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Lean Thinking in Healthcare WESTERN STATES MEETING JUNE 26-27, 2014

Lean Thinking in Healthcare - PAETC | Pacific AIDS ...paetc.org/wp-content/uploads/2014/07/Barbara-R-Lean-Thinking... · Outline – Implementing Lean In Healthcare What is Lean?

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Lean Thinking in HealthcareWESTERN STATES MEETING

JUNE 26-27, 2014

Outline – Implementing Lean In Healthcare

What is Lean?

Why Lean?

Lean Principles and Concepts

Spotlight on two lean applications: Clinical Laboratory

Outpatient Clinic

Keys to success

Advantages and disadvantages

History of Improvement The notion of improving processes

has been around for centuries Scientific Method Toyota Production System Deming/Shewart – PDSA,

systems thinking And a host of spin-offs - lean,

six sigma, lean-sigma, business process re-engineering…..

scientific method

http://www.sciencebuddies.org/science-fair-projects/project_scientific_method.shtml

What is “Lean” Short for “Lean Thinking” Management System for

Continuous Improvement based on the Toyota Production System

Set of principles that guide organizational thinking based on two themes: Elimination of waste or non-value

added activity (continuous Improvement)

Respect for all people

What is Lean?Lean thinking advocates identifying and eliminating the extraneous steps and processes – referred to as “waste” – that are responsible for work delays and added costs. All that’s left are the time, the people and the activities that add value to the customer

(Connolly, Washington Post 6/4/05)

Basic Lean Concepts

Scientific Method to seek perfection Continuous flow and progressive achievement of

tasks Waste minimization Well defined, standardized processes

Respect for people – cultural enabler Build value for the customer Build teamwork, involve everyone

Clear purpose – enterprise alignment Align strategy, systems and performance

© DB, 2006

PatientsLess waiting and delaysSafe environment

EmployeesBetter work processes

OrganizationMission alignmentLower costs – frees FTEs

Why Lean?

Improve patient experience Faster turnaround time, less errors

Improve the employee experience Faster turnaround time, less errors

Discover additional capacity Free up FTE’s

Control cost Less resources devoted to wasteful processes

The Lean ProcessFor each process:

1. Accurately specify the value desired by the customer.

2. Identify every step in the value stream for both product and employee activities;

3. Determine which steps are Value-Added and Non-Value-Added

1. A typical process is 95% non-value added

4. Discover solutions that link Value Added steps together and remove non value added activities.

Redesign workflow processes, layouts, workstations and supplies

Value Added

Definition- “Any activity that contributes directly to satisfying the needs of a Customer”

Non-Value Added

Definition- “Any activity that takes time, space, or resources, but does not contribute directly to satisfying the needs of a Customer”

Need NeedMettime

Improvement at its most fundamental

Seeing Waste

Forms of WasteOperational Waste7 wastes

Muda

Waste = Non-Value Added Activity

The Seven Wastes (Muda) Overproduction- too much work done or work

done too early Waiting- people, paper, information, supplies… Overprocessing – producing things in excess of

value Inventory- excess stuff, or items waiting to be

worked on Motion- operator movement not necessary to

complete a task Defects- work that needs to be re-done/clarified Transportation- movement of something further

than necessary

This is a Value Stream Problem

© DB, 2006

Eliminate the Waste –Basic Concepts of Improvement

Design the system/ process using these principles: Flow Pull Defect Free Visual Management Continuous

Improvement

Better State

Current State

Apply Improvement Concepts

Flow Principle – Allow value to flow

continuously to customer demand, in a standardized way

Anytime work stops, waste is present

Lean Principle: Flow Flow is predicated on zero waste and no

wait times

Must eliminate barriers that impede movement of the product or the service

If flow is interrupted, waste develops as inventory, extra steps or wasted motion

Flow should be “pulled”, not “pushed”

Pull Principle – Perform work only when you

have a true need from the customer

Utilize Pull Systems when work cannot flow continuously

Lean Concept: Pull vs. Push

Push systems – driven by the output of the preceding systems Work is pushed whether it is needed or not

Pull systems – driven by the needs of the receivers (customers) Customers pull the product to them

Lean Concept: Just-in-Time (JIT)

Supply the customer with just what is needed, in the right amount, at the right time, every time. Can be applied to products or services

The most effective mechanism for implementing lean thinking is adopting JIT and pull-from-demand flow

© DB, 2006

Pull true customer demand Pull patients into rooms when ready to be seen

Resources or materials are pulled by customers when needed Blood products are pulled when needed Wheel chairs are pulled, not sequestered Flow when you can, pull when you must

No Batches or Queues!

