Lean for Non Profits - Full Presentation


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  • 8:00 –Welcome and IntroductionsASQ LeadershipUnited WayOther DignitariesAdministrative details:Restrooms,Smoking, Breaks/lunch
  • What Is ASQ?ASQ is a global community of people passionate about quality. We share the ideas and tools that make our businesses, organizations, and communities work better. We offer technologies, concepts, training, solutions, and an active network of quality practitioners, leaders, and innovators second to none.ASQ’s more than 80,000 members—including Enterprise members and Site members—are building the future of quality. They’re advancing the ideas, tools, techniques, and systems that will help the world meet tomorrow’s critical challenges.ASQ Is a Global CommunityHeadquartered in Milwaukee, WI, ASQ champions people passionate about quality in more than 150 countries. ASQ Global operates National Service Centers in India, China, and Mexico, and has World Partners in more than 80 countries.Our global offices provide local access to community, career development, credentials, knowledge, and information services.ASQ HistoryASQ has been at the forefront of the quality movement for 65 years. We trace our beginnings to the end of World War II, as quality experts sought ways to sustain quality improvement. ASQ played a crucial role in upholding these practices.Today, we continue to champion innovations in manufacturing, service, healthcare, education, government, social responsibility, and other fields.ASQ MembershipWhen members join ASQ, they join a community of people passionate about quality who make our world work better.
  • Refer to the agenda in the binderOur objective todayConsistently being effective at meeting your customers needs while making best use of the available resources
  • Take a moment to introduce yourself at your table and discuss this information:
  • See the directions for the paper tearing exercise
  • 8:20 – Indiana General Hospital as example organizationImproving the effectiveness of doing what you do with the resources you have availableIn the weeds and ability to back up and see the big picture
  • 8:30 United Way representative talking about the application process and why continuous improvement is important– 45 minutesAfter – breakWhat you do well & what you struggle with (post it notes)
  • 9:15We met with many of youUnited Way focus on Education, Health, IncomeTo do more work to do than can be done and minimal staff is overworkedAmazing stories of lives you touch every dayASQ’s obligation to help our community by sharing information to help you with these thingsWe have a passion for improvement, whether industry or communityMy experience as an LCR – working together like a puzzle as a safety net
  • Value flow map that we will be referring to today, I will step you through itLeft to right
  • MissionAn organization's basic purposes, often in terms of broad outcomes that it is committed to achieving or the major function it carries out (compelling reason)Why does your organization exist? How do you help your customer meet their need? Access to servicesWhat are you there to do?Formally and informallyExercise - Put that information into the top right box of the diagramAny entity that attempts to operate without a mission statement runs the risk of wandering through the world without having the ability to verify that it is on its intended course.
  • A vision statement what your organization will look like in the future but it’s so much more than that. A vision statement may apply to an entire organization or to a single division of that body, answering the question, "Where do we want to go?“A vision statement is for you and the other members of your company to unite, not for your customers or clients.Exercise- Fill in the lower box on the right
  • Customers – a recipient of your goods and/or services, which may be purchased or given. May be clients, internal customers, external customersStakeholders a person, group, or organization that has an interest or concern in your organization and may be affected by your actions – have something to gain or loose based on your work and how successful you are at itExamples: The Board, investors, employees, community, ASQ sectionExercise – fill in information
  • The benefit that the customer receives from your organizationAspiration of the customer by meeting their needIs it customer satisfaction? Customer loyalty?Firms exist to create value for customersExercise– fill in
  • Core processes – Key activities that produce the product , or add value, for your customers.How do you help your customers meet their need?Exercise– fill in
  • Working to fulfill your mission there is never enough to do the work that needs to be done (doing more with less) waste takes away from being effectiveExercise– fill in
  • Take away from you delivering value to the customer – we’ll talk about this more later, but write down any ideas you haveTake a few minutes to discuss with your partner. Don’t hesitate to share because there’s no right or wrong answer.
  • Why do this?What is holding you back from doing more? Space, money, time, etc.How doing this makes it better: quality- do a better job at it cost- Money spent to do it, serve more people or provide more programs lead time – headache relief, time to get to the end pointCommon ways that processes and systems break down, so we’re presenting these to give you ways to look at your processes and make improvement in your organization.Traditionally taught as tools, understand the thinking behind itWays to identify and address waste so it can be addressed, making you more effectiveSome of these ideas will resonate more with you than others
  • Next topic 5SThings that “get in the way” (physically) of you doing your workHow many of you are neat freaks?Have people close their binders and hand out the 5S packet
  • The 5S’s(numbers game)standardization wherever you do itvisual managementExample pictures
  • Literally or figurativelyWhat to do with this itemWho knows about it?
