Radiology and Lean Leadership


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Radiology and Lean Leadership

  1. 1. Radiology and Lean Leadership Howard B. Fleishon, MD, FACR, MMM Medical Director Department of Radiology John C. Lincoln North Mountain Hospital Disclosure: Council Vice Speaker American College of Radiology Learning Objectives:1. Introduction to concepts of “Lean” process engineering.2. Applications of Lean principles in Healthcare3. Present pros and cons of “Lean”
  2. 2. “The future ain’t what it used to be.” Yogi Berra “Make no mistake: The cost of our health care is a threat to our economy. It’s an escalating burden on our families and businesses. It’s a ticking time bomb forthe federal budget. And it is unsustainable for the United States of America.” President Obama speech to the AMA, June 15, 2009
  3. 3. Bending the Cost Curve - Medicare Costs as % GDP Redefining Health Care“The patients medical condition is the unit of value creation in health care delivery” Michael Porter “Redefining Health Care”
  4. 4. Institute of MedicineAn epidemic of waste blights the US healthcare delivery system. Despite a hugededication of resources to health care inthe United States, the medical system doesnot deliver safe, effective, efficient,patient-centered, timely, and equitablecare as recommended by the Institute ofMedicine.1 Institute of Healthcare Innovation “All organizations, including health care and Radiology organizations, are composed of a series of processes, or sets of actions intended to create value for those who use or depend on them”
  5. 5. Institute of Healthcare Innovation“Agreement is growing among health care leadersthat lean principles can reduce the waste that ispervasive in the US health care system. The Institutefor Healthcare Innovation believes that adoption oflean management strategies, while not a simpletask, can help health care organizations improveprocesses and outcomes, reduce cost, and increasesatisfaction among patients, providers and staff.”"We need health care that is sustainable andexcellent – both. That will require rethinkingour work and redesigning our systems ofcare boldly and guided by proper theory.Lean thinking and true patient-centerednessare not just compatible; they are, at heart,the very same thing.“Donald Berwick, MD, MPP, FRCP, founder and former President and CEO of the Institute for Healthcare Improvement
  6. 6. What is “Lean” • Management strategy to improve processes. • In any given process, distinguish value added steps from non-value-added steps. • Eliminate waste so that ultimately every step adds value to the process. • Evaluate processes by accurately specifying the value desired by the end user. • Making value flow from beginning to end of a process based on the expressed needs of the customer/patient. What is “Lean” “Lean” is the identification and steady elimination of waste through:  The implementation of first time quality approaches to work.  Standardization of processes  Smoothing of flow  Flexibility of work  Long term relationships with customers and vendors  Reduction in time leading to cost reduction and business improvement “Lean” CompaniesAbbott Tool Works Industries Ravalg Sug FBoeing Company Intel Corporation S&P 500 Index, RTHCarlo Scodanibbio Johnson and Johns SSE Composite Index Industrial Consultant NASDAQ Stanley WorksDanaher Newell Rubbermaid Steelcase Inc.Danaher CP Nike Inc. CL B Tesco PLCDeere Company Parker Textron Inc.Djia Parker Hannifin C ToyotaFord Pentair, Inc. VolkswagenGlaxo Pfizer Wabtec CorporationHillenbrand Inc. Pinnacle West Capitol WabtechHospira Rajvir Industries WyethIBM
