of the process will involve the use of several tools discussed thus far:•Observation – time value analysis (TVA). Note times, dates, and any specific circumstances involved with the observation•Spaghetti diagrams•Forms – time observation sheet•Determine current line balance of the process (Takt time of the process applied for each process step).

Standard Work – Identify Opportunities

Examples of the 8 Wastes:Defects: Medication errors, wrong site surgery

Over Production: Preparing IV’s ahead of time

Transportation: Transporting lab specimens, patients

Waiting: Waiting for bed assignments, treatments, discharge orders

Inventory: Lab specimens, supplies

Motion: Searching for charts / supplies

Processing extra: Excessive paperwork, unnecessary tests, using IV over oral meds

Under-utilization: RNs doing non clinical paperwork; CPAs doing basic G/L work, idle equipment

Standard Work – Modify the Process

In this step, Lean tools are employed to change the process and make improvements:•Brainstorming•5S•Visual controls, indicators, signals, guarantees •Line Balancing•Leveling•Quick changeover – setup reduction

Standard Work – Piloting Process

Attempt to conduct a pilot of the process changes first before full implementation in order to demonstrate the feasibility and success of the changes

In a Lean Kaizen event, this is normally the “Trystorming” phase. This occurs quickly in the process, and team participants will in real time make whatever changes are needed based upon feedback from workers in the process.

If a pilot cannot be conducted and full implementation is required for the process, ensure that careful monitoring exists and that changes can be made to the new process if warranted.

Standard Work – Implement New Standard

In order to fully implement new standard work for a process, the following steps need to be taken:

•Training of all personnel affected by the changes must take place through formal verbal communication and written documentation. Install as many visual indicators, signals, or controls as possible to help facilitate understanding and compliance.

•Objective, quantifiable measures (if not done previously in the project or Kaizen) must be created to monitor worker compliance and to determine if improvement is continuing to occur. Monthly or quarterly reports to management should be a norm.

Error - ProofingA technique for eliminating errors

Making it impossible to make mistakes

In Japan: Poka-Yoke. Poka means an inadvertent mistake. Yoke means to prevent

It is good to do it right the first time: it is even better to make it impossible to do

it wrong the first time.

Poke YokePoke-Yoke (pronounced Po-Ka Yo-kay) – stands for mistake –proofing

Usually the physical alteration of a devise or process so as to guarantee only one way (the right way) to carry out a task.•Electrical sockets – only one way to plug in•Petrol vs. diesel spouts at a gas station – a diesel nozzle will not fit into a petrol gas tank

Medical examples of Poke-Yoke:•Anesthesia gas equipment – port valves only designed for correct gas tubing (e.g. oxygen tubes can only fit on oxygen ports of the anesthesia equipment)

Error-Proofing Techniques

Technique Prevention Detection

Control (Shut Down)

An error is impossible

Defective item can’t move on to the next step

Warning An error is about to be made

An error has been made

Errors may either be prevented or detected

Why Do Errors Occur?• Incorrect or non-existent procedures• Overly complex processes• Excessive variation in the process• Excessive variation in the inputs• Inaccurate measuring system• Human error

Human Error Provoking Conditions

1. Adjustments2. Unclear or no instructions3. Undefined process 4. Many units/mixed units5. Multiple steps6. Infrequent production7. Ineffective or lack of standards8. Multiple handoffs9. Hand processing10. Rapid repetition11. High volume demand or deadline pressures12. Environmental conditions

Robust processes reduce Human Errors!

Three Inspection Methods• Traditional inspection (end of the process) – discovers

defects– Sort “good” from “bad” at the end of the process– Measure “Y” into categories (good/bad)

• Informative inspection (during the process) – reduces defects– Use process data to control/correct the process (e.g.

Statistical Process Control Charts)– Measure “Y” for variables information to control “Y”

• Source inspection (before the process) – eliminates defects– Inspect for error producing conditions in the process.– Measure and control “X’s” to create good “Y’s”

7 Steps to Error Proofing

1. Create a process map and identify the locations at which the defects are found and made

2. Evaluate current procedures for adequacy and determine if they are being followed

3. Identify defect provoking conditions at each process step

4. Identify the root cause(s) (error) of each type of defect and in which process step it occurs (FMEA, 5 Whys, Cause & Effect Diagram)

5. Identify the type of error-proofing device or process required (Brainstorming)

6. Create the device or process and try it

7. Measure for effectiveness

Section Review

• Standard Work• Error Proofing• Poke Yoke• Inspection Methods• Visual Controls

Break-out

Simulation

Simulation Round 4• Run for 5 minutes• Colors must be applied in sequence – first Red, then Green,

Orange, Blue, and Yellow• Great news! The hospital has gained such a reputation for

efficient and patient friendly operation that the department’s volume is expected to increase sharply. Your VP will tell you what volume you will need to handle during this round

• The Department Director recognizes that in order to meet the increased demand without adding staff, the department will have to operate more efficiently. She suggests that you may want to make additional improvements by redesigning the job descriptions. You will have 10 minutes to redesign the jobs, train everyone and rearrange the work layout as needed to accommodate the new roles.

• In your group, apply the concepts of Standard Work and error proofing to your simulated process

Dot Exercise Debrief

• What are the “Lessons Learned”?• Can you Apply these “Lessons

Learned” to your area?

Kaizen not maintained dissipates like smoke.

the lean proverbs

Lean Summary• Linking value stream map, cycle time analysis and

value analysis creates a compelling business case for change

• Making the process visible highlights potential problems and sources of variation

• Evaluate the flow through the operations to determine what hinders the flow

• Use the best tools available to help identify solutions / improvements (e.g., process maps, C&E diagrams, brainstorming, etc.)

• The leveled schedule and process sequencing should allow for the process flow to be paced according to customer demand

• TAKT is used to set the pace of the process step• Use Lean and Six Sigma tools in combination and / or

alone to solve your process problems

WebsitesPerformance Excellence Website (go live 8/20)Free Lean Six Sigma & Kaizen forms / images:

www.bmgi.org http://www.youtube.com/watch?v=wfsRAZUnonI

http://www.youtube.com/watch?v=lwWI-3z1wZ0

Pull system

Total Productive Maintenance

Total Preventive Maintenance

Value stream analysis in healthcare

Push system

Gemba kaizen Continuous Improvement

Kanban and Pull systems

Kanban

Lean kaizen Lean six sigma 5S Lean Visual Controls

Problem solving Value stream analysis 5S visual controls OEE

PEx Website (Online 8/20)

http://inside.uams.edu/performance-excellence

The End

What questions do you have?

Technology

Leadership institute lean kaizen briefing 8 16 13 handout