6. The 5 Key Lean Principles
• Value – what the customer buys
• Value Stream – the way the Value is delivered
• Flow – putting value-adding steps in sequence
• Pull – triggering flow from customer needs
• Perfection – continuous improvement forever
source: LEAN THINKING, Womack and Jones, 1996.
Intellectually these principles are easy to understand, making
them routine in your organization is never easy
WhatisLean?
7. - OSHA Recordable Injuries
- HAT Scores
- Employee Engagement Index
- Operating Margin
- Productivity
Financial StewardshipPeople
Safety/Quality
- Preventable Mortality
- Medication Errors
- Access
- Turnaround Time
- Quality of Time
Customer
Satisfaction
True North Metrics
8. Copyright 2010 All rights reserved
Ideal State Information Flow
StaffStaffStaff
Lead
CEO
VP
Sr VP
Super-
visor
Level 1
Strategy
Goals
Purpose
•Mentoring
•Teaching
•Barrier Removal
•Strategy
•True North
Status of the
Business:
•Information
•Continuous
Improvement
•Metrics
•Escalation
Manager
Level 2
Level 3
Level 4
Level 5
Level 6
Level 7
•Goals
•Tactical Management
•Control
•Daily assessment
•50-75% Standard Work
•Executive Functions
•Strategic
•Innovative
•Weekly/Monthly Assessment
•10-25% Standard Work
9. A3
• As a standard process, it becomes easier for
you
– To describe key ideas to others, and
– to understand others
• It fosters dialogue within the whole
organization
• It develops problem-solvers
• It encourages front-line initiative
• Teaches scientific method
10. Deploying Level 1 Priorities to Level 2ThedaCare’s
Strategic
Plan
Safety
(level 2)
People
(level 2)
People
level 2 A3
Safety
(level 2)
Safety
(level 2)
Safety
(level 2)
Safety
(level 2)
Safety
(level 2)
Safety
level 2 A3
Shared Growth
(level 2)
Shared Growth
(level 2)
Shared Growth
(level 2)
Shared Growth
(level 2)
Shared Growth
(level 2)
Shared Growth
level 2 A3
Productivity
(level 2)
Productivity
level 2 A3
Safety A3
(level 1)
People A3
(level 1)
Shared
Growth A3
(level 1)
Productivity A3
(level 1)
Plan Plan Plan Plan
ThedaCare’s Breakthrough Objectives
“Measurably Better Value”
Cross
Function
Team
Cross
Functional
Team
Cross
Function
Team
Cross
Function
Team
Cross
Function
Team
Cross
Function
Team
Cross
Function
Team
Cross
Function
Team
Cross
Functional
Team
Cross
Function
Team
Cross
Function
Team
Cross
Function
Team
Cross
Function
Team
Cross
Function
Team
Cross
Functional
Team
Cross
Function
Team
Cross
Functional
Team
Problem
statement,
background and
targets deployed
11. Background
Why are you talking about it ?
Current Situation
Where do we stand ?
What’s the problem?
Analysis
- What is the root cause(s) of the problem?
- What requirements, constraints and
alternatives need to be considered?
Goal Where we need to be?
What is the specific change you
want to accomplish now?
Plan
What activities will be required for
implementation and who will be responsible
for what and when?
Recommendations
What is your proposed countermeasure(s)?
Follow-up
How we will know if the actions have the
impact needed? What remaining issues can
be anticipated ?
A3 or PDSA: What Are We Talking About?
13. SUPPORT
(shared support of the Delivery, Demand
and Development value streams)
The Lean Enterprise: 4 Key Value Streams
• Businesses typically have four value streams:
Where to start…it depends….
DELIVERY (delivering to customers what the Business sells)
DEMAND (generating demand or orders for what the Business sells)
DEVELOPMENT (developing and improving what the Business sells)
WhatisLean?