  • When we do it, we do it in a consistent fashion-every place-all things-every wayGood if people move around – different situations or offices
  • Housekeeping and organization
  • Calculator and stapler removed
  • Read benefitsHow relates to lean – waste created by not being neat and organizedShare at your table – how can 5S be used to make your organization more effective
  • Information from Wikipedia on 10/23/2012 on ‘Benchmarking’ and ‘Best practice’Benchmarking originally came from cobblers to measure peoples feet for shoes. They would place a persons foot on a bench and mark it out to make the patterns for the shoes.You don’t have to reinvent the wheel. Chances are that someone has struggled with the same thing (or something very similar) and has come up with a solution that can be implemented quicklyBest practices may be templates/forms, processes, materialsReview the wall of Well/Struggles
  • After the lunch we had some breakout sessions so that people could get more specific information based on their interest. Some of them included United Way, Volunteer coalition, Quality, 5S, sources of fundingHave some people share what they picked up during the breakout sessions
  • Use the sheet in your packet to create a flowchart for one of your processes you listed. Appropriate level of detail
  • Exercise – turn to next page and get a pen ready
  • http://www.lean.state.mn.us/LEAN_pages/tools_resources_kaizen_facilitator_tandm.html1. Draw a capital M, so the tip of the middle V of the M touches the intersection of the grid lines in the NW quadrant 2. Draw a capital W, so the tip of the middle V of the W touches the intersection of the grid lines in the SW quadrant 3. Draw a capital W, so the tip of the middle V of the W touches the intersection of the grid lines in the SE quadrant 4. Go back to the M you drew in Step 1, and draw a slightly upwardly bowed line that runs from the most eastern point of the M, to the intersection of the grid lines in the NE quadrant. 5. Continue that line from the intersection of the grid lines in the NE quadrant to the most easterly point of the W that you constructed in the 3rd step.  6. Draw a downwardly bowed line from the most western point of the W in the SE quadrant, to the most easterly point of the W in the SW quadrant.  7. In the exact middle of the box between the NW quadrant and the SW quadrant, draw a circle the size of a dime.  8. Draw an inwardly bowed line from the most westerly point of the M created in Step 1, to the top of the circle you just drew in Step 7 9. Draw an inwardly bowed line from the most westerly point of the W created in Step 2, to the bottom of the circle you drew in Step 7.  10. Draw a horizontal straight line about ½ inch in length starting from the middle of the line you created in Step 8.  11. Draw a horizontal straight line about 1/3 inch in length starting from the middle of the line you drew in step 9.  12. Draw a curly-cue about 1 inch in length starting at the upper third of the line you created in Step 5, extending in an easterly direction.  13. Put two dots in middle of the circle you drew in Step 7, arranged horizontally, and about ¼ of an inch apart.
  • Make sure not to print this page so that people won’t see what they’re drawing
  • Key to building a consistently performing organization
  • Opening/closing proceduresCommon processes to trainUse of volunteers
  • There is no silver bullet for standard work – it is different for every organization in every area of work. The key to standard work is keeping it clear and simple, so staff can quickly and accurately complete their work. Below you will find a portion of one agency's standard work. Teachback
  • 1. Define the extent of the task for which you are creating standard work (e.g. starts at… ends at…)Standard work for key tasks in a multi-function processPeople doing the same job will use the same standard workThe end point will be the starting point for the next task in the work sequence.Determine the appropriate standard work requirementsName of processAuthor Revision dateTask name Work sequence (i.e. checklist, procedure) Time allotted for task – next task in sequence3. Gather best practicesWhenever developing a standard work document is collected for standard work, it is important to search for best practices. Observing multiple people doing the same work is a good way to let everyone see how much variation there is from unit to unit and from person to person.4. Create the standard work documentNow that you have gathered the required information, you are ready to create the standard work document (s).5. Train everyone on the standard work documentThis is an essential step. The supervisor is accountable to insure that the employee is doing the standard work as described. Once trained, each employee must be able to demonstrate their ability to perform the standard work well. If they are unable to do the work, they may need to be reassigned to other duties.6. Run the process and observe the resultsOnce standard work has been created and everyone is trained, it is time to start the process and make observations. This is the time to look for improvements.Look for:Training needsInadequate processesWaste in any of the 7 forms7. Make adjustments and modifications to the standard work Standard work should be a document subject to change; however, a process should be implemented for making changes to the standard work. Revision levels should be recorded each time standard work is changed and old standard work should be filed for future reference.
  • Write standard work for opening and eating candy using the form in your packet – be specificShare the standard work with someone else and have them perform it just as you’ve written it – be literal
  • What is it that gets in the way of value being created?
  • -Specialized areas-office space, meeting rooms, public areas. Example at the hospital for surgery area hosting weddings on the weekends.---Nursing stations the same (5S material)-Storage -digging through things, storing the Christmas decorations
  • One last topicA passion for this from my manufacturing daysDealing with the same things over and overWhat is that doing? Stealing resourcesWhat could your resources be doing if they were not in this endless loop? Adding value for the customer.
  • From the sample hospital
  • A local nonprofit organization that takes clothes donations and sells them
  • going back tomorrow – meetings, voice mail messages, and e-mails
  • Hopefully you have some great ideas for improving the effectiveness of your organizationAs you take this back, you will face some resistance
  • Have we been successful?Funding is getting tighter, greater need for your servicesYou have amazing passion for your work and those you serveOur goal:1. To understand what your customer values2. Develop the process to deliver that value3. Continuously improve those processesby identifying and eliminating waste4. Measure and monitor your effectiveness at doing thatSharing with you and now your obligation is to improve your organization and share with others in your organizations and communities
  • Old Adage:“If you always do what you always did, you’ll always get what you always got.”
