March 26, 2103

1

KAIZEN AND LEAN SMALL TOOLS

2

BACKGROUND TEMECULA VALLEY HOSPITAL

3

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

4

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.

5

BACKGROUND TEMECULA VALLEY HOSPITAL

6

BACKGROUND TEMECULA VALLEY HOSPITAL

7

KAIZEN

What is Kaizen?

• Continuous Improvement • Deming Circle/PDCA

How is it implemented?

• Toyota Production System • Small Tools

8

LEAN SMALL TOOLS

Examples

• 5-why • 5S • A3 • Value Stream Mapping • Reflection

10

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

12

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

14

5 WHY TEMECULA EXAMPLE

15

5 WHY TEMECULA EXAMPLE

16

17

5S

From manufacturing… • Sort • Simplify • Sweep • Standardize • Sustain

18

5S

For design and construction…

19

5S

20

5S

21

5S

22

5S

23

5S – TEMECULA EXAMPLE

24

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

25

PROCESS & VALUE STREAM MAPPING

26

PROCESS & VALUE STREAM MAPPING

TEMECULA ED PROCESS MAP

27

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

28

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

29

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%

30

ED FUTURE STATE FLOOR PLAN

Entrance

Ambulance Vestibule

31

A3

When do we use them?

• Multi-faceted problem • Multi-disciplinary problem • For complicated analysis • Presentation of value proposition • As a record of decision

32

33

34

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