14. The 7-Week Cycle of an R.I. Event
• 3 weeks before – Value Stream review, Event
Selection, Select Team Leader/Co-Leader and team
members estimated financial, quality and staff impact
• 1-2 weeks before – RI Checklist, preparation .. Cell
Communication, aim statement, measures
day 1 - current conditions
day 2 – create the future
day 3 - run the new process
day 4 - standard work
day 5 - presentation
1st week after - Capture the savings
2nd week after – Update Standard
Work
3rd week after – CFO validation
•Step 1 “Identify” waste
•Step 2 “Eliminate” waste
19. Doing Lean versus Becoming LeanSummary
Doing LEAN Becoming LEAN
Focus on reducing costs Growing the business by improving processes
Project Business Strategy
Delegated Leadership Top led, constant reinforcement
Tools only used during event weeks Waste ID and elimination part of everyone’s
job
Set of “tools” Strategy for improvement
Complex measures Simple, brief, visual, customer focused
metrics
Internally focused Customer focused
Pushing to sustain results Organizational inertia, everyone owns the
results
Wondering “are we LEAN”? Knowing this is never ending journey, it is not
about “getting there”
23. Value Stream Mapping
• Value Stream Mapping – the visual representation of
the processes (work units and information) required to meet
customer demand
Includes both value-added and non value-added activities
Allows for “seeing” areas of waste in current state
Future state is roadmap and apt to change
Maps should be the plan for 6 months – 2 years
25. Intense 4 day knowledge building session
Multidisciplinary team of experts brainstorm and
share information to kick-off the design process
Gain deeper understanding of cultural, process
and spatial needs of project
Builds trust amongst team members
Team takes ownership
Accelerates design schedule
Facilitated by Simpler and ThedaCare
Improvement System staff
The 2P (Preparation and Process)
26. Team Members: Team Role:
Beth Malchetske Team Leader
Heather Murphy Team Leader
Jill Menzel Facilitator
Mike Franz, Architect Participant
Kelly Jung, Trauma Services Participant
Dan Karlin, TC ICU RN Participant
Katie Klinke, TC ICU Secretary Participant
Christine Krizenesky, TC ICU RN Participant
Sarah Langjahr, Architect Participant
Albert Park, Facilities Planning Participant
Jackie Phillips, Purchasing Participant
Theda Clark ICU Room 2P
Team Members: Team
KC Schuler, Chaplin Participant
Dan Storzer, APAP Participant
David Yeazle, RT Participant
Jaime Ross, TC INU RN Fresh Eyes
Randy Schoenrock, AMC ICU RN Fresh Eyes
Shirley McGlin Customer
Dr. Burkett, Surgical Associates Adhoc
Dr. Georgen, Surgical Associates Adhoc
Dr. Greene, NeuroSpine Adhoc
Dr. Price, Neuro Science Adhoc
Dr. Sekhar, Surgical Associates Adhoc
Dr. Whiteside, FV Pulmonary Adhoc
27. Reason for Action
The ThedaClark ICU will be relocating to a newly designed unit on the 2nd Floor as a
part of Hospital of the Future Initiative. In order to optimize an improved room
layout, the following areas need to be addressed:
• It is challenging in the current physical space to perform key patient
processes
• Provider frustration due to intermediate bed capacity issues
• Lack of effective space for families to be involved in the patient
progression of care
• Hunting and gathering of supplies and equipment takes care team
away from patient care
Scope: Intensive Care Unit and Intermediate Care Unit Patient Rooms
28. Initial State
The current ICU process flows are a result of the 1st Floor location which has limited space
and is not adjacent to intermediate level of care
Currently the ICU and INU are on separate floors which results in:
• A failure to optimize staff with similar skill sets
• An increase in patient transfers, handoffs, and care team changes.
• No association between units even though they provide similar services
The current ICU Room Layout results in waste and defects:
• Nurses spend an average of 4.2% of their time outside the patient room
looking for supplies, equipment, etc.
• The average nurse travels 197 feet per hour when treating patients
• The average respiratory therapist travels 474 feet per hour when treating
patients
• Rooms are crowded when families are visiting making it difficult to provide
care
• In room procedures are inefficient due to lack of supplies and equipment
accessible to staff.
29. Initial State
The current ICU process flows are a result of the 1st Floor location which has limited space
and is not adjacent to intermediate level of care
Currently the ICU and INU are on separate floors which results in:
• A failure to optimize staff with similar skill sets
• An increase in patient handoffs
• No association between units even though they provide similar services
The current ICU Floor Layout results in waste and defects:
30. Broke into 3 groups to develop “paper doll” layouts
Rated floor plans on criteria:
Safety/Ergonomics
Warm/Friendly Family Environment
Common Footprint/Efficiency
Security
Line of Sight
Privacy
Flexibility
Cost
Rapid Experiments
31. Target State
Space that allows family to feel welcome and present for their loved one.
Intermediate Level space that have the ability to go to ICU acuity during surges
Measure Initial Target
Quality % of Patients Satisfied with ICU Family Areas 0% 90%
% of ICU Patient Rooms that are in the care team’s
line of sight
38% > 90%
# Interruptions when charting in Nurses Station 5.5 times per hour 2.8 times per hour
Business # of Interruptions to Patient Care per day to search
for supplies and equipment
360 times per day on
the unit
120 times per day
on the unit
Employee
Engagement
TC ICU physical space supports a private
consultation process
No Yes
Time for workforce response to team need 0-5 minutes 0-3 minutes
35. Confirmed State
Quality
Customer
Business
Employee
Engagement Meeting target
Not meeting target
Measure Initial Target Achieved
Quality % of Patients Satisfied with ICU
Family Areas
0% 90% “Big Time
Improvement”
% of ICU Patient Rooms that are in
the care team’s line of sight
38% > 90% 100%
# Interruptions when charting in
Nurses Station
5.5/hour 2.8/ hour 2.5/hour
Business # of Interruptions to Patient Care per
day to search for supplies and
equipment
360 times per day 120 times per day 63 times per
day
Employee
Engagement
TC ICU physical space supports a
private consultation process
No Yes Yes
Time for workforce response to
team need
0-5 minutes 0-3 minutes 0-3 minutes
36. Copyright 2010 All rights reserved
Leader
Standard
Work
Daily Stat Sheet
Daily Defect
Huddle
Leadership Team
Monthly
Scorecard
Monthly
Performance
Review
Meeting
PDSA
and
Countermeasures
Visual
Management
Leader
Standard
Work
The Business Performance System
37. Business Performance System
• Daily Stat Sheet- Learning & Understanding the
business
• Daily Performance Review Huddle – Daily Problem
Solving in the work
• Leadership Team – The support to see performance,
understand problems & implement responses
• Monthly Scorecard- knowing our numbers
• Process observation-monitoring method for
standard work processes
39. Level: Manager Score Card Owner: Heather Murphy Mgr Monthly Scorecard -(Page 2 )
Hospital Division Drivers: The Performance we must respond to and focus daily improvements on to move the System True North Metrics.