  7. 7. Lean Industries: Validated Industry Averages• Direct Labor/Productivity Improved 45–75%• Cost Reduced 25–55%• Throughput/Flow Increased 60–90%• Quality (Defects/Scrap) Reduced 50–90%• Inventory Reduced 60–90%• Space Reduced 35–50%• Lead Time Reduced 50–90%*Summarized results, subsequent to a five-year evaluation, from numerous companies (more than 15 aerospace-related). Companies ranged from 1 to >7 years in lean principles application/ execution. Source: Virginia Mason Medical Center Source: -- Mark Graban Virginia Mason Production System Reduced lab reporting times by more than 85% Improved time nurses spend in direct patient care from 35 % to 90 %. Reduced bedsores from 8% to less than 2% Saved $1 million in supply expense in 2009. Reduced professional liability insurance 48.9 percent from 2004 to 2009. Pharmacy improved medication from 2.5 hours to 10 minutes, reduced incomplete inpatient medication orders from 20 to 40 percent to less than 0.2 percent Saved $8 million in planned expansion projects since 2002
  8. 8. Seattle Children’s Hospital Continuous Performance Improvement• Cut costs per patient by 3.7 percent for a total savings of $23 million.• Avoided spending $180 million on capital projects by using its facilities more efficiently.• Served 38,000 patients, up from 27,000, without expansion or adding beds.• Reduced the average waiting time for non-emergency M.R.I.’s from 25 days to 1.5 days. University of Pittsburgh Pittsburgh Regional Healthcare Initiative• Reduced catheter related infection rates dramatically.• Pathology decreased staff by 28% through attrition.• Time needed to order inventory was cut from eight hours weekly to minutes daily.• Stock levels were reduced by 50%.• Overstocking and rush orders due to stock outs were virtually eliminated. 46ACE63F1B1C/0/ ShadysideSuccessStory.pdf ThedaCare Improvement System Collaborative Care Units• Patient Satisfaction- from 68% to 90%• Quality of Care- Pneumonia: 38% to 95%• 30% reduction in costs• Projected improvement in NPV when disseminated throughout the system: 63% or more than $23 million
  9. 9. University of Michigan Michigan Quality System Projects• 2 day reduction in LOS for uncomplicated cardiac patients• Over 30 minute per patient decrease in time spent in ER waiting room• 4 hour decrease (from 7 hours to 3 hours) in time from ER MRI requisition to scan started• 34% improvement in payments posted within 3 days of receipt• Interventional Radiology on-time starts improved from 13% at baseline in July 2007 to 58% in January, 2010Ontario Wait Time Information Program• CT avg wait time: 42% improvement• MRI avg wait time: 12% improvement The Application of Lean Thinking to the Care of Patients With Bone and Brain Metastasis With Radiation TherapyResults and Conclusion: Reduced the number of individual steps to begin treatment from 27 to 16 Percentage of new patients with brain or bone metastases receiving consultation, simulation, and treatment within the same day rose from 43% to nearly 95%. “By implementing the ideas of lean thinking, we improved the delivery of clinical care for our patients with bone or brain metastases.”
  10. 10. MRI Room Turnover Process START: Previous patient off exam table. Process END: Current patient on table Before: Observed Cycle Time = 17.5 minutes includes 14.5 minutes waiting for patientTransporter Transport Get w/c, Transport prev Pt to cart if Pt to MRI Unit needed START Tech Clean, Patient Position, resupply WAIT FOR PATIENT to Exam Instruct END room Table Patient After: Observed Cycle Time = 4.1 minutes, includes 0 minutes waiting for patient Patient “on TransportTransporter Get w/c, Transport cart if deck” before prev Pt to Pt to MRI procedure Unit needed Clean, Patient START resupply to Exam room Table Position, Instruct END Tech Patient TPS - Basis for Lean The Toyota Production System (TPS) is a major part of the more generic "Lean manufacturing". TPS is the philosophy which organizes manufacturing and logistics at Toyota, including the interaction with suppliers and customers.
