© 2008, Park Nicollet Health Systems & John Black and Associates LLC Building a Profound Lean Infrastructure for Durable Success Sam Carlson, MD, FACP

© 2008, Park Nicollet Health Systems & John Black and Associates LLC

Building a Profound Lean Infrastructure for Durable Success

Sam Carlson, MD, FACPChief Medical Officer and EVP,Park Nicollet Health Services

John Black, John Black & Associates, LLC

Revised 2/28/08


Conflict of Interest

John Black of John Black and Associates LLC (JBALLC)

John Black is President of JBALLC and his consulting firm consults to Park Nicollet Health Systems on Lean, Global Production System. The presentation could be perceived as a conflict as JBA receives payment for services for consulting to Park Nicollet on the Lean, Global Production System principles presented in this presentation.


Park Nicollet Health Services is…

Non-profit integrated care system

8000+ employees

600+ employed physicians

Over $1 billion annual revenue


Park Nicollet Health Services is…

Park Nicollet Clinic - 45 medical specialties and sub-specialties in 25 clinic locations in suburban Minneapolis

3 million patient visits annually

Park Nicollet Methodist Hospital – 426 bed facility 26,000 admissions annually

Park Nicollet Institute – Engages in research, education and innovation to improve quality and public and private decision making in healthcare.

Park Nicollet Foundation – The fund-raising arm of Park Nicollet Health Services, using philanthropy to build healthy communities by supporting patient care, research and education.


We realized we were far short of where we needed to be

We knew we had lots of ineffective, non-value-added processes and activities

AND we knew the U.S. healthcare industry as a whole was not “world class”

Prior improvement methodologies weren’t having traction

Why is PNHS Aiming at World-Class Performance?


Because we knew we weren’t delivering “world class” health care

Because we had heard promising reports about implementation of the Virginia Mason Production System (Lean) at VM’s Medical Center in Seattle

We were intrigued with its potential, but wanted to do a test run at Park Nicollet before departing from our six sigma improvement strategy

Why Did We Take a Look at Lean?


What Does Infrastructure Mean? Why Is It Important?

I35W Bridge, Minneapolis, MN, before and after collapse

PROBABLE CAUSE: Federal investigators have concluded that steel

plates on the [I-35W] bridge that collapsed last summer in Minneapolis were inadequate to hold the structure together…

Design changes in 1977 and 1998 added additional pavement and concrete barriers that increased the weight of the bridge…

Gusset plates are flat steel structures used to bolt together the steel girders that carry the weight of a bridge. Bridge engineers typically design the plates to be far stronger than the girders because if one fails, the whole bridge will collapse.

In the wreckage of the I-35W bridge, investigators found 16 gusset plates that were fractured… Eight of the plates were in the location on the south side of the bridge where the collapse began… What [engineers] found was that the half-inch thick plates should have been an inch thick – double the size…

USA Today, 1/15/08

Construction of theBridge in 1967.


Creating the Vision

“Everyone caring every day, creating with the individuals we serve optimal health and greater value”


Our Strategic Plan

#1 regionally in state of the art measures of quality & safety for high impact conditions

Patients respond positively to: “I get exactly what I want (and need), exactly when I want (and need) it”

Reduce total risk-adjusted per capita cost of care relative to other MN care systems to below average