Key: TN/True North, SD/Strategy Deployment HD/Hospital Driver HI/Hospital Initiative HW/Hospital Watch True North Metrics: System measures we aim to improve through our drivers.
Measure of
Source
SD,
HD, HW Department Drivers
YTD Status
(Fillin Red/Green Only No
Numbers)
Sponsor/Owner Measure Of True North Metrics
Safety/Quality Reduce the number of unplanned extubations Rachel Janzen Safety /Quality Reduce the Number of Preventatble Mortalities to (# of mortalities/month)
FinancialStewardship Decrease productive hours/UOS Heather Murphy Safety /Quality Reduce the Number of Medication Errors to (# of med errors/month)
FinancialStewardship Decrease managed expenses/UOS Heather Murphy People Reduce the number of OSHA Recordables to (# of OSHA Rcrdbls/month)
People Reduce turnover to (# of terms/month)
People Increase Employee Health Assessment Tool Scores
CustomerSatisfaction Patient Results Turnaround to (# hours? Turnaround time)
CustomerSatisfaction Increase % of Same Day access (% of pts granted same day/month)
CustomerSatisfaction Qualtiy of Time
FinancialStewardship Increase Operating Margin to x%
FinancialStewardship ProductivityAutomatic feed
Watch Indicators: The Performance we are watching and may only respond to if the metric is changed to a DRIVER. COLOR BOTH THE
MONTH AND YEAR To Date RED OR GREEN
Measure of
Source TN,
SD, HD, HI
HW Watch Indicators Owner
Target or Trigger (only
if there is one)
Previous Year or
Baseline
Estimated
Completion Date Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec YTD Avg YTD % Change vs Baseline)
Safety/Quality
% Completed NIHSS assessments to order written Kristin 90.0% 80.0%
Plan > 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%
Actual > 93.0% 93.0% 90.0% 92.0% -15%
Safety/Quality
%Clinicaltriggers called appropriate to UW-OPO standards Sue 1.0
Plan > 100.0 100.0
Actual > 0.6 0.6 #DIV/0!
People
low rate for forceover hours per 24 hour period Heather 0.4 0.4
Plan > 0.4
Actual > 0.0 0.0 0.5 100%
Safety/Quality
Emergent Airway situations Jenny 0.0 4.0
Plan > rm 246/ICU
Actual > 1.0 0.0 0.0 100%
People TN
Number of unmet competencies bydue date Allyson 0.0 2.0 Plan > 0.00 0.00 0.00
Actual > 2.00 4.00 8.00 100%
People
OSHA recordable incident rate for Strains/Sprains Heather 0.0 0.1
Plan > 0.00 0.00 0.00
Actual > 0.00 0.00 0.00 100%
CustomerSatisfaction
Patients readmitted to the unit after transfer Heather 2.2 2.2
Plan > 2.20% 2.20% 2.20% 40%
Actual > 5.70% 5.90% 1.70% 100%
Plan >
Actual > #DIV/0!
Safety/Quality
Numberof Improvements Heather
Plan >
Actual > 9.0 20.0 15.0 #DIV/0!
Safety/Quality
%compliance to standard work transfer checklist to floor to ICU
transfers
Rachel 90.00 90.00
Plan > 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0
Actual > 90.0 82.0 96.0 100%
Manager Score Card
40. Process Observation Calendaring
Sun Mon Tue Wed Thu Fri Sat
Process Observation Pareto
Processes
Nove
mber
Dece
Janua
ry
Febru
ary
Marc
h
April
May
June
July
Augus
t
Septe
mber
Octo
ber
Nove
mber
Dece
mber
Example Process
White Board
PCB Problem Solving Tool
(tollgates/delays)
I&O
Pain Management
Environmental Safety
Safe Patient Handling
Care Plan Notes
Purposeful Rounding
Fall Bundle
41. Process: #1 Standard Work Observation Card
Role:
Process: #1
SW location:
Process:#1
42.
43. Observation of standard work will
require coaching when the standard
isn’t followed
Coaching is a leadership
competency
Managers – DO NOT delegate this
responsibility until you KNOW the
person you are delegating to is able
to coach effectively!