  11. 11. Learning to Lead at Toyota-4 Principles• There is no substitute for direct observation• Proposed changes should always be structured as experiments• Workers and managers should experiment as frequently as possible• Managers should coach, not fix Lean Manufacturing is a manufacturing philosophy which shortens the time between the customer order and the product build / shipment by eliminating sources of waste. Business as Usual CUSTOMER Waste PRODUCT ORDER BUILT & SHIPPED Lean Manufacturing Time CUSTOMER PRODUCT ORDER BUILT & SHIPPED Waste Time (Shorter) “Waste” in TPS The original seven wastes are: 1. Transportation 2. Waiting 3. Inventory 4. Motion 5. Over Processing 6. Defects 7. Rework There has now been identified an 8th Waste 8. Unused Human talent
  12. 12. “Lean” and Quality "It turns out--what weve learned," summarizes Kaplan, "is that the best way to improve quality is to eliminate non-value-added variation. This is a way, a method for that. And its working!“ Gary Kaplan, MD Chairman and CEO Virginia Mason Lean Thinking as the Scientific Method Applied to Daily Work Scientific Method Lean Thinking • Observation • Go see, ask why, respect • Hypothesis • Plan P • Intervention • Do D • Results/reflection • Check/reflect C • Revise hypothesis • Adjust A • New intervention… • Repeat PDCA cycle… • Structured abstract • A3 report, Value Stream Map 35MANAGEMENTSYSTEMS MINDSET METHODS
  13. 13. Culture Change Culture Shift Traditional Culture Lean Culture• Function Silos • Interdisciplinary teams• Managers direct • Managers teach/enable• Benchmark to justify not • Seek the ultimate performance, improving: “just as good” the absence of waste• Blame people • Root cause analysis• Rewards: individual • Rewards: group sharing• Supplier is enemy • Supplier is ally• Guard information • Share information• Volume lowers cost • Removing waste lowers cost• Internal focus • Customer focus• Expert driven • Process driven Applications in Radiology• Standard Work Protocols Policies Structured reporting Standard Lexicon• Streamline workflow in Billing and Collections
  14. 14. Criticisms of Lean• Standardization versus patient variability• Standard work flow and lack of inventory and may not be able to readily adapt to rapid changes in demand (i.e ER). ?mod=googlenews_wsj#articleTabs%3Darticle• Reiteration of past methods- Six Sigma, CQI, etc. Summary• “Lean” is a method of process engineering based on the Toyota Production System.• As Radiology group leaders we should be aware of “Lean’s” increasing profile in healthcare.• Potential applications in Radiology ASRT Code: VAD0110025
  15. 15. Books: References• Womack, Jones. Lean Thinking. (An overview)• Liker. Toyota Way. Liker, Meier. Toyota Way Fieldbook. Liker, Hoseus. Toyota Culture.• Shook. Managing to Learn. (Best book on leadership in a lean organization and A3 use)• Sobek, Smalley. Understanding A3 Thinking. (Problem solving and A3 use)• Dennis. Getting the Right Things Done. (Strategy deployment or hoshin kanri)• Rother, Shook. Learning to See. (Value stream mapping)• Baker, Taylor. Making Hospitals Work (From Lean Enterprise Academy, UK)• Graban. Lean Hospitals. (Applies Lean principles to health examples)Articles:• Kim, Spahlinger, Kin, Billi. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med. 2006;1:191.• Kim, Hayman, Billi, Lash, Lawrence. The Application of Lean Thinking to the Care of Patients With Bone and Brain Metastasis With Radiation Therapy. J Oncology Practice. 2007;3:189.• Kim, Spahlinger, Kin, Coffey, Billi. Implementation of Lean Thinking: One Health Systems Journey. Joint Commission J Quality and Safety 2009;35:406.• Bush. Reducing Waste in the US Healthcare System. JAMA 2007;297:871.• Spear. (all Harvard Business Review) Fixing Health Care from the Inside, Today (9/05); Learning to Lead at Toyota. (4/04); Decoding the DNA of Toyota Production System. (9/99)• IHI. Going Lean in Health Care• Michigan Quality System at UMHS:• Lean Enterprise Institute: webinars, books, meetings…• Lean Healthcare Value Leaders Network• Lean Enterprise Academy (UK):• Ideal Patient Care Experience at UMHS