Lean for Non Profits - Full Presentation

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Lean for Non Profit Organizations

Sponsored by:American Society for Quality

Lafayette Section 0917

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American Society for Quality

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Your SpeakerBrian W. HudsonLean Six Sigma Coordinator-FSEHBSIT 1990 and MSIT 1995 from Purdue University

[email protected]

16 Years industrial experience as a Manufacturing Engineer

15 years experience with Lean Production and Six Sigma

Associations:United Way LCR 2012ASQ Section Program Chair and SecretaryWabash Valley Lean Network Steering CommitteeAmerican Heart Association Heart Walk Chair

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Today’s ObjectivesLearn ways to help our organizations be more

effectiveChallenge existing attitudes and processesIdentify improvement opportunitiesLearn by doingHave fun

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Ice BreakerWhat parts of your organization do you wish would be more efficient?

What gets in the way?

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Exercise #1

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Indiana General Hospital

The Story – Lean improvement in a non-profit environment – the Emergency room

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United Way Application ProcessShowing improved effectiveness in outcomesThe application process and showing outcomes for your work

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The feedback from you-The situation you are faced with:Greater need for our servicesMany cutbacks and things are getting

tighterThe needs of our customers continue

to increaseExpectation of showing outcomesDoing more with less

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Customers & Stakeholders What do they Value? Your Mission

The Vision for the Future

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Your MissionYour mission defines your organizations

reason for existence. It embodies its philosophies, goals, ambitions and morals.



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The Vision for the futureYour vision statement is your inspiration, the

framework for all your strategic planning.Addresses the questions

“Where are we headed”“Where do we want to go”



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Your Customers and StakeholdersWho are your customers?Who are your stakeholders?



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Customer ValueWhat do they value about your organization?How do you help them meet their need?How do you measure the value you provide?

#/countSatisfaction / surveyOutcomesOther

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Your Core Processes or SystemsWhat core processes does your organization

use to deliver the value to your customers?



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How does it work together?

Values

Vision

Mission

Strategic planand

Measures

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Your Resources to make it happenFinancialLabor / timeEquipment / Capital



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The WastesIdentify the things that take away from the

effectiveness of your processes and systems



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What do Patients of Indiana General value?Favorable patient outcomesTo be treated safelyImplement new procedures & capabilitiesSlow the rising healthcare costs

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Example: Waking up with a crushing headache before work

Wake up with painCall for appointmentGo to officeDo paperworkSee the DoctorDiagnosis: migraineGet a prescription

Finish paperworkGo to pharmacy Do paperworkPrescription filledReturn homeTake medicinePain subsides

How long between steps?

Which steps add value?How long is each step?

“You don't get paid for the hour. You get paid for the value you bring to the hour.” — Jim Rohn, entrepreneur

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The aim of Lean is to meet the customer need by understanding what they value, then providing that value in a system without

waste

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So then we ask-How do we create that value?What is it that gets in the way of value being

“created”How are we addressing the things that get in

the way?

The answers to these questions are the basis for continuous improvement!

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BreakWhat we do wellWhat we struggle with

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Improvement ApproachesWaste

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Waste Any activity that consumes resources but

creates no value for the customer

Waste can be identified as anything not adding value to the quality or delivery of the final product or service.

Anything our customers would not be willing to pay us to do

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Toast Kaizen VideoExercise #2Please takes notes on wasteful activities you see in your organization.

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Waste in HealthcareHow much waste is present in Healthcare?

"The national numbers for waste in healthcare are between 30% and 40%, but the reality of what we've observed doing minute-by-minute observation over the last three years is closer to 60%.”

Cindy Jimmerson, medical researcher

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Value-Added ActivitiesTransforming materials and information into

products and services the customer wants.

Creating a Birth

Certificate

Painting

Treating a Patient

Receiving a P.O.

Designing

Installing a Phone System

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Non Value-Added ActivitiesOperations that consumes resources (labor

and materials), but don’t add value for the customer.

Transferring Information

Moving

Re-enteringInformation

ReworkInspection/

Testing

Waiting

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WasteWaste is present in all work at all

organizationsThe identification of waste and its elimination

is the drive for lean processes and continuous improvement.

Recognizing waste in our organizations is the first and most essential step in transforming waste to wisdom.