  • How to be successful as you can be meeting customer needs (creating value) with the resources available (space, staffing/volunteers, capital, $)
  • Thank-American Society for QualitySIAUnited WayOther volunteers
  • FeedbackLessons learnedHow this will apply in your organizationDescribe the barriers you will faceHelp you need & how you would like to be supported
  • Lean for Non Profits - Full Presentation

    1. 1. 1
    2. 2. American Society for Quality 2
    3. 3. Your Speaker  Brian W. Hudson  Lean Six Sigma Coordinator-FSEH  BSIT 1990 and MSIT 1995 from Purdue University  brian.hudson@franciscanalliance.org  765-502-4371  16 Years industrial experience as a Manufacturing Engineer  15 years experience with Lean Production and Six Sigma Associations:  United Way LCR 2012  ASQ Section Program Chair and Secretary  Wabash Valley Lean Network Steering Committee  American Heart Association Heart Walk Chair 3
    4. 4. Today’s Objectives  Learn ways to help our organizations be more effective  Challenge existing attitudes and processes  Identify improvement opportunities  Learn by doing  Have fun 4
    5. 5. Ice Breaker What parts of your organization do you wish would be more efficient? What gets in the way? 5
    6. 6. Exercise #1 6
    7. 7. Indiana General Hospital  The Story – Lean improvement in a non- profit environment – the Emergency room 7
    8. 8. Showing improved effectiveness in outcomes The application process and showing outcomes for your work 8
    9. 9. The feedback from you- The situation you are faced with:  Greater need for our services  Many cutbacks and things are getting tighter  The needs of our customers continue to increase  Expectation of showing outcomes  Doing more with less 9
    10. 10. Customers& Stakeholders Whatdo theyValue? YourMission TheVision for the Future 10
    11. 11. Your Mission  Your mission defines your organizations reason for existence. It embodies its philosophies, goals, ambitions and morals. Customers & Stakeholders What do they Value? Your Mission The Vision for the Future 11
    12. 12. The Vision for the future  Your vision statement is your inspiration, the framework for all your strategic planning.  Addresses the questions  “Where are we headed”  “Where do we want to go” Customers & Stakeholders What do they Value? Your Mission The Vision for the Future 12
    13. 13. Your Customers and Stakeholders  Who are your customers?  Who are your stakeholders? Customers & Stakeholders What do they Value? Your Mission The Vision for the Future 13
    14. 14. Customer Value  What do they value about your organization?  How do you help them meet their need?  How do you measure the value you provide?  #/count  Satisfaction / survey  Outcomes  Other 14
    15. 15. Your Core Processes or Systems  What core processes does your organization use to deliver the value to your customers? Customers & Stakeholders What do they Value? Your Mission The Vision for the Future 15
    16. 16. How does it work together? Values Vision Mission Strategic plan and Measures 16
    17. 17. Your Resources to make it happen  Financial  Labor / time  Equipment / Capital Customers & Stakeholders What do they Value? Your Mission The Vision for the Future 17
    18. 18. The Wastes  Identify the things that take away from the effectiveness of your processes and systems Customers & Stakeholders What do they Value? Your Mission The Vision for the Future 18
    19. 19. What do Patients of Indiana General value?  Favorable patient outcomes  To be treated safely  Implement new procedures & capabilities  Slow the rising healthcare costs 19
    20. 20. 20 Example: Waking up with a crushing headache before work  Wake up with pain  Call for appointment  Go to office  Do paperwork  See the Doctor  Diagnosis: migraine  Get a prescription  Finish paperwork  Go to pharmacy  Do paperwork  Prescription filled  Return home  Take medicine  Pain subsides How long between steps? Which steps add value? How long is each step? “You don't get paid for the hour. You get paid for the value you bring to the hour.” — Jim Rohn, entrepreneur
    21. 21. 21 The aim of Lean is to meet the customer need by understanding what they value, then providing that value in a system without waste
    22. 22. So then we ask-  How do we create that value?  What is it that gets in the way of value being “created”  How are we addressing the things that get in the way? The answers to these questions are the basis for continuous improvement! 22
    23. 23. What we do well What we struggle with 23
    24. 24. Waste 24
    25. 25. Waste  Any activity that consumes resources but creates no value for the customer  Waste can be identified as anything not adding value to the quality or delivery of the final product or service.  Anything our customers would not be willing to pay us to do 25
    26. 26. Exercise #2 Please takes notes on wasteful activities you see in your organization. 26
    27. 27. Waste in Healthcare How much waste is present in Healthcare? "The national numbers for waste in healthcare are between 30% and 40%, but the reality of what we've observed doing minute-by-minute observation over the last three years is closer to 60%.”  Cindy Jimmerson, medical researcher 27
    28. 28. Value-Added Activities  Transforming materials and information into products and services the customer wants. Creating a Birth Certificate Painting Treating a Patient Receiving a P.O. Designing Installing a Phone System 28
    29. 29. Non Value-Added Activities Operations that consumes resources (labor and materials), but don’t add value for the customer. Transferring Information Moving Re-entering Information Rework Inspection/ Testing Waiting 29
    30. 30. Waste  Waste is present in all work at all organizations  The identification of waste and its elimination is the drive for lean processes and continuous improvement.  Recognizing waste in our organizations is the first and most essential step in transforming waste to wisdom. 30
    31. 31. Identifying Waste 31
    32. 32. Identifying Waste  Inventory  Any supply in excess of customer requirements necessary to provide service just-in-time Organization Examples:  Stock of forms  Supply closets with excess supplies  Outdated items 32
    33. 33. Identifying Waste  Motion  Any movement of people or machines in excess of what is necessary to provide required services Organization Examples:  Traveling to get needed items or supplies  Walking across room to answer phone  Travelling to get the paperwork  Hunting for coworkers 33
    34. 34. Identifying Waste  Overproduction  Producing more than needed or Producing faster than needed Organization Examples:  Reports printed and / or mailed when not needed  Printing extra brochures to get cheaper price  Preparing more food “just in case” 34
