a brief on lean fundamentals for healthcare · define value from the customer’s perspective. 2....

A Brief on LEAN Fundamentals for HealthcareJerry Green, PhDJune 28, 2016

© 2016 International Business Machines Corporation

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First: What is LEAN?

Cycle-time reduction through waste elimination

• Tools and techniques that focus eliminating non-

value added activities (waste).

• A LEAN Organization produces what is needed,

when it is needed, with the minimum possible

amount of resources.

• A LEAN organization maximizes the ability of all

employees to add value.

– LEAN is about employee empowerment

– LEAN will NOT work in Command and Control

organization

When cycle-time is

the problem


Always LEAN first

Use LEAN before deploying other methodologies or your

organization will spend unnecessary time improving activities

that should have been

– eliminated,

– automated,

– or significantly simplified.

LEAN can be deployed within other frameworks such as

PDCA/PDSA or traditional DMAIC.


Agenda

• Why is LEAN important to healthcare?

• The five LEAN Steps & Tools

1. Define Value

2. Map the Value Stream

3. Eliminate the Waste

4. Implement the Solution and Pull Value

5. Maintain the Gain and Pursue Perfection

• In Conclusion

• Q&A


Five Step LEAN Process

1. Define Value from the customer’s perspective.

2. Map the Value Streams and identify issues and constraints. Things that impede what the customer wants.

3. Eliminate the Waste and allow the customer to flow through

the value stream without interruption.

4. Implement the Solution and let the customer Pull Value

through the work flow.

5. Maintain the Gain and Pursue Perfection

Define

Measure

Analyze

Improve

Control

Within DMAIC


Plan

Do

Check

Act

PDCA

Plan

WHY IS LEAN IMPORTANT TO

HEALTHCARE?


TechnologyIBM WH

EMRMIDASEtc…

PeopleKnowledge,

Skills,Abilities

ProcessWays of Working

The way we work is constantly changing

Training & ExperienceProcesses

Systems

Tools


Process flow

optimized

and aligned

to the

technology Upfront pre-visit

planning

eliminates

downstream

rework cycles

Team members

collaborate in

huddles to

prepare for

patient arrivals

Downstream

wait time is

eliminated as

workers and

supplies are

ready when the

patient arrives

Patient is

ready with

Labs, Med

list, etc

All team members

ebb and flow to keep

patient moving

through the work flow

without waiting or

interruption

Patient is at

the top of the

clinical

universe

Upfront pre-visit planning

is most efficient at

reducing care gaps. All

other methods require

getting the patient back in

the office.

They’re already here!

All team

members work

at the top of

license (what is

legally allowed]

Percentage

of “No

Shows”

reduced with

remind

An uninterrupted flow for the patient is the end goal

Example not meant to be read© 2016 International Business Machines Corporation

Transparency is critical: Identifies the area to focus on

Helps to create a sense of urgency and ensure that the

project team focuses on the right areas of the value

stream.


Client Feedback from LEAN Workshops

• Reduced the percentage of billing errors by 50% +

• Designed a virtual visit process for wellness exams

• Designed a process to track patients through the system using rfid

• Designed a discharge process to align to Transition

• Improved the cycle time for patients to get into chemo chair from 8.5 hrs to 2.5 hours

• Decreased hand-off issues occurring during shift changes for 2 discharge groups

• Decreased fall prevention percentage

• Decreased cycle time for OR equipment sterilization

• Decreased the # of incomplete orders for an entire healthcare system

• Improved ability to hit on elements of ACO commitments

• Improved the capacity of clinics in which Outreach was driving up demand

• Decreased the cycle time for hiring clinical staff impacting percentage accepting

• Reduced wheels in and wheels out cycle time (45 to 20 min)

• Streamlined specimen processing cycle time and standardized across all shifts

• Designed a Comprehensive Primary Care initiative to reduce A1C scores for a population

• Reduce the approval process cycle time for high priority projects in a healthcare system

• Reduced cycle time for patient diagnostic communication in oncology process


1. DEFINE VALUE FROM THE

PATIENT’S PERSPECTIVE.


Always start with a Charter

No Charter, No Project

• Releases approved resources

– A living document: “progressively elaborated”

– Helps control “scope creep”

• All Charters must at least identify a:

– Definition of problem to solve

– Champion to approve

– Project Leader

– Project Team (5-8 recommended)

– Scope (What is included and excluded)

• Boundaries for project team

– Goal(s): The Key Measure(s) and can be multiple

Example not meant to be read


Define the Voice of your Customer (VoC)

• Who is our customer(s)?

– Internal VoB / external VoC

• What do they want?

– What do they care about? (willing to pay for)

• When does the customer need the output?