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Identifying Waste

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Identifying WasteInventory

Any supply in excess of customer requirements necessary to provide service just-in-time

Organization Examples:Stock of formsSupply closets with excess suppliesOutdated items

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Identifying WasteMotion

Any movement of people or machines in excess of what is necessary to provide required services

Organization Examples:Traveling to get needed items or suppliesWalking across room to answer phoneTravelling to get the paperworkHunting for coworkers

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Identifying WasteOverproduction

Producing more than needed or Producing faster than needed

Organization Examples:Reports printed and / or mailed when not neededPrinting extra brochures to get cheaper pricePreparing more food “just in case”

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Identifying WasteOver-processing

Effort that adds no value to the product or service

Organization Examples:Redundant capture of informationOrdering unnecessary workupsData entry into multiple systemsDouble / Triple checking

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Identifying WasteTransportation

Any material or information movement in excess of what is required

Organizational Examples:Transporting items from location to locationEquipment moved to patient location Information triplicates

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Identifying WasteRework / Correction

Inspection and / or correction of information, products or materials

Organizational Examples:Fixing errors made in documentsMisfiling documentsDealing with complaints about service Mistakes caused by incorrect information Illegible handwriting

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Identifying WasteWaiting

Idle time when people wait for people, people wait for machines, or machines wait for people

Waiting accounts for 95% of the time that is required to produce a product or service.

Organizational Examples:Patient waiting roomsWaiting for call backsWaiting for drug validationWaiting for equipment or supplies

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We must always keep in mind that the greatest waste is waste we do not see!

-Shigeo Shingo

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5SHousekeeping and organization

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The goal of 5S training

To introduce participants to 5S, the benefits of workplace organization and provide

examples of successful workplace improvements.

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What is 5S? A systemized approach to workplace organization, to keep rules and standards, and to maintain the discipline needed to do a good job.

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Exercise - Handout

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Importance of 5SQuality is improved

Productivity in enhanced

Safer work environment for all

Reduced floor space

Reduced cost to operate

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The 5S’s

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SORTDefinition:

What is accomplished in this step:

Guidelines:

Information:

Identify and eliminate items that are not needed in the workplace

Take old, obsolete, and unneeded items out of thework area For each item ask:What is this used for?Who uses this?When was it last used?When and where do we use it?

Red Tag system for unneeded items

RED TAGThe Red Tag system

is a method used to identify items that are found in the work area, but their use and need are unknown or not needed

RED TAGItem Description

Reason fortagging

(circle one)

Manufacturer, partnumber, serial

number

Dispositioned byand date

Quantity andItem value

Disposal method(circle one)

Specialinstructions

1. Item not needed2. Excess material3. Material outdated4. Defective material5. Use unknown6. Other ____________________

1. Throw away2. Destroy-specify date:__/__/___3. Return to manufacturer4. Other ____________________

Contact person forquestions

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Additional Sort informationTake digital pictures of current state

before starting 5S activity.Establish an area, cart, or table as a red

tag zone.Place unneeded items in this area.Fill out red tags to determine

disposition.When finished with elimination, take

pictures of items accumulated in the red tag area

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SET IN ORDERDefinition:


Guidelines:

Information:

Arrange needed items so they are in good order and are easy to find, use, and put away

Designating a location for the needed items

Store commonly used items near the point of useInfrequently used items stored away from the areaOrganize commonly used items togetherLabel item locations

Red Tag system for unneeded items“A place for everything and everything in its place”

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SHINEDefinition:


Guidelines:

Information:

Clean, wipe, and sweep all of the surfaces in the work area. Paint if necessary.

Provide a baseline for keeping the area clean and organized in the future

Be safe!Understand how the area became dirty and take

steps to eliminate the causeCreate an area where cleaning supplies are kept

Not just cleaning–but seeing what areas are getting dirty

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STANDARDIZEDefinition:


Guidelines:

Information:

Develop a method and schedule to keep everything clean and organized

Standardize and maintain the use of the first 3 S’s

Develop standards to organize in a consistent mannerVisually maintain conditionsCreate a schedule / checklist to maintain the area

See next slide

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Standardize GuidelinesMake placement of equipment and

tools visual as follows:Blue tape ¼” or ½” on walls, desks, tables

when marking designated areas Optional in office areas Required in common (shared) areas

1” or 2” Yellow tape on floor for items that move Required in common areas

Storage areas markedSupply shelves labeledDigital photo posted in office area or cubicle

showing office organizationLabels (black letters on white)

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Standardize Guidelines cont’dBulletin Board Information

When submitting items for the bulletin boards, please include the date, person responsible for information, and the date for removal.