    35. 35. Identifying Waste  Over-processing  Effort that adds no value to the product or service Organization Examples:  Redundant capture of information  Ordering unnecessary workups  Data entry into multiple systems  Double / Triple checking 35
    36. 36. Identifying Waste  Transportation  Any material or information movement in excess of what is required Organizational Examples:  Transporting items from location to location  Equipment moved to patient location  Information triplicates 36
    37. 37. Identifying Waste  Rework / Correction  Inspection and / or correction of information, products or materials Organizational Examples:  Fixing errors made in documents  Misfiling documents  Dealing with complaints about service  Mistakes caused by incorrect information  Illegible handwriting 37
    38. 38. Identifying Waste  Waiting  Idle time when people wait for people, people wait for machines, or machines wait for people  Waiting accounts for 95% of the time that is required to produce a product or service. Organizational Examples:  Patient waiting rooms  Waiting for call backs  Waiting for drug validation  Waiting for equipment or supplies 38
    39. 39. We must always keep in mind that the greatest waste is waste we do not see! -Shigeo Shingo 39
    40. 40. Housekeeping and organization 40
    41. 41. The goal of 5S training To introduce participants to 5S, the benefits of workplace organization and provide examples of successful workplace improvements. 41
    42. 42. What is 5S? A systemized approach to workplace organization, to keep rules and standards, and to maintain the discipline needed to do a good job. 42
    43. 43. Exercise - Handout 43
    44. 44. 10 13 23 27 30 47 51 58 62 79 40 44
    45. 45. Importance of 5S Quality is improved Productivity in enhanced Safer work environment for all Reduced floor space Reduced cost to operate 45
    46. 46. The 5S’s 46
    47. 47. SORTDefinition: What is accomplished in this step: Guidelines: Information: Identify and eliminate items that are not needed in the workplace Take old, obsolete, and unneeded items out of the work area For each item ask: What is this used for? Who uses this? When was it last used? When and where do we use it? Red Tag system for unneeded items 47
    48. 48. RED TAG  The Red Tag system is a method used to identify items that are found in the work area, but their use and need are unknown or not needed RED TAG Item Description Reason for tagging (circle one) Manufacturer, part number, serial number Dispositioned by and date Quantity and Item value Disposal method (circle one) Special instructions 1. Item not needed 2. Excess material 3. Material outdated 4. Defective material 5. Use unknown 6. Other ____________________ 1. Throw away 2. Destroy-specify date:__/__/___ 3. Return to manufacturer 4. Other ____________________ Contact person for questions
    49. 49. Additional Sort information  Take digital pictures of current state before starting 5S activity.  Establish an area, cart, or table as a red tag zone.  Place unneeded items in this area.  Fill out red tags to determine disposition.  When finished with elimination, take pictures of items accumulated in the red tag area 49
    50. 50. 10 13 23 27 30 47 40 50
    51. 51. SET IN ORDERDefinition: What is accomplished in this step: Guidelines: Information: Arrange needed items so they are in good order and are easy to find, use, and put away Designating a location for the needed items Store commonly used items near the point of use Infrequently used items stored away from the area Organize commonly used items together Label item locations Red Tag system for unneeded items “A place for everything and everything in its place” 51
    52. 52. 10 13 23 27 30 47 40 52
    53. 53. SHINEDefinition: What is accomplished in this step: Guidelines: Information: Clean, wipe, and sweep all of the surfaces in the work area. Paint if necessary. Provide a baseline for keeping the area clean and organized in the future Be safe! Understand how the area became dirty and take steps to eliminate the cause Create an area where cleaning supplies are kept Not just cleaning–but seeing what areas are getting dirty 53
    54. 54. STANDARDIZEDefinition: What is accomplished in this step: Guidelines: Information: Develop a method and schedule to keep everything clean and organized Standardize and maintain the use of the first 3 S’s Develop standards to organize in a consistent manner Visually maintain conditions Create a schedule / checklist to maintain the area See next slide 54
    55. 55. Standardize Guidelines  Make placement of equipment and tools visual as follows:  Blue tape ¼” or ½” on walls, desks, tables when marking designated areas  Optional in office areas  Required in common (shared) areas  1” or 2” Yellow tape on floor for items that move  Required in common areas  Storage areas marked  Supply shelves labeled  Digital photo posted in office area or cubicle showing office organization  Labels (black letters on white) 55
    56. 56. Standardize Guidelines cont’d  Bulletin Board Information  When submitting items for the bulletin boards, please include the date, person responsible for information, and the date for removal.  Common work areas and Meeting Rooms  Standardized Arrangement  Standardized postings and information  Will be framed near entrance to the room  Documentation for training and meetings  Standard items kept in room  Cabinet with refill supplies to be maintained  Specific instructions for facilitator  Room placed in order when finished  Lights turned out  Items replaced as needed 56
    57. 57. Supply organization at Indiana General Color Meaning Symbol Red IV supplies / needles Yellow Urinary supplies Brown GI / Ostomy supplies Blue Respiratory supplies Orange ADL supplies Green Dressing supplies Black Miscellaneous
    58. 58. Sample meeting room layout 58
    59. 59. 10 13 23 27 30 47 40 59
    60. 60. Definition: What is accomplished in this step: Guidelines: Information: Practice and repeat the procedures to have it become a way of life Develop a method to maintain the improvements Audit the workplace to insure its being maintained Review and post the audit results for all to see This is the most critical step by maintaining the improvements by developing discipline “You get what you inspect – not what you expect” SUSTAIN 60
    61. 61. 10 13 23 27 30 47 51 58 62 79 40 61
    62. 62. 62
    63. 63. Nurses Station – Before 5S 63
    64. 64. Sort 64
    65. 65. Set in order 65
    66. 66. Shine (Clean) 66
    67. 67. Nursing Unit Example – After 5S
    68. 68. Supply Closet–Before 5S 68
    69. 69. Closet – After 5S 69
    70. 70. Sorted Items Return to use Trash Donation 70
    71. 71. Other examples of 5S
    72. 72. Book Drawer Labels
    73. 73. Book Storage with Diagonal Tape
    74. 74. Cabinet Arrangement
    75. 75. Desk Drawer Arrangement
    76. 76. Desk Drawer Arrangement What’s missing?