– Covered in Waste/Flow

– How often do they need what we’re providing them?

• Overall, what value are we providing them?

Identify these for your process, dept. or organization

Don’t forget the Voice of your Business (VOB)


First, brainstorm using the 5M & P method

People Method Machine Material Measurement Mother

Nature

Physicians

Nurses

Analysts

Patients

Qlty Mgr

Etc…

Processes

Methods

Check Lists

Approaches

Workflows

Etc...

Laptops

Medical Eqp.

SW

Programs

Vehicles

Routers

Etc…

Sponges

Paper

Glue

Tile

Desks

Etc…

Thermometer

Story Points

Blood

Pressure

Lab Scores

Coordinate

Etc…

Temperature

Rain/Wind

Policies

HIPAA

NCQA

Etc…


From the 5M and P identify the Customers

• Primary entity needs must be met

• However, needs go well beyond

that of the primary entity

• Keep these stakeholders at the

front of mind as you go through the

LEAN steps


Satisfaction

Dissatisfaction

FunctionalDysfunctional

The Kano Model

Expected: Customer

clearly ask for this

Basic Needs:

Customers expect

this without having to

ask for it

If included, patients/customers will be satisfied

If omitted, patients/customers will not be dissatisfied

If included, patients/customers will NOT be satisfied

If omitted, patients/customers will be dissatisfied

Wow: Delighters

customers don’t

know exists

“Wants” that

patients/customers

may not think to

ask for

Items

move

down

over

time

© 2015 International Business Machines Corporation 24

KANO

• What’s important:

– Not to forget Basic Needs

– To reaffirm what the

customers are asking for,

the Expected Needs

– Not trading Basic Needs for

Wows

– To ensure that all

stakeholder needs are

cared for in the new design

(5M and P)


2. MAP THE VALUE STREAM

AND IDENTIFY ISSUES AND

CONSTRAINTS.


Use the 5M’s & P to help identify what goes into the map

Methods

Processes

Materials

Supplies

Mother Nature

Policies, Weather

Measurement System

How things are measured

Machines

Equipment, HW & SW

People

Any person


A SIPOC can help when there is ambiguity about a process

EMR System

Medical Supply

Companies

BD Medical

Syringes

IBM

Etc...

Appointment

Sign in Form

Lab Results

Patient Summary

Etc…

Vital Signs

Head

Ears

Nose

Mouth

Etc…

Diagnosis

Orders

Treatment Plan

Supply Ordering

Etc…

Patient

Clinic

Etc…

S I P O C

Suppliers Inputs Processes Outputs Customers


Think Horizontally, NOT Vertically

• It is natural to think only about my own functional area

• Vertical Thinking

– Many defects occur during the handoff or downstream

– Vertical thinking will not show after handoff issues

• Horizontal Thinking

– Visualize the “Entity” flowing through the process – end to end

– Start at the point the entity first enters the flow

– End at the point the entity is no longer touched by the process

• If a coffee shop had bad tasting coffee, the cause could be anywhere

in the process, not just in the coffee pot.

– Identify the Value Stream for Coffee

– Field to Cup


What is a Process Map?

Action Step

?

Decision

or Path

• Visual representation of a process flow

– Illustration of what actually happens

– Shows the flow of a process

• Demonstrates scope of a project

– Start and end; steps and decisions


Standard Process Map Symbols

Start Stop

Process Step or Operation

Decision

or Transport of movement

Storage, waiting time

Delay

24

A complex process step

that could be broken out

into it’s own map


Always map the current state in detail

• Effective change agent

– Evokes an emotional response

• Becomes a common language

• Identifies sources of waste

• Identifies the potential inputs, actions and

decision points that may impact a

process and its outputs

• Serves as the foundation for process improvement activities

“…and then it ends here”

Start here

Visual and

engaging!Easy to

do!


Example of a Cross-Functional Value Stream Map

Original Paper Map completed in our workshop

Turned into a Cross-Functional Value Stream Electronic Map

Examples not meant to be read in detail© 2016 International Business Machines Corporation

Registration w/Exam Exam w/Treatment

50/day 20/day 50/day

Treatment

40/day

• Removing all the NVA could improve patient satisfaction, but capacity for

this workflow would not increase.

• The overall capacity of a process = the single largest “constraint”

• The exam would need to be mapped in detail to identify and

DOWNTIME, then eliminate waste in the value added step

Time the activities and identify the constraints

CAPACITY

Backlog

or WIP

Capacity: 40/day

0% 100% 0% 90%VA: 80%

VA

NVA


A Few Process Mapping Tips and Hints

• Use mapping paper and sticky notes to make changes easy

• Involve Subject Matter Experts or you may be remapping

• Be the entity flowing through and capture everything– Even wait points and rework loops

• Start and Stop at extremes

• Only one activity per sticky

• Don’t put swim lanes on the paper map– Instead, write down the swim lane on the sticky note pad, put on the left

• For decisions, show the percentage that goes down each path (even if

just estimated)

• Don’t have naked lines (email is not an activity but a line, label it as

such, driving, email, meeting, face to face etc.)

