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March 26, 2103
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KAIZEN AND LEAN SMALL TOOLS
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BACKGROUND TEMECULA VALLEY HOSPITAL
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BACKGROUND TEMECULA VALLEY HOSPITAL
Target Cost • Owner – Universal Health Services • Hospital costs in California - $1.5M to $2M per
bed • Target Cost for TVH was $140,000,000
• 140 beds • 178,000 square feet
• An extremely aggressive target helps reinforce the need for innovation and collaborative spirit
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BACKGROUND TEMECULA VALLEY HOSPITAL
IFOA Contract Signers Signing the contract was as symbolic as it was legally binding. Everyone was present – no one mailed it in.
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BACKGROUND TEMECULA VALLEY HOSPITAL
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BACKGROUND TEMECULA VALLEY HOSPITAL
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KAIZEN
What is Kaizen?
• Continuous Improvement • Deming Circle/PDCA
How is it implemented?
• Toyota Production System • Small Tools
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LEAN SMALL TOOLS
Examples
• 5-why • 5S • A3 • Value Stream Mapping • Reflection
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5 WHYS
• Problem solving tool • Helps to identify symptoms • Will identify root cause as symptoms are
explored • Use for problems related to human
interaction
Symptom? Problem?
5 WHYS
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5 WHYS
How do you do a 5 Why?
• Form a group • Develop Problem Statement • Ask “why?”, ask “why?”, ask “why?”… • Develop countermeasures • Implement change
5 WHYS
5 WHY TEMECULA EXAMPLE
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5 WHY TEMECULA EXAMPLE
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5 WHY TEMECULA EXAMPLE
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5S
From manufacturing… • Sort • Simplify • Sweep • Standardize • Sustain
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5S
For design and construction…
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5S
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5S
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5S
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5S
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5S – TEMECULA EXAMPLE
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PROCESS & VALUE STREAM MAPPING
When do we use them?
• When there is waste • Improve workflow
How? • Understand all aspects of current state
– Activities, Operations, Steps, Durations
• Identify target areas of improvement
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PROCESS & VALUE STREAM MAPPING
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PROCESS & VALUE STREAM MAPPING
TEMECULA ED PROCESS MAP
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Triage Waiting Assign Room
Provider Encounter
Collect Data
Assess Data Treatment Disposition
Non-Value Added, Pre-Process Waiting
Triage Initial Treatment
Test Result Waiting
Assess Data
Assign Room
Definitive Treatment Disposition
Provider Encounter
Collect Data
Non-Value Added IN-Process Waiting
TEMECULA ED PROCESS MAP
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Xray 51.0% 20 5 TransportUltrasound 8.0% 15 5 TechEKG 25.0% 8 4 TechLabs 60.0% 10 2 RNMRI 1.0% 45 10 TransportCT 21.0% 20 5 TransportFluoro 5.0% 40 10 Transport
Task Time Variability
(min.)
ED Resource RequiredService Probability
Task Time Mean (min.)
IV 58% 8 4 RNSplintWrap 13% 15 10 RNNeogastric Endotracheal Intubation 2% 15 10 RNBladder Catheter 5% 8 4 RNRespiratory Therapy 11% 15 3 RTLaceration Repair 10% 10 5 MDWound Debridement 4% 20 8 MDIncision Drainage 2% 20 8 MDForeign Body Removal 1% 20 10 MDCast 1% 20 12 MD
Task Time Variability
(min.)Procedure ProbabilityTask Time
Mean (min.)
ED Resource Required
Diagnostic Services
Treatment Services
TEMECULA ED PROCESS MAP
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Patient Arrival: Empirical Daily Variability
Empirical Acuity Distribution Empirical Arrival Distribution
Quick Registration Uniform Distribution
Triage Available
Wait for Triage
PDQ RN/MD Triage Triangular Distribution
Wait for ED Bed
Bed Available
MD Assessment (Levels 1 – 4 Only)
Triangular Distribution
RN Assessment Triangular Distribution
Diagnostic Services
Point of Care Services:
Labs Ultrasound
EKG
Uniform Distribution
Centralized Services:
X-Ray CT / MRI
Fluoro
Uniform Distribution
Wait for Results
Meds Ordered
RN Administer Meds Triangular Distribution
RN Follow-up Triangular Distribution
MD Follow-up Triangular Distribution
Treatment Services
Point of Care Services:
IV Splint/Wrap
Laceration Repair Neo/Endo Intubation
Bladder Catheter Wound Debridement Incision & Drainage
Foreign Body Removal Cast
Uniform Distribution
MD Follow-up Triangular Distribution
Admit Ordered
MD Order Discharge Percentage of Task
Time
RN Admin Discharge Triangular Distribution
EVS Room Clean Triangular Distribution
Wait for Bed in Hospital
RN Report Call Triangular Distribution
RN Transport Call Triangular Distribution
NO YES
NO YES
YES 47%
NO
NO YES 76%
NO YES 15%
YES
NO
68%
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ED FUTURE STATE FLOOR PLAN
Entrance
Ambulance Vestibule
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A3
When do we use them?
• Multi-faceted problem • Multi-disciplinary problem • For complicated analysis • Presentation of value proposition • As a record of decision
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REFLECTION
Fundamental in creating an environment of learning and kaizen When do we use them? • Following a breakdown • But…they should be occurring regularly
START, STOP, KEEP