    77. 77. The 5S’s 77
    78. 78. 5S Benefits  Pride in the workplace and supports team development  Sorting means removing unnecessary items that congest the work area  Clean equipment allows everyone to notice problems  Sorting retains only the needed items. This allows for a smaller work area resulting in reduced effort (walking, reaching, etc.) to do the work.  Reduced changeover times result from being organized and minimizing search time. 78
    79. 79.  Get everyone involved  Integrate 5S principles into daily work requirements  Communicate need for 5S, roles of all participants, how it is implemented  Be consistent in following 5S principles in all areas  Follow through - finish what is started - 5S takes effort and persistence  Link 5S activities with all other improvement initiatives Keys to 5S success 79
    80. 80. 80
    81. 81. Benchmarking / Best Practices The process of comparing one’s business processes and performance results to industry bests or best practices from other industries.  Collaborative benchmarking-  Best Practices - voluntarily working with others to develop a method that others can use  Maybe competitors or have similar processes Reference the “Things do well” / ”Struggles” display 81
    82. 82. 82
    83. 83. 83
    84. 84. Definition – Process Mapping Process Mapping, often referred to as Flowcharting, is a visual representation of the work-flow either within a process - or an image of the whole operation. It comprises a stream of activities that transforms a well defined input or set of inputs into a pre-defined set of outputs. Source – www.isixsigma.com84
    85. 85. Processes Series of actions that takes inputs, transforms them and makes an output. A process consists of repeatable tasks, carried out in a specific order. A set of common tasks that creates a product, service, process, or plan that will satisfy a customer or group of customers. Input Output Activity Activity Activity Activity Input 85
    86. 86. Inputs Process Outputs Material Services Information Documents Scrap By-products Data Reports Material Supplies Energy Information Machines Data People Methods Services 86
    87. 87. Why is Process Mapping important?  Help to see the bigger picture and how a process works  Facilitates discussion to break down ‘silo’ barriers between functions  Its use can reveal duplication, waste, over processing or unnecessary steps  It can be used to communicate the vision of where we’re going 87
    88. 88. Symbols used in flowcharts Start / End Task / Step Decision Flow Arrow Burst No Yes 88
    89. 89. # AConnector Document Measurement Delay or Wait More symbols 89
    90. 90. Start Get bread Get JellyGet PB Apply PB&J Open new jar Yes No Assemble sandwich Get potato chips Get a drink Eat lunch End Enough in Jar? A A Buy natural peanut butter Eat carrot sticks instead of chips Drink water instead of soda Flowchart Example-Making lunch 90
    91. 91. Orientation Staff Director Front Office Staff Application ReviewApplication Review Make sure folder is complete Send folder to faculty committee Send denied letter; signed by faculty Share folder with all Review folder materials no yes Send packet about registering and orientation Admission decision Swimlane Chart 91
    92. 92. Four Techniques of Process Mapping 1. Macro (high level) 2. Micro (lists all sub-processes) 3. Current State – “as is” today 4. Future State – “could be” state 92
    93. 93. Current State vs. Future State How the process works today How the process will function after the changes Run Cypress reports (2X month on 12th and 24th) for previous month Get reports from Carl on 25th of month Linda-Develop pull lists in Excel & notify Michele/Cathy that it is ready Pull charts, put into carts, identify, and scan to PI Data abstraction, mark chart, and update pull list Update definitions on worksheets & communicate to staff Scan chart back to Medical Records File information sheets in folders Linda/Michele enter information into COP Stop automatic print of Cypress report on 24th (Cathy) Have someone else maintain pull list from data (Linda) Training communication to staff for changes Folder with latest worksheets (Michele) Cook the disk and deliver (Due date is1st day of 3rd month after qtr.) File report COP accumulates information and sends CD Copy report and take to Committees File report Wait Request for 5 charts Send for review after being identified by PI Get feedback Is score less than 80? Yes No May appeal End Start Access to QNET score - more people with access (Linda) Print summary sheets of CMS data and file Run Cypress report (Monthly on 12th) for previous month Get reports from Carl on 25th of month Linda-Develop pull lists in Excel & e- mail staff that it is ready Abstract data, mark chart, & highlight pull list in yellow Update definitions on worksheets & communicate to staff File information sheets in folders Enter information in COP, & highlight pull list in pink Submit data on website (Due date is1st day of 3rd month after qtr.) COP accumulates information and sends CD Copy report and take to Committees Wait Request for 5 charts Send for review after being identified by PI Get feedback Is score less than 80? Yes No May appeal End Start Print summary sheets of CMS data and file 93
    94. 94. 1. Document the Current State map 2. Identify bursts with the current process 3. Develop the Future State map 4. Make the Action Plan to achieve the Future State 5. Work on the Action Plan 6. Go back to the beginning How you go about it- 94
