Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management

Chapter 9. The Lean Enterprise

An Integrated Approach to Improving Quality and Efficiency

Daniel B. McLaughlinJulie M. Hays

Healthcare Operations Management

Copyright 2008 Health Administration Press. All rights reserved. 9-2

Chapter 9. The Lean Enterprise

• Definition of Lean• Types of waste• Kaizen• Value stream mapping• Tools

- Takt time, throughput time, five Ss, spaghetti diagrams, kaizen events, standardized work, jidoka, andon, kanban, SMED, flow and pull, heijunka, advanced access

• Lean Sigma


What Is Lean?

• Elimination of waste- Toyota Production System (TPS)

• Philosophy- Produce only what is needed, when it is

needed, with no waste

• Methodology- Determination of value added in the process

• Tools- Five Ss, kaizen event, standardized work, etc.


Types of Waste (Muda)

• Overproduction

• Waiting

• Transportation

• Inventory

• Motion

• Overprocessing

• Defects


Kaizen Philosophy

• Employee-led continuous improvement

• Five steps- Specify value- Map and improve the value stream- Flow - Pull- Perfection

• Even if it isn’t broken, it can be improved.


Value Stream Mapping

• Process map of the value stream

• Includes information processing and transformational processing

• Value-added steps: “Would the customer be willing to pay for this activity?”

• Non-value-added steps- Necessary- Unnecessary


Value Stream Mapping

Radiology LabHouse-keeping

PharmacySuppliesAnesthes-

iologySocial

Services

Porter

Stabilize

Incorrect patient forms

Rooms unavailable

Long wait after cleared to discharge

Education late

Slowturnaround

Patients

30-90 min

Admitting

1-3 hr

Triage

1-60 hr

Labor and

Delivery

20-80 hr

Post Partum

3 hr

Discharge

0-2 hr 1-3 hr 1-8 hr 1-5 hr

LOS

Rooms not available

Nurses’ time spent on non-patient care

Diagram created with eVSM software from

GumshoeKI, Inc., a Microsoft Visio

add-on.


Tools

• Takt time

• Throughput time

• Five Ss

• Spaghetti diagram

• Kaizen blitz or event

• Jidoka

• Andon

• Standardized work

• Kanban

• Single minute exchange of die (SMED)

• Flow

• Pull

• Heijunka


Takt Time

• The speed with which customers

must be served to satisfy demand for the service.

• Cycle time is the time to accomplish a task in the system.

• System cycle time is equal to the longest task cycle time in the system—the rate at which customers or products exit the system, or

“drip time.”

demand/dayCustomer

/day work timeAvailableTakt time


Throughput Time

• Time for an item to complete the entire process, which includes:- Waiting time- Transport time- Actual processing time


Riverview ClinicCycle, Throughput, and Takt Time

Diagram created with eVSM software from GumshoeKI, Inc., a Microsoft Visio add-on.

Move to examining room2 minutes

Patient check-in3 minutes

Nurse does preliminary exam

5 minutes

Physician exam and consultation

20 minutesVisit complete

Wait 15 minutes

Wait 15 minutes

Wait 10 minutes


Riverview ClinicCycle, Throughput, and Takt Time

• Patient check-in cycle time = 3 minutes.• System cycle time = cycle time for longest task =

physician exam and consultation = 20 minutes.• Throughput time = 3 + 15 + 2 + 15 + 5 + 10 + 20 =

70 minutes.

•

tient.minutes/paphysician 24 ent hours/patiphysician 0.4

aypatients/d 100hours/day 5 physicians 8Takt time


Riverview ClinicValue-Added Time

• Valued-added tasks:- Nurse preliminary exam- Physician exam and consultation

• Non-value-added steps, necessary:- Patient check-in

• Value-added time = 5 minutes (nurse preliminary exam) + 20 minutes (physician exam and consultation) = 25 minutes.

• Percentage value-added time = 25 minutes/70 minutes = 35 percent.


Five Ss

• Seiri (Sort)—Separate necessary from unnecessary items, including tools, parts, materials, and paperwork, and remove the unnecessary items.

• Seiton (Straighten)—Arrange the necessary items neatly, providing visual cues to where items should be placed.

• Seiso (Sweep)—Clean the work area.• Seiketsu (Standardize)—Standardize the first

three Ss so that cleanliness is maintained.• Shitsuke (Sustain)—Ensure that the first four

Ss continue to be performed on a regular basis.


Spaghetti Diagram


Kaizen Blitz or Event

• Determine and define the objectives• Determine the current state of the process• Determine the requirements of the process• Create a plan for implementation• Implement the improvements• Check the effectiveness of the improvements• Document and standardize the improved process• Continue the cycle

Plan

Check

Act

Do


Results of 175 Rapid Process Improvement

Weeks at Virginia Mason Medical Center

Source: Womack, J. P., A. P. Byrne, O. J. Fiume, G. S. Kaplan, and J.Toussaint. 2005. "Going Lean in Healthcare." Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Online information available at: http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm.


Standardized Work

• Written documentation of the way in which each step in a process should be performed

• Not a rigid system of compliance, but a means of communicating and codifying current best practices

• Massachusetts General Hospital care paths


Jidoka and Andon

• Jidoka is the ability to stop the process in the event of a problem.- Prevents defects from passing from one

step in the system to the next- Enables swift detection and correction of

errors

• Andon is a visual or audible signaling device used to indicate there is a problem in the process.


Kanban

Task 1Workstation

1

Task 2Workstation

2

Full Kanban

Customer Order

Full Kanban

Empty Kanban

Empty Kanban

Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.


Kanban

patientspatients echo

Signal

CT

Signal

Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.


Single Minute Exchange of Die (SMED)

• Used to reduce changeover or setup time, which is the time needed between the completion of one procedure and the start of the next procedure

• Steps- Separate internal activities from external

activities- Convert internal setup activities to external

activities- Streamline all setup activities


Flow and Pull

• Continuous or single piece flow—move items (jobs, patients, products) through the steps of the process one at a time without interuptions or waiting.

• Pull or just-in-time (JIT)—products or services are not produced until the downstream customer demands them.

• Heijunka—“make flat and level”; eliminate variation in volume and variety of “production”- Level patient demand


Advanced Access

• Patients are unable to obtain timely primary care appointments.

• Advanced access scheduling reduces the time between scheduling an appointment for care and the actual appointment.

• The goal is swift, even patient flow through the system.


Advanced AccessAdvantages

• Decreases no-show rates

• Improves patient satisfaction

• Improves staff satisfaction

• Increases revenue- Higher patient volumes- Increased staff and clinician productivity

• Promotes greater continuity of care- Increased quality of care- More positive outcomes for patients


Advanced AccessImplementation

• Advanced access challenges established practices and beliefs.

• Balance supply and demand:- Obtain accurate estimates of supply and

demand.- Reduce or eliminate backlog.- Minimize the variety of appointment types.- May need to:

• Adjust demand profiles.• Increase availability of bottleneck resources.


Lean Sigma

Lean

Eliminate waste• Achieve flow

and pull

Six Sigma

Eliminate defects• Reduce

variation in processes

6666Lean and Six Sigma are focused on

continuous improvement of the system.

Documents

Chapter 9. The Lean Enterprise An Integrated Approach to Improving Quality and Efficiency Daniel B. McLaughlin Julie M. Hays Healthcare Operations Management