Operating margin ≥ 3.5%

By 2012, # unique patients served grows by 20%

2012

Traditional PN Organization Chart

Prototype Lean Organization

MarketingMarketing FacilitiesFacilities Human ResourcesHuman Resources

PurchasingPurchasingOperationsOperations KaizenKaizenPromotionPromotion

OfficeOffice

Healthcare Lean Organization

LeadershipLeadershipFellowsFellows

FinanceFinance

PresidentPresident

CEOCEO

JBA ConsultantsJBA Consultants

Surgery Surgery KOTKOTHospitalHospital KOTKOTCancerCancer KOTKOT

KOTKOTAdministrationAdministration

Model LinesModel Lines Special Ops KOTSpecial Ops KOT

KOTKOTSurgerySurgery

CancerCancer KOTKOT

HospitalHospital KOTKOT

ClinicsClinics KOTKOT

10

10

10

10

10

15

10 10 10

25

20

Se

rvic

e L

ine

s

*KOT-Kaizen Operations Team

Implemented

Underway

Not Started

Pat. Returns to Function

In Patient Hospital

TBDPre-Op Preparation

Pre-visit L/T

Day ofClinic

Visit L/T

Post-Visit L/T

Day ofSurgery

L/T

Pre-SurgeryL/T

Daily Management Boards

Materials Flow

Use of Non-Surgeon Clinicians

Staggered Starts

OR Scheduling Process

Staggered Starts

Case Carts: Standardize, Waste

Standardize Rooms

Staff Cross Training

Visual ControlPull Signals

PrimaryCare

7days

Total Surgical SpecialtiesPatient Lead Time

/

208 minutes

8days

TBD

22minutes

Accurate Surgery Times

Interoperative Standard Work for MDs

Pre-Op Preparation

Defining Best Practice Guidelines

PICIS: Surgery Information

SystemInstrument room

Pre-Op Patient PrepLoad Level During Day

Load level by DOW

Turnover Time

Reduced Surg./staff NVA Time

OR 21

Standard Rooming

Med. Rec.

Nurse Post-op Clinics

Model Line (Future) – Surgical Specialties

Implemented

Underway

Not Started


In Patient Hospital

TBDPre-Op Preparation

Pre-visit L/T

Day ofClinic

Visit L/T

Post-Visit L/T

Day ofSurgery

L/T

Pre-SurgeryL/T


Materials Flow

Use of Non-Surgeon Clinicians

Staggered Starts

OR Scheduling Process

Staggered Starts

Case Carts: Standardize, Waste

Standardize Rooms

Staff Cross Training

Visual ControlPull Signals

PrimaryCare

7days

Total Surgical SpecialtiesPatient Lead Time

208 minutes

8days

TBD

22minutes

Accurate Surgery Times

Interoperative Standard Work for MDs

Pre-Op Preparation

Defining Best Practice Guidelines

PICIS: Surgery Information

SystemInstrument room

Pre-Op Patient PrepLoad Level During Day

Load level by DOW

Turnover Time

Reduced Surg./staff NVA Time

OR 21

Standard Rooming

Med. Rec.

Nurse Post-op Clinics

Model Line (Future) – Surgical Specialties

Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)

Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)

JUST IN TIMEJUST IN TIME

Operate with the Operate with the minimumminimum resource required to resource required to consistentlyconsistently deliver deliver

• JustJust what is needed. what is needed.• In In justjust the required the required

amount.amount.• JustJust where it is where it is

needed.needed.• JustJust when it is needed when it is needed.

JidokaJidoka

One-by-one confirmation One-by-one confirmation to to detectdetect abnormalities. abnormalities.

StopStop and and respond respond to to every abnormality.every abnormality.

Separate machine work Separate machine work from human work. from human work.

Enable machines to Enable machines to detectdetect abnormalities and abnormalities and stopstop autonomously. autonomously.

Pull SystemPull System ProductionProduction

One Piece Flow Production

Supermarket System

Takt TimeProduction

AndonAndonOperational Operational AvailabilityAvailability

Standard Workin Process Kanban

StandardWork

Materials

MachinesMachines

People

Park NicolletSystem of CarePark Nicollet

System of CareTo Care for Patients the Right WayTo Care for Patients the Right Way


Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)

Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)

JUST IN TIMEJUST IN TIME

Operate with the Operate with the minimumminimum resource required to resource required to consistentlyconsistently deliver deliver

• JustJust what is needed. what is needed.• In In justjust the required the required

amount.amount.• JustJust where it is where it is

needed.needed.• JustJust when it is needed when it is needed.