    95. 95. Looking for improvements Ask the following questions-  How many steps are being taken for each step?  How many handoffs are there between staff  Or between departments?  How much time is taken for each step?  What is the total time from first to last steps?  Where do delays occur?  What value does each step contribute?  Where is flow stopped in this process? 95
    96. 96. Identify bursts with the current process What quality issues exist? Where is the process bottleneck? Where is the process inconsistent? 96
    97. 97. Develop the Future State map  How would the process look if we addressed all the bursts? 97
    98. 98. A couple of additional thoughts-  Its not rocket science-making the process map does not have to be high-tech  Its not about blaming or criticizing anyone or any department  ‘Go see’ the process  This is only the starting point that will lead to a lot of other improvements  Its fun! 98
    99. 99. A # No Yes Review- 99
    100. 100. Exercise #4  One of your processes – Using at least 4 symbols 100
    101. 101. How can you use this in your organization? Process mapping 101
    102. 102. “Where there is no standard, there can be no kaizen.” Taiichi Ohno Vice-president, Toyota Motor Corporation 102
    103. 103. Exercise #5 103
    104. 104. 104 1 2 3 4 5 6 7 8 9 10 11 12 13
    105. 105. Standard Work Defines consistent performance of a task, according to prescribed methods, without waste, to make most effective use of the resources People Materials Methods Equipment Without Standard Work there can be not sustained improvement Inconsistent Process Inconsistent Results Desired Results Consistent Process 105
    106. 106. What is Standard Work?  A simple written description of the safest, highest quality, and most efficient way known to perform a particular task, (i.e. a checklist to lead someone through the task).  The only acceptable way to do the process it describes.  Expected to be continually improved  Needed in most, if not, all work areas  May be met with resistance by staff. 106
    107. 107. Standard Work  Standard work supports the lean system of continuously improving capacities and efficiencies by defining 3 critical elements for every person doing the work 1. The most efficient work routine / procedure or steps 2. The elapsed time required to complete work elements and move to the next step of the process 3. Any quality checks required to minimize defects/errors 107
    108. 108. Example of standard work (TWI) http://www.trainingwithinindustry.net/JBS-IPOV.pdf 108
    109. 109. Standard Work information • Includes the amount of time allotted to hand-off the task to the next step of the process. • Focuses on the person, not the equipment or materials • Reduces variation, increases consistency 109
    110. 110. Steps for Creating Standard Work 1. Define the extent of the task for which you are creating standard work (e.g. starts at… ends at…) 2. Determine the appropriate standard work requirements 3. Gather best practices 4. Create the standard work document 5. Train everyone on the standard work document 6. Run the process and observe the results 7. Make adjustments and modifications to the standard work 110
    111. 111. Tips for Creating Standard Work DO:  Keep standard work simple  Make it accessible  Include all information on one, easy-to-read document  Create one standard work document for each part of the process  Always look for ways to improve the process. 111
    112. 112. Tips for Creating Standard Work  DON’T: • Put standard work in a desk drawer • Change processes without changing standard work • Make standard work difficult to change • Give up on standard work – it can be tough, but it’s very important 112
    113. 113. Role of the Supervisor The supervisor should ask the following 4 questions for every person who will perform standard work: 1. Do you understand why it is important for you to follow the standard work? 2. Are you willing to follow the standard work? 3. What are the consequences for choosing not to follow standard work? 4. What is the process for changing standard work? 113
    114. 114. Exercise #6 114
    115. 115. 115
    116. 116. “To move or run smoothly with unbroken continuity, as in the manner characteristic of a fluid.” www.answers.com/topic/flow on 5/29/09 Customer flow – the “movement” of customers through the process creating value Flow – what is it? 116
    117. 117. What does it look like? 117
    118. 118. 118
    119. 119. What is the affect of not having flow? Not having flow creates waste- 119
    120. 120. Registration Arrival EKG IR ICU Lab Cath Lab Surgery Intake Unit CT X-Ray PAT ED Inpatient Rehab Inpatient Units MRI PT Discharge RT 120
    121. 121. And waste consumes resources 121
    122. 122. What can impede flow and keeps us from having it? You have to understand why flow is not present 122
    123. 123. A. Focus on the constraint or bottleneck of the process B. Identify how the process is inadequate– methods, equipment, etc. C. Changeovers take too long D. The area is not organized and ready for work E. Quality or scrap issues exist that consume time and resources Strategies for improving flow 123
    124. 124. A. Constraints and process bottlenecks  Every process has a constraint that limits its throughput (capacity) 124
    125. 125. Five focusing steps 1. Identify the system’s constraint 2. Exploit the system constraint 3. Subordinate everything else to the constraint 4. Elevate the system’s constraint 5. Go back to step 1 The Goal – Eli Goldratt 125
    126. 126. vs. Flow and Pull 126
    127. 127. 127
    128. 128. Facility layout Making best use of land, facilities, equipment, furnishings to deliver value  Facilities are expensive to obtain and maintain  Layout can often dictate how the processes is done in an organization 128