– Transportations go on the lines, so show how it was transported to the next

process step


Use the LEAN criteria to identify non-value add activities

(NVA) in the value stream

The LEAN criteria for a patient centered value stream

1. The patient must care about it

AND

2. The activity must change the patient or knowledge about the patient

AND

3. The activity must be done right the first time


To identify non-value added activities, it helps to think

about the 8 LEAN Wastes in the Muda Wheel

Defects - Incorrect data entry, incomplete information,

mistakes

Overproduction - Preparing extra reports, making too

much

Waiting – Batching work, downstream step is not ready

uNused Creativity - Not working at the Top of a

License

Transportation - Travel to/from facilities, walking to

copy machine

Inventory - Purchasing supplies in bulk and storing in

cabinet

Motion - Extra steps and movement during an exam

Excess Processing - multiple sign-offs, most

meetings, downstream inspections, rework, approvals

Defects

Transporta-

tion

Over -

Production

Waiting

Motion

Unused

Employee

Talent

Inventory

Non Value

Added

Processing

Waste

“muda”

Muda Wheel


Conduct a Value Add Flow analysis: Red Dot/Green Dot

• Red and Green

dots were used to

decide if an

activity was a

Value Add [Green]

or Non-Value Add

[Red]

1. Customer cares about it

2. It transforms the entity

3. It is done right the first time

Activity does not meet

the value add criteria

Evaluate via VA CriteriaChange Management

Starts Now


A Spaghetti Diagram Map is another good way to

identify process flow issues, especially Transportation

• A “Birds Eye” view of the flow of a process

• Can identify areas in which

– Activities could be done in parallel

– Walking can be addressed via redesigning

the work area

• U Shaped work areas could reduce walk

time

• Moving supplies, equipment, files closer

• iPads

• Etc…

1 3

2825

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26

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19 20 21

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31

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33-36

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50-51

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6566 67 68 69

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8283CHANGING HALLWAY

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IMPLANT

OXID, P-

P+

BASE

TEOS-NI-TEOS

EP

EMITTER

S-FIELD

DC, PT SILICIDE

1ST METAL

3RD CONTACT

2ND METAL


3. ELIMINATE THE WASTE AND

ALLOW THE PATIENT TO

FLOW THROUGH THE VALUE

STREAM WITHOUT

INTERRUPTION.


Ensure continuous flow in your design so the entity

(patient) never waits

IDLE WORKERS

VS

IDLE PATIENT


5 Why

Problem Statement: An item was missing in the Exam Room

A new delegate was never appointed

Why was an item missing from the exam room

Someone forgot to re-stock

The Kanban card was not pulled in time

The key person went on vacation, no backup

WHY?

WHY?

WHY?

WHY?

WHY?

There may be more than one “Why” for each

issue and each “Why” can have multiple paths


Using a Fishbone (Ishikawa Diagram) with the 5M’s and

P and the 5 Why can help identify root causes

1. The Problem statement is the Fish head

2. Use the 5Ms and P as the major bones

3. Use the 5 why process with each failure mode to move from

symptoms and get to the root causes for each bone

4. Place the root causes on the diagram as smaller bones


Use the FMEA (Failure Modes and Effects Analysis) to

calculate the Risk Priority (what to do first, second etc.)

Process

Step/Input

Potential Failure

Mode

Potential Failure

Effects

S

E

V

Potential Causes

O

C

C

Current Controls

D

E

T

R

P

N

Actions

Recommended

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0

What

is the

input?

What

can go

wrong

with the

input?

What can

be done?

What is

the effect

on the

outputs?

What are

the

causes?

How can

these be

found or

prevented

?

How

bad?How

often?

How

well?