JidokaJidoka

One-by-one confirmation One-by-one confirmation to to detectdetect abnormalities. abnormalities.

StopStop and and respond respond to to every abnormality.every abnormality.

Separate machine work Separate machine work from human work. from human work.

Enable machines to Enable machines to detectdetect abnormalities and abnormalities and stopstop autonomously. autonomously.

Pull SystemPull System ProductionProduction

One Piece Flow Production

Supermarket System

Takt TimeProduction

AndonAndonOperational Operational AvailabilityAvailability

Standard Workin Process Kanban

StandardWork

Materials

MachinesMachines

People

Park NicolletSystem of CarePark Nicollet

System of CareTo Care for Patients the Right WayTo Care for Patients the Right Way






Kaizen Office Locations

Park Nicollet Methodist Hospital Inpatient and Surgical/Orthopedic Services Visibility Room

Park Center Campus Specialty Services (CV/Onc/Medical Specialties); Primary Care Corporate Services KPO Offices Stand-up wall


Strategy and Tactics

Kaizen Guidance Team CEO/CEO/CMO/VP and Chief of KPO/Consultants

evaluate the overall plan and progress

Kaizen Leadership Team All service-line chiefs/VPs with Sr. Leadership and

KDs: yearly plan/timeline and progress

CEO weekly “wall walk” and review Progress towards yearly goals

Working the visibility room Monthly reviews of corporate health, quality, and

access data; setting longer-term strategy


CEO Weekly Wall Walk


Succession Planning and Replacement Tables

Succession Planning and Performance Management at

Park Nicollet Health Care Services

Senior Leader Replacement Table

Leader Replacement Ready Now

Replacement Ready in 1-3 years

Replacement Ready in > 3 years


Park Nicollet Leadership Fellows at Boeing 777 Factory



Developing Our Own “World Class” Leaders

RPIWs

5S

KEEP

3P

VSM


Just-In-Time

Jidoka

Wall WalkLeadership Fellows

KPO


What Does “World Class” Mean?


“World Class” Companies Excel in Five Areas


What Does “World Class” in Health Care Mean?

Safe

Effective

Patient Centered

Timely

Efficient

Equitable


The Importance of Going to Japan

Understanding the possibilities

Seeing with “new eyes”


Learning from Manufacturing Companies in Japan


Yamatake Corporation Isehara Plant Shonan Plant

Toyota Motor Corporation Kamigo Plant(Engine) Motomachi Plant(Assembly & Welding) Tsutsumi Plant(Assembly & Welding)

Toyota Boshoku Kariya Plant

Denso Takatana Plant

The Yokohama Rubber Co. Ltd. Hiratsuka Plant

Aisin Nishio Plant

Yamaha Motor Co. Ltd. Yamaha

Learning from Manufacturing Companies in Japan


The Infrastructure Must Be in Sync with the Improvement Plan

Improvement efforts must not get ahead of infrastructure

Model lines should be an inch wide and a mile deep

Taiichi Ohno’s Seven Wastes

MUDAMUDA

Time on Hand(Waiting)

Transportation

DefectiveProducts

Processing

Movement

Stock on Hand(Inventory)

Overproduction



The Seven Flows of Medicine

Flow of patients

Flow of clinicians

Flow of medication

Flow of supplies

Flow of information

Flow of equipment

Flow of process engineering


Surgical Services Case Study

Background Approximately 17,000 surgeries performed at Methodist Hospital in

2006: Each surgery requires multiple instrument trays with potentially

hundreds of instruments/supplies Multiple surgeons means multiple instrument/supply preferences Techniques and instruments added over time, but many old

instruments remain unused in trays, demonstrating both reprocessing and inventory waste:

Range for unused instruments has been 22-50% Mean score for unused supplies is 25% (but as high as 88% for certain

procedures)