    129. 129. Facility Layout factors to consider  Arrangement according to how often its used (ABC)  Flow and steps in common processes (__ times/day)  Specialized areas vs. flexibility in layout  Consider other facilities at your disposal  Have arrangement be consistent between locations  Minimize storage and handling 129
    130. 130. 130
    131. 131. 1. Identify and define the problem 2. Organize the team 3. Describe the problem 4. Contain the problem 5. Find the root cause 6. Generate, select, & verify the corrective action 7. Implement the permanent corrective action 8. Prevent reoccurrence 9. Communicate and congratulate the team The problem solving process 131
    132. 132. 3. Describe the problem What do we know about the situation?  Is this common cause or special cause?  Collect the relevant data  Create a process flowchart Process step Process step DecisionBegin End Yes No Process step Process step Process step 132
    133. 133. 5. Identify the Root Cause  Tools to analyze-  5-why  Brainstorming  Pareto diagram / histogram  Failure Mode and Effects Analysis  Cause and Effect (Fishbone diagram) 133
    134. 134. 5 Why example –“I was late for work”  Why were you late for work?  Because I had to park far away  Why did you have to park far away?  Because the close spots were full  Why were the close spots full?  Because I arrived later than other people  Why did you arrive late?  Because I left the house late  Why did you leave the house late?  Because I forgot to set the alarm  Solution - Buy an alarm you only set once and it goes off the same time every weekday. Make sure it has battery backup in case of power failure. 134
    135. 135. Take Action  Examine the prioritized ideas  Develop specific action items that will address root causes and reduce risk  Important to assign a person responsible for each action item, and a due date for completion  Need to follow up on assigned actions 135
    136. 136. Hierarchy for improvement actions  Weaker actions– Vigilance and hard work  New memorandum, policy, or procedure  Training and personal reminders  Double checks  Intermediate actions– Address Human Factors  Redundancy, checklists, reminders  Software modifications  Stronger actions– Sophisticated behavioral changes  Architectural / physical changes  Control or interlock (force function)  Removing unnecessary steps or ability to do task 136
    137. 137. 8. Prevent reoccurrence Prevent it from happening again by asking the questions:  Where else-  Who else-  How else- Revise the system as needed-  Procedures  Training  Consider all current and future staff could this exist? could this potential problem exist? has the same system? has the same process? would this be done? 137
    138. 138. Bringing it all together 138
    139. 139. Indiana General Emergency Room  Goal Statement: 1. Improve the ‘Door to Doctor’ time for ER patients to achieve goal of 30 minutes 2. Roll out improvements to other hospitals  Project Scope: Start: Patient arrival at the ER door Stop: Time when the Patient is seen by the Physician Includes: All ER patients entering through door Excludes: Those arriving by ambulance 139
    140. 140. Baseline information – Average Door to Doc- just over 45 minutes Average Length Of Stay – About 3 hrs. 15 min. Home Hospital LWBS January 2006-December 2007 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Date %RateofLWBS Rate Average of 1.66% Indiana General. 140
    141. 141. Patient travel with current layout TRIAGE REGISTRATION ED WAITING ROOM Patient travel with the existing layout 141
    142. 142. How the team went about it A two-day event focusing on:  Change management  Process mapping  7 kinds of waste  Constraint management 142
    143. 143. Swim-lane chart of the process Earlier in process on top-later below Several places where waiting occurs Kaizen bursts Red circles indicate the critical path Registration ED Staff- Bedside Nurse Home Hospital Patient Triage and Registration Flowchart ED TriagePatient Pt arrives & goes to Triage window Take chart form & go to Central Registration Pt identified- Medical chart & complaint W AIT Full Reg- Scan, consent, co-pay ID, Paperwork, insurance Go to Triage window with papers Triage pt- Medical hist., allergies, stickers, med rec, etc. Patient goes to assigned bed Patient changes into gown and gets situated Patient seen by Doctor Discharge and exit interview W AIT W AIT W AIT W AIT Register in Affinity Scan, consent, co-pay ID, insurance Assemble paperwork and send patient to Triage window Upgrade patient Update information not obtained at Registration Assign pt to bed, give report, put pt on board Report from Triage nurse Discharge and exit interview Dr.’s orders S.O. IV’s, ekg, x-ray, blood draw Primary assessment c/o, hx of c/o Clean bed, pt off tracking board, chart to basket W AIT W AIT W AIT Triage pt- Medical hist., allergies, stickers, med rec, etc. Complaint and time of arrival documented-send pt to Reg Pt arrives & goes to Triage window W AIT Registration ED Staff- Bedside Nurse Home Hospital Patient Triage and Registration Flowchart ED TriagePatient Pt arrives & goes to Triage window Take chart form & go to Central Registration Pt identified- Medical chart & complaint W AIT Full Reg- Scan, consent, co-pay ID, Paperwork, insurance Go to Triage window with papers Triage pt- Medical hist., allergies, stickers, med rec, etc. Patient goes to assigned bed Patient changes into gown and gets situated Patient seen by Doctor Discharge and exit interview W AIT W AIT W AIT W AIT Register in Affinity Scan, consent, co-pay ID, insurance Assemble paperwork and send patient to Triage window Upgrade patient Update information not obtained at Registration Assign pt to bed, give report, put pt on board Report from Triage nurse Discharge and exit interview Dr.’s orders S.O. IV’s, ekg, x-ray, blood draw Primary assessment c/o, hx of c/o Clean bed, pt off tracking board, chart to basket W AIT W AIT W AIT Triage pt- Medical hist., allergies, stickers, med rec, etc. Complaint and time of arrival documented-send pt to Reg Pt arrives & goes to Triage window W AIT 15 Pieces of paper for Registration Finding nurse to give report M ore in-depth assessm ent Searching for patient One person in Triage Adjusting tim e in system for when pt arrives Pt. goes to Triage, Registration, back to Triage No privacy for patient Key Critical Path Im provem ent Burst 143 Indiana General
