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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
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
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
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
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
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-03
2005
-02
2005
-01
2004
-12
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-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