16 RPIWs done over 2-year period to reduce unused instruments/supplies across all surgical specialties.


Surgical Services Case StudyRPIW Methodology

Standard Work

Standard Work

Each team included a circulatingnurse & a surgical scrub tech

Makeup of Teams

RPIW target:Reduction of unused instruments/Supplies across all surgical specialties

Baseline for change 5 weeks prior to RPIW:* Scope & procedure/case types

selected* Product quantity analysis (PQA)

data collected* Supply pick lists color-coded to

identify utilization* Instrument counts/tray compiled

During Prep Weeks:* Data collected on instruments

(used vs. nonused) by followingtrays after surgery

* Cycle times for tray processing& supply picks measured

* Surgeon-unique additionalinstrumentation evaluated

Surgeons used as contentexperts to RPIW teams

Surgeon meetings during RPIW week; discussed:* Display of new recommended trays & supplies

by procedure* Consensus on standardization



Results at End of 2006

% of Case Volume % of UnusedEvaluated Instruments Difference(2004-2006) (Pre- vs. Post-Standardization)

18% reduction in processed instruments (translates to 79,530 fewer instruments handled & processed per month)


Follow-up/Implications:

Follow-up Audits

• 30/60/90/120 day audits in place to maintain gains.

• Each RPIW audits previous case cart standardizations. One instrument tray is evaluated for compliance with standard.

• Standard work is in place for surgeons to reintroduce an instrument. (To date, no surgeons have utilized this process.)

Time Savings

• Reduction of instruments significantly affects workload of scrub tech & instrument room staff

• 79,530 fewer instruments processed per month = 2,615 fewer instruments per day

• Time savings per day: 20,917 seconds (349 minutes, or 5 hours, 50 minutes)

* Assuming 3 staff members touch each instrument for 2 seconds (scrub tech touches them twice)


Goal: A Model Line

Line ImprovementsLine ImprovementsLine

Line

Verticaldevelopment(Link processes to create a cell)

• Change production method from “Push” to• Plan for Leveling “Pull”• Develop Standard Operations• Quickly Solve Flow Problems• Practice “Visual Control”

Plane ImprovementsPlane Improvements

Plane

(Link cells to produce a product)

Goal: Spread Across Plane

15-20Years

15-20Years

Critical Transition from Point

to Line

5-10Years

5-10Years

Point

Point

Point

(Eliminate waste

at source - Just start

somewhere)

Point ImprovementsPoint Improvements

Goal: Flow vs. Batch

10-15

Years

10-15

Years

Height3rd Dimensional

(Link all elements from concept to

customer)

Goal: Raise to Other Planes

Spatial ImprovementsSpatial Improvements

Other processes

make point and line

improvements based on the model line

Where Does PN See Itself Now?