Risk Priority Number (RPN): Severity X Occurrence X Detect ability = RPN #

Severity of Effect (1=Not Severe, 10=Very Severe)

Occurrence of Cause (1=Not Often, 10=Very Often)

Detection of Current Controls (1=Likely to Detect, 10=Never able to Detect)© 2016 International Business Machines Corporation

Example from our LEAN workshop:

FMEA with paper and sticky notes


Waste elimination strategies

Once Waste (NVA) is identified:

1.First Priority: Eliminate (do not improve an activity that should be

eliminated)

2.Second Priority: Automate

• Poka Yoke

• Auto populate

3.Third Priority: Simplify

• Reduce handoffs

• Eliminate redundancy

• Co-locate and sequence tasks

• Reduce approvals

• Standardize

• Reduce motion

• Prioritize efforts

• Balance resources

• One piece flow

• 5S


Poka Yoke Ideas

• Reduce NVA by eliminating rework loops, auto populating data entry

– Drop down menus for data entry

– Color coding items that go together

– Manual processes automated (not manumated)

– Electronic sensors for danger areas

– Bar coding

– Collision detection systems

– Correct position setting tape so item is always placed in the correct

location

– Barriers to electronic files

– Computerized Physician Ordering Systems

– Plug protections for children

http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/mistakeproof/mistake8.html


5S Detail Steps

1. Sort: Keep only what is needed, discard

everything else. Sort the remaining into

categories

2. Store: A place for everything and

everything in its place. Store and label all

items in an area that is easily visible and

accessible to the group.

3. Shine: Keep the workplace tidy and

organized and labels obvious.

4. Standardize: All areas must be set up

exactly the same way.

5. Sustain: Maintain, plan, schedule, train,

track and audit all areas periodically.


Examples of 5S

http://www.moreeffective.com/products/5shandbook.html

http://totalqualitymanagement.wordpress.com/2010/03/23/some-

images-of-5s-houskeeping-in-factories-and-offices/

http://5sbestpractices.ning.com/photo/tool-shadow-

boards-before-and-after?context=user

http://runningahospital.blogspot.com/2009/10/5s-projects-are-spreading.html

Labels Styrofoam Inserts

Clear Visuals

Archived Obsolete Files

Set in Order


Finally: Map the “to be” process

As-Is

To-Be

Map the “To Be” with

all combined ideas

and create an action

item list to start

implementing them!


4. IMPLEMENT THE SOLUTION

AND LET THE PATIENT PULL

VALUE THROUGH THE WORK

FLOW.

Up to this point, everything is still on paper


• Kanban is literally a “signal” that something needs to be ordered or that

the next step in the process is now ready for the entity flowing through

• No one from an upstream step moves the entity to the next step until

the next step is ready for it

• Only reorder when signaled (the Kanban card is on top)

A Kanban can help with Pull

Pull

Step 1 Step 3 Step 4 Step 5Step 2

“I’m ready!”


Now, it’s all about Change Management

http://aurorasblog.com/2013/05/15/im-not-too-busy-part-2/

Let the fun begin


It’s now all about Change Management

• The easy part is done

• Now, the real hard part begins

Change is individual not organizational


16% 16%68%

PioneersWill embrace and support

the change early. Won’t

understand why it took so

long

DinosaursWill never accept the change

and will fight any efforts to

get them on-board

SettlersWill go along with the

change once it has been

proven ‘safe’ for them

Get the Pioneers to help you pull up Settlers

This group is already on

board and will pull

others to join

This group, the majority,

is watching to see

what happens

This group is afraid

of losing its value

Early Adopters

Majority

Laggards

The Adoption Curve


Kotter’s 8-Steps for Managing Change

1. Create a sense of urgency

2. Form a guiding coalition– Those who can help move the project forward

– Up and down the organizational hierarchy

3. Create a vision of the future

4. Communicate the vision

5. Empower action

6. Create short term wins

7. Don’t let up

8. Make change stick

Kotter’s 8-Steps can help with change management


5. MAINTAIN THE GAIN AND

PURSUE PERFECTION.


Compare before and after measures

• Measure Before VS After and report on improvement

Before

After


Monitor and Close: Pursue Perfection

• Go back and review the Charter and patient values from the KANO

• Redefine new and tougher targets

• Find additional waste to remove using the LEAN Criteria

• It takes about 90 days for a change to stick

• Only the Champion can close the project

• Must insist on evidence that the project was successful and when

doing more is not worth the cost to continue

• Monitoring and measuring the key measures must

continue…FOREVER


IN CONCLUSION


End toend

ProcessingApprovalsRework


TechnologyIBM WH

EMRPeopleSoft

Etc…

PeopleKnowledge,

Skills,Abilities

ProcessWays of Working

Why LEAN? To Optimize all three bubbles

Training & ExperienceProcesses


Systems

Tools

If you want more, we have our LEAN

Fundamentals Workshop for Healthcare coming

up in July

For more information email: [email protected]

Or visit the LEAN Fundamentals Workshop website

https://www.ibm.com/events/ast/lean/16leanhealth.nsf.


mailto:[email protected]

https://www.ibm.com/events/ast/lean/16leanhealth.nsf

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a brief on lean fundamentals for healthcare · define value from the customer’s perspective. 2....

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