Common work areas and Meeting RoomsStandardized Arrangement

Standardized postings and information Will be framed near entrance to the room Documentation for training and meetings

Standard items kept in room Cabinet with refill supplies to be maintained

Specific instructions for facilitator Room placed in order when finished Lights turned out Items replaced as needed

Supply organization at Indiana GeneralColor Meaning Symbol

Red IV supplies / needles

Yellow Urinary supplies

Brown GI / Ostomy supplies

Blue Respiratory supplies

Orange ADL supplies

Green Dressing supplies

Black Miscellaneous

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Sample meeting room layout

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Definition:


Guidelines:

Information:

Practice and repeat the procedures to have it become a way of life

Develop a method to maintain the improvements

Audit the workplace to insure its being maintainedReview and post the audit results for all to seeThis is the most critical step by maintaining the improvements by developing discipline

“You get what you inspect – not what you expect”

SUSTAIN

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5S Examples

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Nurses Station – Before 5S

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Sort

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Set in order

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Shine (Clean)

Nursing Unit Example – After 5S

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Supply Closet–Before 5S

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Closet – After 5S

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Sorted Items

Return to use

Trash

Donation

Other examples of 5S

Book Drawer Labels

Book Storage with Diagonal Tape

Cabinet Arrangement

Desk Drawer Arrangement

Desk Drawer Arrangement

What’s missing?

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The 5S’s

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5S BenefitsPride in the workplace and supports team

developmentSorting means removing unnecessary items

that congest the work areaClean equipment allows everyone to notice

problemsSorting retains only the needed items. This

allows for a smaller work area resulting in reduced effort (walking, reaching, etc.) to do the work.

Reduced changeover times result from being organized and minimizing search time.

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Get everyone involvedIntegrate 5S principles into daily work

requirementsCommunicate need for 5S, roles of all

participants, how it is implementedBe consistent in following 5S principles in

all areasFollow through - finish what is started - 5S

takes effort and persistenceLink 5S activities with all other

improvement initiatives

Keys to 5S success

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Benchmarking &Best Practices

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Benchmarking / Best PracticesThe process of comparing one’s business

processes and performance results to industry bests or best practices from other industries.

Collaborative benchmarking-Best Practices - voluntarily working with

others to develop a method that others can use

Maybe competitors or have similar processes

Reference the “Things do well” / ”Struggles” display

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Lunch & Breakout sessions

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Flowcharting

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Definition – Process MappingProcess Mapping, often referred to as

Flowcharting, is a visual representation of the work-flow either within a process - or an image of the whole operation. It comprises a stream of activities that transforms a well defined input or set of inputs into a pre-defined set of outputs.

Source – www.isixsigma.com

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ProcessesSeries of actions that takes inputs, transforms them

and makes an output.

A process consists of repeatable tasks, carried out in a specific order.

A set of common tasks that creates a product, service, process, or plan that will satisfy a customer or group of customers.

Input

Output

Activity Activity Activity Activity

Input

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Inputs Process Outputs

MaterialServicesInformatio

nDocumentsScrapBy-

productsDataReports

MaterialSuppliesEnergyInformationMachinesDataPeopleMethodsServices

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Why is Process Mapping important?Help to see the bigger picture and how a

process worksFacilitates discussion to break down ‘silo’

barriers between functionsIts use can reveal duplication, waste, over

processing or unnecessary steps It can be used to communicate the vision of

where we’re going

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Symbols used in flowchartsStart / End

Task / Step

Decision

Flow Arrow

Burst

No

Yes

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#

AConnector

Document

Measurement

Delay or Wait

More symbols

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Start

Get bread Get JellyGet PBApply PB&J

Open new jar

Yes

No

Assemble sandwich

Get potato chips

Get a drink

Eat lunch End

Enough in Jar?