Defect Free Principle – Build quality into the process to

exactly meet customer specified value the first time

We always have time to do work the second time

Manage Visually Principle – See normal

conditions from abnormal conditions at a glance so corrective action can be taken in real-time

Visual Management gives employees the

knowledge and motivation to succeed!

Lean Principle: Define and Standardize Processes

Eliminate variation Define value-added processes through

careful analysis Standardize the ideal process

Events aren’t always as they appear!

More Waste

Equipment down time Excessive approvals Variation in practices Variation in skill levels Physical layout

Lean Principle: Center on the People Who Add Value

Customer-focused and worker-focused Give people the highest skill level tasks

that they are capable of accomplishing Train workers to detect defects Balance work among the team Move to team-oriented processes Make work easy with Kanban and visual

prompts

Kaizen Rapid Process Improvement

Purpose: To ensure sustainable change through aggressive improvement initiatives focused on reducing waste and increasing value Method: Cross-functional teams quickly

implement Lean tools to find creative solutions at minimal costs Time Interval: 1-3 months

Kaisen Workshop Pre- Planning Process Goal and charter setting Team development Initial training

Event Create current and ideal maps Create checklists and milestones

Post- Planning Process Sustainability Plan

Value Stream Mapping

Conduct team walk-through Take time observations Construct current state map for each

process Determine whether each step adds value Look for push/pull systems Examine supply management – first in,

first out

Time Observations

Time each task in the identified process Differentiate each as value-added time or

non-value-added time Record reasons for interruptions and

waiting and searching Observe at least five cycles for each

process

Future Value Map

Eliminates identified barriers Eliminates non-value added steps Depicts continuous flow, pull systems Eliminates hand-offs Creates parallel processes Uses visual controls (kanban) Changes in physical layout Includes prioritized change initiatives

© DB, 2006

Scope - Core Testing Laboratory Closest process to manufacturing, an item is

processed through a sequence of steps, value is added and product is given to customer

Aim: To improve patient quality of care by eliminating waste and minimizing turnaround time through teamwork, education and the implementation of lean principles

Project Spotlight – Lean Implementation in a Laboratory

© DB, 2006

Lean Core Lab Project Scope

High Volume In-Patient & Out-Patient Tests Approx. 3500 specimens/day 4.7 Million Tests per year (71% of total)

In-Patient Measure - Collect Time to Test Result Time

Out-Patient Measure - Patient Arrival Time to Test Result

Time

© DB, 2006

Phlebotomy Supplies Organized Sequence of use

First-In-First-Out (FIFO)

Visual management

Re-supply quantities

Standardized Carts

© DB, 2006

Stockroom Supplies Mgmt.

-Phlebotomy Supplies allocated shelf space based on usage

-Tags on shelf for each item include order#, minimum qty. and re-order qty.

-Ordering performed twice per week utilizing a handheld device, order submitted electronically overnight, supplies arrive next day

© DB, 2006

2

3

1

2

3

1

Changes to Layouts & Workflow-Processor Work Zones

Processor Steps: • Get specimens• Log in specimens• Drop off specimen• Place in centrifuges • Return to repeat the loop

© DB, 2006

Inner Loop Technician(s) Steps: • Load / Unload centrifuges at stations • Load / Unload analyzers• Complete auto-verifications• Set aside those needing manual verification• Repeat the loop for varied equipment• Work per the demand needs

12

3

Inner Loop Technician(s) Steps: • Load / Unload centrifuges at stations • Load / Unload analyzers• Complete auto-verifications• Set aside those needing manual verification• Repeat the loop for varied equipment• Work per the demand needs

12

3

Changes to Layouts & Workflow-Inner Loop Work Zones

Inner Loop Technologist(s): • Load / Unload centrifuges• Load / Unload analyzers• Run auto-verifications• Set aside those needing