    144. 144. Inventory  Chairs in the triage area  Use of counter space Motion  Patient - 6 points before getting to a bed  ER going to get patient – bed, nurses station and entering into tracking board  Going to waiting areas to find the patient  Finding wheelchairs  Getting gown & blanket in the room for patient  Triage nurse leaving the triage area  Registration walking between printers  Sorting the paperwork – stickers  Moving L&D patients upstairs Overproduction  Unneeded tests or specimens used  Getting extra information from patient  Only 3 face sheets needed instead of 4 Overprocessing  Duplicate documentation like nurses notes Transportation  Movement of patient triage  registration  triage  bed  Taking patient for Radiology or lab tests Rework / correction  Incorrect information for the patient  Several calls to register one patient  Medicaid printout / scanning - on-line insurance eligibility  Timely ER tracking board information Waiting  Waiting to register / triage  Waiting for a bed – clean or occupied  Results from Lab or Radiology  Physician  change of shifts  seeing other patients  waiting for a patient to get through the process  Clinical processing of patient 7 Kinds of Waste 144
    145. 145. The approach  Looked at the current floor plan to see how they could improve flow with minimal changes  Analysis of staffing patterns – when do patients arrive and how many staff to have  Roles and responsibilities of the staff analyzed– who needs to be doing what? 145
    146. 146. Improvements implemented Changed location of the check-in desk and made use of rarely used area Revised the physical layout of the area Added one additional Registration person Implemented the bedside and ‘Quick registration’ process 146
    147. 147. Patient travel with the new layout TRIAGE REGISTRATION ED WAITING ROOM 147
    148. 148. Project Results  Reduced average LOS by 29 minutes  Reduced ‘Door to Doc’ time by 16 mins.  Reduced ‘Door to bed’ time by 7 minutes  Improved patient satisfaction by 7 points 148
    149. 149.  Cross-functional team involvement  Keep it simple when making changes  We’re not waiting for it to be perfect  Implementation plan  Small scale start  Daily debriefing to identify opportunities and changes to be made  Don’t sweat the big stuff Lessons Learned 149
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    154. 154. 154
    155. 155. Putting it all together  Culture change  Empowerment  Vision & alignment (rowing the boat / true north)  Sense of urgency (addressing waste, speed)  Improvement teams, projects, resources,  Designing new processes (cardboard mock-up),  Overcoming resistance-facilitate / coach vs. author 155
    156. 156. Values Vision Mission Strategic plan and Measures 156
    157. 157. Customers & Stakeholders What do they Value? Your Mission The Vision for the Future 157
    158. 158. Lean challenges you will face  This is not industry, we’re not Toyota, and we’re not making cars  We’ve always done it this way  We’re too busy taking care of clients  Nonprofit world is very much siloed 158
    159. 159. What is a Lean Hospital? It all works together without waste Physicians Cath Lab Surgery Housekeeping ED Radiology Lab HIM Staff L&D PharmacyMaterials Management Food Service Nursing Units 159
    160. 160. Review of objectives  Learn ways to help our organizations be more effective  Challenge existing attitudes and processes  Identify improvement opportunities  Learn by doing  Have fun 160
    161. 161. Lean organizations Working to eliminate waste through:  Goals and measures leading to accountability and driving improvement  Areas organized and arranged  Trained and empowered staff  Smooth and consistent processes working in unison  Problem solving and proactive failure mode analysis  Working to promote the value stream (service line) instead of silos  Getting everyone involved 161
    162. 162. Our Offer to Your Organization  What we are offering - Partnering with our membership on using information on improvement projects 162
    163. 163. Reflection and sharing  What are you going to do when you return 163
    164. 164. Additional Resources  Local ASQ section 0917  Brian Hudson & Sarah-Louise Kerney  Wabash Valley Lean Network - www.WVLN.org  www.lean.org Recommended Readings  Lean Thinking by Jim Womack  Becoming Lean by Jeffrey Liker  The Machine That Changed the World by Jim Womack and Daniel T. Jones  The Goal by Eli Goldratt  Lean Production Simplified by Pascal Dennis 164
    165. 165. Additional Resources  Gupta, Praveen. Six Sigma Business Scorecard. New York: McGraw Hill, 2004. Print.  Hammer, Michael and Lisa Hershman. Faster Cheaper Better. New York: Random House Inc, 2010. Print.  Jackson, Thomas. Hoshin Kanri for the Lean Enterprise. New York: Productivity Press, 2006. Print  Tague, Nancy. The Quality Toolbox. 2nd ed. Milwaukee: ASQ Press, 2005. Print. 165
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