A

A

Buy natural peanut butter

Eat carrot sticks instead

of chips

Drink water instead of

soda

Flowchart Example-Making lunch

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OrientationStaff

Director

Front Office Staff

Application ReviewApplication Review

Make sure folder is complete

Send folder to faculty

committee

Send denied letter; signed by

faculty

Share folder with all

Review folder materials no

yes

Send packet about registering and

orientation

Admissiondecision

Swimlane Chart

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Four Techniques of Process Mapping

1. Macro (high level)

2. Micro (lists all sub-processes)

3. Current State – “as is” today

4. Future State – “could be” state

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Current State vs. Future StateHow the process works today

How the process will function after the changes

Run Cypress reports (2X month on 12th and 24th) for previous month

Get reports from Carl on 25th of

month

Linda-Develop pull lists in Excel & notify Michele/Cathy that it

is ready

Pull charts, put into carts, identify, and

scan to PI

Data abstraction, mark chart, and update pull list

Update definitions on worksheets & communicate to

staff

Scan chart back to Medical Records

File information sheets in folders

Linda/Michele enter information

into COP

Stop automatic print of Cypress report on

24th (Cathy)

Have someone else maintain pull list from data (Linda)

Training communication to staff for changes

Folder with latest worksheets

(Michele)

Cook the disk and deliver (Due date

is1st day of 3rd month after qtr.)

File report

COP accumulates information and

sends CD

Copy report and take to Committees

File report

Wa

it

Request for 5 charts

Send for review after being

identified by PIGet feedback

Is score less than 80?

Yes

No

May appeal

End

Start

Access to QNET score - more people with access (Linda)

Print summary sheets of CMS

data and file

Run Cypress report (Monthly on 12th) for previous

month

Get reports from Carl on 25th of

month

Linda-Develop pull lists in Excel & e-mail staff that it is

ready

Abstract data, mark chart, &

highlight pull list in yellow

Update definitions on worksheets &

communicate to staff

File information sheets in folders

Enter information in COP, & highlight

pull list in pink

Submit data on website (Due date

is1st day of 3rd month after qtr.)

COP accumulates information and

sends CD

Copy report and take to Committees

Wa

it

Request for 5 charts

Send for review after being

identified by PIGet feedback

Is score less than 80?

Yes

No

May appeal

End

Start

Print summary sheets of CMS

data and file

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1. Document the Current State map2. Identify bursts with the current process3. Develop the Future State map4. Make the Action Plan to achieve the

Future State5. Work on the Action Plan6. Go back to the beginning

How you go about it-

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Looking for improvementsAsk the following questions-How many steps are being taken for each step?

How many handoffs are there between staff

Or between departments?

How much time is taken for each step?

What is the total time from first to last steps?

Where do delays occur?

What value does each step contribute?

Where is flow stopped in this process?

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Identify bursts with the current process

What quality issues exist?

Where is the process bottleneck?

Where is the process inconsistent?

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Develop the Future State mapHow would the process look if we addressed

all the bursts?

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A couple of additional thoughts-Its not rocket science-making the process

map does not have to be high-tech

Its not about blaming or criticizing anyone or any department

‘Go see’ the process

This is only the starting point that will lead to a lot of other improvements

Its fun!

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A

#

No

Yes

Review-

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Exercise #4One of your processes – Using at least 4

symbols

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How can you use this in your organization?Process mapping

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Standard Work“Where there is no standard, there can be no kaizen.”

Taiichi OhnoVice-president, Toyota Motor Corporation

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Exercise #5

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Standard WorkDefines consistent performance of a task,

according to prescribed methods, without waste, to make most effective use of the resources

PeopleMaterialsMethodsEquipment

Without Standard Work there can be not sustained improvement

Inconsistent Process

Inconsistent Results

DesiredResults

Consistent Process

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What is Standard Work?A simple written description of the safest,

highest quality, and most efficient way known to perform a particular task, (i.e. a checklist to lead someone through the task).

The only acceptable way to do the process it

describes.

Expected to be continually improved

Needed in most, if not, all work areas

May be met with resistance by staff.

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Standard Work Standard work supports the lean system

of continuously improving capacities and efficiencies by defining 3 critical elements for every person doing the work

1. The most efficient work routine / procedure or steps

2. The elapsed time required to complete work elements and move to the next step of the process

3. Any quality checks required to minimize defects/errors

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Example of standard work (TWI)

http://www.trainingwithinindustry.net/JBS-IPOV.pdf

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Standard Work information• Includes the amount of time allotted to

hand-off the task to the next step of the process.