In Patient Hospital

TBD

Pre

-Op

Pre

pa

rati

on

Pre-visit L/T

Day of Clinic Visit L/T

Post-Visit L/T

Day of Surgery L/T

Pre-SurgeryL/T

Da

ily

Ma

na

ge

me

nt

Bo

ard

s

Ma

teri

als

Flo

w

Us

e o

f N

on

-Su

rge

on

Cli

nic

ian

s

Sta

gg

ere

d S

tart

s

OR

Sc

he

du

lin

g P

roc

es

s

Sta

gg

ere

d

Sta

rts

Ca

se

Ca

rts

: S

tan

da

rdiz

e,

Wa

ste

Sta

nd

ard

ize

Ro

om

s

Sta

ff C

ros

s T

rain

ing

Vis

ua

l C

on

tro

l

Pu

ll S

ign

als

Primary Care

14.8 days

Total Surgical Services Patient Lead Time

415.5 minutes15.1 daysTBD43.8 minutes

Ac

cu

rate

Su

rge

ry T

ime

s

Inte

rop

era

tiv

e S

tan

da

rd W

ork

fo

r M

Ds

Pre

-Op

Pre

pa

rati

on

De

fin

ing

Be

st

Pra

cti

ce

Gu

ide

lin

es

PICIS: Surgery Information System

Implemented Underway

Not Started

Ins

tru

me

nt

roo

m

Pre

-Op

Pa

tie

nt

Pre

p

Lo

ad

Le

ve

l D

uri

ng

Da

y

Lo

ad

le

ve

l b

y D

OW

Tu

rno

ve

r T

ime

Re

du

ce

d S

urg

./s

taff

NV

A T

ime

OR

21

Sta

nd

ard

Ro

om

ing

Me

d.

Re

c.

Nu

rse

Po

st-

op

Cli

nic

s

5 Year Block (Point): Surgical Specialties


In Patient Hospital

TBD

Pre

-Op

Pre

pa

rati

on

Pre-visit L/T

Day of Clinic Visit L/T

Post-Visit L/T

Day of Surgery L/T

Pre-SurgeryL/T

Da

ily

Ma

na

ge

me

nt

Bo

ard

s

Ma

teri

als

Flo

w

Us

e o

f N

on

-Su

rge

on

Cli

nic

ian

s

Sta

gg

ere

d S

tart

s

OR

Sc

he

du

lin

g P

roc

es

s

Sta

gg

ere

d

Sta

rts

Ca

se

Ca

rts

: S

tan

da

rdiz

e,

Wa

ste

Sta

nd

ard

ize

Ro

om

s

Sta

ff C

ros

s T

rain

ing

Vis

ua

l C

on

tro

l

Pu

ll S

ign

als

Primary Care

7 days

Total Surgical Services Patient Lead Time

208 minutes8 daysTBD22 minutes

Ac

cu

rate

Su

rge

ry T

ime

s

Inte

rop

era

tiv

e S

tan

da

rd W

ork

fo

r M

Ds

Pre

-Op

Pre

pa

rati

on

De

fin

ing

Be

st

Pra

cti

ce

Gu

ide

lin

es

PICIS: Surgery Information System

Implemented Underway

Not Started

Ins

tru

me

nt

roo

m

Pre

-Op

Pa

tie

nt

Pre

p

Lo

ad

Le

ve

l D

uri

ng

Da

y

Lo

ad

le

ve

l b

y D

OW

Tu

rno

ve

r T

ime

Re

du

ce

d S

urg

./s

taff

NV

A T

ime

OR

21

Sta

nd

ard

Ro

om

ing

Me

d.

Re

c.

Nu

rse

Po

st-

op

Cli

nic

s

10 Year Block (Line): Surgical Specialties


Dramatic Improvement in Health Care is Possible Through Lean!

“It was exciting to see the chance for making changes, since there is no time in our typical day to make the changes we would like to make. Also, this process was good because we didn’t have to talk it to death. It was fun, and a good experience.” (Clinician, RPIW team participant)

“I was struck by the complexities of our systems, and how presumably small changes in a process can have such an important impact on the work of others in the system. It is a challenge to develop new procedures in a way that benefits all the participants on the clinical side, and keeps focus on the ultimate goal – doing what is best for the patients.” (Clinician)

“This was the best RPIW ever! I finally feel as though someone actually cares that I work at home until 12:30 many, many nights. This has changed my life! Please keep the DA!!!” (Clinician)

“The improvements will have a great impact to the amount of time saved preparing for a case. This saved time will be directly shifted to the patient, increasing the amount of time the RN will have for patient care.” (Clinician)

“I never felt like I was at a hospital, because having worked at the Marriott for over 20 years, I felt that the Park Nicollet staff totally embodied the service philosophy and took care of my father-in-law’s needs.” (Patient, RPIW team participant)


QUESTIONS?QUESTIONS?

Documents

© 2008, Park Nicollet Health Systems & John Black and Associates LLC Building a Profound Lean Infrastructure for Durable Success Sam Carlson, MD, FACP