manual verification• Repeat the loop

© DB, 2006

Changes to workstation design

Standardized Workstations

Visual Control of Workflow

© DB, 2006

Min

tues

2005

-12

2005

-11

2005

-10

2005

-09

2005

-08

2005

-07

2005

-06

2005

-05

2005

-04

2005

-03

2005

-02

2005

-01

2004

-12

2004

-11

2004

-10

2004

-09

2004

-08

2004

-07

2004

-06

2004

-06

2004

-06

2004

-05

2004

-04

2004

-03

2004

-02

160

150

140

130

120

110

100

90

80

70

__X=93.6

UCL=100.1

LCL=87.1

BaselineLLT changes After renovation

lab renovation

Inpatient Order to Complete TAT TrendsIn-Patient Turnaround Times

15% improvement

© DB, 2006

Min

utes

2005

-12

2005

-11

2005

-10

2005

-09

2005

-08

2005

-07

2005

-06

2005

-05

2005

-04

2005

-03

2005

-02

2005

-01

2004

-12

2004

-11

2004

-10

2004

-09

2004

-08

2004

-07

2004

-06

2004

-06

2004

-05

2004

-05

2004

-04

2004

-03

75

70

65

60

55

50

45

40

35

30

__X=39.1UCL=43.1

LCL=35.1

baseline After renovation ACB opensDICT renovation

Outpatient Overall Average TAT TrendsInlab to Complete

Outpatient Turnaround Times

28% improvement

© DB, 2006

Other Results

Labs consolidated from 4 labs to 2 labs Capital equipment for new building eliminated No lab or phlebotomy hiring needed for new

building Staffing scheduled to better match demand Improved performance measurement Daily raw data database for detailed analysis Flow Roadblock log / tracking

ROI Breakeven at 14 months

Project Spotlight: Implementing Lean in an Outpatient Clinic Setting

Aim: Decrease patient wait time by 25% from appointment to completion of doctor visit within 6 months.

Implementation plan included weekly working meetings culminating in a week- long kaizenevent

Strong, visible support from leaders Team selected from the front line

Clean Utility

Reception Desk

Triage

Consult

Room

Business Center

Endocrine lab

Workroom 5Workroom 4

Workroom 2

Workroom 1

Break RoomSandee

12

10

8

11

9

7

5

3

1

6

4

2

12

Waiting Area

Internal Medicine Floor Plan

Patient Flow – Baseline Process

1

2

3

456

7

8

Clean Utility

Reception Desk

Triage

Consult

Room

Business Center

Endocrine lab

Workroom 5Workroom 4

Workroom 2

Workroom 1

Break RoomSandee

12

10

8

11

9

7

5

3

1

6

4

2

12

Waiting AreaInternal Medicine Floor Plan

Patient Flow – New Process

1

25

3

4

Notes on new process:1. Patient receives forms to fill out

as he/she arrives

2. Vitals now part of the rooming process

3. Rooming controlled by room cards and information board next to receptionist area, if slot is empty on board, you know room is occupied, if card is there you know room is available

4. Less travel for the patient

5

Checkout

Enter/

Exit

© DB, 2006

Results: Outpatient Clinic Kaizen Patient Flow Walking distance: 216ft down to 108ft Exam room wait time decreased by 43% Wait time from a patient’s appointment to

completion of doctor visit reduced by 33% Productivity Clinic setup time reduced by 52%

Quality Defects Patients with a return appointment in 2 weeks or less

that leave the clinic without their schedule dropped from 41% to 18%

Lean Concepts Utilized In Solutions

One Piece Flow Batching eliminated- centrifuging, front desk

preparation Setup Time Reduction 45’ of sorting eliminated plus no paperwork processed

for no-shows, documents printed real time Kanban and Visual Management Room cards and clinic board utilized to manage patient

flow Patient checklist placed in each room to put patient in

charge of their visit Supply inventory managed with cards

Lean Concepts Utilized In Solutions

Standard Work Teams designed new process, then

standardized and trained personnel to follow new process

Balanced Work Some activities re-distributed to better match

patient flow Employees flexed responsibilities to even out

the amount of work between employees

Advantages of Lean

Will remove waste Personnel time Supplies ( inventory control)

More apt to hold the gains due to physical changes in the process

Will reduce cycle times Buy-In from employees because they are

involved in developing the future processes, however…….

© DB, 2006

Disadvantages

Be prepared to handle moral issues: Physical layout of the work space will likely change

Employee’s level of cross training may increase

Solutions will probably include some form of standardization

Can be apprehensive about the future of their job

Many solutions involve facilities and/or Information System changes

Employee Involvement Provide time for a dedicated team to participate with defined

timeline Move decision- making to the lowest levels Train all involved

Willingness to implement solutions Once a solution is identified as better than the way it’s done

now, put it in motion Avoid “analysis paralysis”; don’t sacrifice better for best Don’t underestimate the human side of change

Upper Management Support How will the gains in the loss of FTEs be realized? Communicate with a single voice Provide the ability to implement solutions, smooth the way with support

from outside departments, including IS and Facilities

Keys to Success

SLIDES AND CONCEPTS COURTESY OF SHERRY MARTIN, NQC COACH EXTRAORDINAIRE