• Focuses on the person, not the equipment or materials

• Reduces variation, increases consistency

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Steps for Creating Standard Work1. Define the extent of the task for which

you are creating standard work (e.g. starts at… ends at…)

2. Determine the appropriate standard work requirements

3. Gather best practices4. Create the standard work document5. Train everyone on the standard work

document6. Run the process and observe the results7. Make adjustments and modifications to

the standard work

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Tips for Creating Standard WorkDO:

Keep standard work simple Make it accessible Include all information on one, easy-to-read

document Create one standard work document for each

part of the process Always look for ways to improve the process.

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Tips for Creating Standard WorkDON’T:

• Put standard work in a desk drawer

• Change processes without changing standard work

• Make standard work difficult to change

• Give up on standard work – it can be tough, but it’s very important

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Role of the SupervisorThe supervisor should ask the following 4

questions for every person who will perform standard work:

1. Do you understand why it is important for you to follow the standard work?

2. Are you willing to follow the standard work?3. What are the consequences for choosing not to

follow standard work?4. What is the process for changing standard

work?

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Exercise #6

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Flow, Push, and Pull

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“To move or run smoothly with unbroken continuity, as in the manner characteristic of a fluid.”

www.answers.com/topic/flow on 5/29/09

Customer flow – the “movement” of customers through the process creating value

Flow – what is it?

http://www.answers.com/topic/flow

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What does it look like?

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What is the affect of not having flow?Not having flow creates waste-

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Registration

Arrival

EKG

IR

ICU

Lab

Cath Lab

Surgery

Intake Unit

CT

X-Ray

PAT

EDInpatient

Rehab

InpatientUnits

MRI

PT

Discharge

RT

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And waste consumes resources

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What can impede flow and keeps us from having it?

You have to understand why flow is not present

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A. Focus on the constraint or bottleneck of the process

B. Identify how the process is inadequate–methods,

equipment, etc.

C. Changeovers take too long

D. The area is not organized and ready for work

E. Quality or scrap issues exist that consume time and

resources

Strategies for improving flow

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A. Constraints and process bottlenecksEvery process has a constraint that limits its

throughput (capacity)

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Five focusing steps1. Identify the system’s constraint2. Exploit the system constraint3. Subordinate everything else to the constraint4. Elevate the system’s constraint5. Go back to step 1

The Goal – Eli Goldratt

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vs.

Flow and Pull

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Facility Layout

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Facility layoutMaking best use of land, facilities,

equipment, furnishings to deliver valueFacilities are expensive to obtain and

maintainLayout can often dictate how the

processes is done in an organization

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Facility Layout factors to considerArrangement according to how often its

used (ABC)Flow and steps in common processes (__

times/day)Specialized areas vs. flexibility in layoutConsider other facilities at your disposalHave arrangement be consistent between

locationsMinimize storage and handling

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Problem Solving

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1. Identify and define the problem2. Organize the team3. Describe the problem4. Contain the problem5. Find the root cause6. Generate, select, & verify the corrective

action7. Implement the permanent corrective action8. Prevent reoccurrence9. Communicate and congratulate the team

The problem solving process

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3. Describe the problem

What do we know about the situation?

Is this common cause or special cause?

Collect the relevant data

Create a process flowchart

Process step Process step DecisionBegin End

Yes

No

Process step Process step

Process step

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5. Identify the Root CauseTools to analyze-

5-why Brainstorming Pareto diagram / histogram Failure Mode and Effects Analysis Cause and Effect (Fishbone diagram)

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5 Why example –“I was late for work”Why were you late for work?

Because I had to park far awayWhy did you have to park far away?

Because the close spots were fullWhy were the close spots full?

Because I arrived later than other peopleWhy did you arrive late?

Because I left the house lateWhy did you leave the house late?

Because I forgot to set the alarm

Solution - Buy an alarm you only set once and it goes off the same time every weekday. Make sure it has battery backup in case of power failure.

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Take ActionExamine the prioritized ideasDevelop specific action items that will

address root causes and reduce riskImportant to assign a person responsible for

each action item, and a due date for completion

Need to follow up on assigned actions

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Hierarchy for improvement actionsWeaker actions– Vigilance and hard work

New memorandum, policy, or procedureTraining and personal remindersDouble checks

Intermediate actions– Address Human FactorsRedundancy, checklists, remindersSoftware modifications

Stronger actions– Sophisticated behavioral changesArchitectural / physical changesControl or interlock (force function)Removing unnecessary steps or ability to do task

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8. Prevent reoccurrencePrevent it from happening again by asking

the questions:Where else-Who else-How else-

Revise the system as needed- Procedures Training Consider all current and future staff

could this exist?could this potential problem exist?

has the same system?has the same process?

would this be done?

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Improvement project examples

Bringing it all together

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Indiana General Emergency RoomGoal Statement:

1. Improve the ‘Door to Doctor’ time for ER patients to achieve goal of 30 minutes

2. Roll out improvements to other hospitals

Project Scope:Start: Patient arrival at the ER doorStop: Time when the Patient is seen by the

PhysicianIncludes: All ER patients entering through doorExcludes: Those arriving by ambulance

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Baseline information – Average Door to Doc- just over 45 minutesAverage Length Of Stay – About 3 hrs. 15

min.Home Hospital LWBS

January 2006-December 2007

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

Jan-

06

Feb

-06

Mar

-06

Apr

-06

May

-06

Jun-

06

Jul-0

6

Aug

-06

Sep

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Oct

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Nov

-06

Dec

-06

Jan-

07

Feb

-07

Mar

-07

Apr

-07

May

-07

Jun-

07

Jul-0

7

Aug

-07

Sep

-07

Oct

-07

Nov

-07

Dec

-07

Date

% R

ate

of

LW

BS

Rate

Average of 1.66%

Indiana General.

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Patient travel with current layout

TRIAGE

REGISTRATION

ED

WAITINGROOM

Patient travel with the existing layout

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How the team went about itA two-day event focusing on: Change management Process mapping 7 kinds of waste Constraint management

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Swim-lane chart of the processEarlier in process

on top-later belowSeveral places

where waiting occurs

Kaizen burstsRed circles

indicate the critical path

Registration ED Staff-Bedside Nurse

Home Hospital Patient Triage and Registration Flowchart

ED TriagePatientPt arrives & goes to

Triage window

Take chart form & go to Central Registration

Pt identified- Medical chart & complaint

WAIT

Full Reg- Scan, consent, co-pay ID, Paperwork,

insurance

Go to Triage window with papers

Triage pt- Medical hist., allergies, stickers,

med rec, etc.

Patient goes to assigned bed

Patient changes into gown and gets situated

Patient seen by Doctor

Discharge and exit interview

WAIT

WAIT

WAIT

WAIT

Register in AffinityScan, consent,

co-pay ID, insuranceAssemble paperwork and

send patient to Triage window

Upgrade patient

Update information not obtained at Registration

Assign pt to bed, give report, put pt on board

Report from Triage nurse


Dr.’s orders

S.O. IV’s, ekg, x-ray, blood draw

Primary assessmentc/o, hx of c/o

Clean bed, pt off tracking board, chart to basket

WAIT

WAIT

WAIT


med rec, etc.

Complaint and time of arrival documented-send

pt to Reg

Pt arrives & goes toTriage window

WAIT

Registration ED Staff-Bedside Nurse

Home Hospital Patient Triage and Registration Flowchart

ED TriagePatientPt arrives & goes to

Triage window

Take chart form & go to Central Registration

Pt identified- Medical chart & complaint

WAIT

Full Reg- Scan, consent, co-pay ID, Paperwork,

insurance

Go to Triage window with papers


med rec, etc.

Patient goes to assigned bed

Patient changes into gown and gets situated

Patient seen by Doctor


WAIT

WAIT

WAIT

WAIT

Register in AffinityScan, consent,

co-pay ID, insuranceAssemble paperwork and

send patient to Triage window

Upgrade patient

Update information not obtained at Registration

Assign pt to bed, give report, put pt on board

Report from Triage nurse


Dr.’s orders

S.O. IV’s, ekg, x-ray, blood draw

Primary assessmentc/o, hx of c/o

Clean bed, pt off tracking board, chart to basket

WAIT

WAIT

WAIT


med rec, etc.

Complaint and time of arrival documented-send

pt to Reg

Pt arrives & goes toTriage window

WAIT15 Pieces of paper

for Registration

Finding nurse to give reportMore in-depth

assessment

Searching for patient

One person in Triage

Adjusting time in system for when

pt arrives

Pt. goes to Triage, Registration, back

to Triage

No privacy for patient

KeyCritical Path

Improvement Burst

Indiana General

144

Inventory Chairs in the triage area Use of counter space

Motion Patient - 6 points before getting to a bed ER going to get patient – bed, nurses

station and entering into tracking board Going to waiting areas to find the

patient Finding wheelchairs Getting gown & blanket in the room for

patient Triage nurse leaving the triage area Registration walking between printers Sorting the paperwork – stickers Moving L&D patients upstairs

Overproduction Unneeded tests or specimens used Getting extra information from patient Only 3 face sheets needed instead of 4

Overprocessing Duplicate documentation like

nurses notesTransportation

Movement of patient triage registration triage

bed Taking patient for Radiology or

lab testsRework / correction

Incorrect information for the patient

Several calls to register one patient

Medicaid printout / scanning - on-line insurance eligibility

Timely ER tracking board information

Waiting Waiting to register / triage Waiting for a bed – clean or

occupied Results from Lab or Radiology Physician

change of shifts seeing other patients waiting for a patient to get

through the process Clinical processing of patient

7 Kinds of Waste

145

The approachLooked at the current floor plan to see

how they could improve flow with minimal changes

Analysis of staffing patterns – when do patients arrive and how many staff to have

Roles and responsibilities of the staff analyzed– who needs to be doing what?

146

Improvements implementedChanged location of the check-in desk

and made use of rarely used areaRevised the physical layout of the areaAdded one additional Registration

personImplemented the bedside and ‘Quick

registration’ process

147

Patient travel with the new layout

TRIAGE

REGISTRATION

ED

WAITING ROOM

148

Project ResultsReduced average LOS by 29 minutesReduced ‘Door to Doc’ time by 16 mins.Reduced ‘Door to bed’ time by 7 minutesImproved patient satisfaction by 7 points

149

Cross-functional team involvement Keep it simple when making changes We’re not waiting for it to be perfect Implementation plan

Small scale start Daily debriefing to identify opportunities and

changes to be made

Don’t sweat the big stuff

Lessons Learned

150

Trinity Mission

151

152

153

154

155

Putting it all togetherCulture changeEmpowermentVision & alignment (rowing the boat / true

north)Sense of urgency (addressing waste, speed)Improvement teams, projects, resources,Designing new processes (cardboard mock-

up),Overcoming resistance-facilitate / coach vs.

author

156

Values

Vision

Mission

Strategic planand

Measures

157



158

Lean challenges you will faceThis is not industry, we’re not

Toyota, and we’re not making carsWe’ve always done it this wayWe’re too busy taking care of clientsNonprofit world is very much siloed

159

What is a Lean Hospital?

It all works together without waste

Physicians

Cath Lab

Surgery

Housekeeping

ED

Radiology

Lab

HIM

Staff

L&D

PharmacyMaterials Management

Food Service

Nursing Units

160

Review of objectivesLearn ways to help our organizations be more

effectiveChallenge existing attitudes and processesIdentify improvement opportunitiesLearn by doingHave fun

161

Lean organizationsWorking to eliminate waste through:

Goals and measures leading to accountability and driving improvement

Areas organized and arrangedTrained and empowered staffSmooth and consistent processes working in unisonProblem solving and proactive failure mode analysisWorking to promote the value stream (service line)

instead of silosGetting everyone involved

162

Our Offer to Your OrganizationWhat we are offering - Partnering with our

membership on using information on improvement projects

163

Reflection and sharingWhat are you going to do when you return

164

Additional ResourcesLocal ASQ section 0917

Brian Hudson & Sarah-Louise KerneyWabash Valley Lean Network - www.WVLN.orgwww.lean.orgRecommended ReadingsLean Thinking by Jim WomackBecoming Lean by Jeffrey LikerThe Machine That Changed the World by Jim

Womack and Daniel T. JonesThe Goal by Eli GoldrattLean Production Simplified by Pascal Dennis

165

Additional ResourcesGupta, Praveen. Six Sigma Business Scorecard.

New York: McGraw Hill, 2004. Print.

Hammer, Michael and Lisa Hershman. Faster Cheaper Better. New York: Random House Inc, 2010. Print.

Jackson, Thomas. Hoshin Kanri for the Lean Enterprise. New York: Productivity Press, 2006. Print

Tague, Nancy. The Quality Toolbox. 2nd ed. Milwaukee: ASQ Press, 2005. Print.

166

Closing and Evaluation