Leadership institute lean kaizen briefing 8 16 13 handout

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  • Critical About Virtually Everything
  • Skeptics – they think boat is going to sink, row up to them and come along side, show them it won’t Critics – shoots hole in boat to prove it will sink
  • The Kaizen event newspaper: Needs to be posted on an easel in the area during and after the Kaizen event. It needs to remain until the activities are completed. This serves as a nice visual reminder to people walking by, as well as management, as they can check on leftover items from the Kaizen event.
  • Advance to bring in each item, one at a time
  • Advance to bring in each item, one at a time
  • During a Kaizen event, the comment was made: “The opportunities are easy to spot if you just remember the three M’s — Men, Machine, & Materials.” When you walk to the floor, find places where people are not moving. Even if they’re moving slowly it’s OK — but if they’re not moving at all, that’s an opportunity for you.
  • What you want to drive to – Utopia – is spontaneous Kaizen. For Example: Toyota, in Georgetown, KY – had 100,000 Kaizen events last year. Obviously the only way to generate that kind of volume is by making sure that the workforce has the tools and the understanding and the principles of Lean all down; need to create an environment for them to continue to improve their processes, at all times. Note to Facilitator: This might be a good place, where we start this module, to put the small coins out there – replications of quarters, dimes, nickels, pennies. When the participants come back and sit back in their seat, ask if they know what they are, and how they represent Lean Manufacturing, especially Kaizen, or Continuous Improvement. They represent a “small change” every day in yourself and in your business.
  • This example is from Dallas, Texas. Seems like every place you go, you end up with one or more people on a Kaizen team who have what has been called the “McGyver” capability. This means that they’re going to invent and come up with solutions. The Low Cost Part Feeder is self-explanatory in the picture. The object is to deliver little-tiny steel bearings that go in the end of extension adapters, in mechanic’s tools. The object was to get these ball bearings down onto the parts so they could get peened in there. One guy came up with a Pepsi bottle and some surgical tube. It was perfect. The engineers involved in the Kaizen event of course were thinking about vibratory feeder bowls, and all these extravagant solutions. This guy made one by hand and it worked great! That’s the spirit of Kaizen – the spirit of creativity – the solution is in your head, not in your wallet .
  • Kaizen Improvement Idea sheets need to be presented every day at the team leaders’ meeting. The top of the sheet is just descriptions of problem, steps taken, and results. Below is before Kaizen and after Kaizen. You can do in one of two ways: (1) digital photographs, to insert in presentation in team leaders’ meetings as well as weekly wrap-up. (2) draw cartoons! Can just be stick figures, but lots of pictures should be drawn.
  • Advance to bring in each item, one at a time
  • Advance to bring in each item, one at a time
  • Leadership institute lean kaizen briefing 8 16 13 handout

    1. 1. Introduction to Lean Leadership InstituteLeadership Institute && Performance ExcellencePerformance Excellence
    2. 2. AgendaAugust 16, 2013 • Welcome, Objectives, Expectations • Lean Background/ History • Kaizen Overview • Lean in Healthcare • Dot Simulation 1 Exercise • Value & Waste Overview • Kaizen Process • Lean Tools: Circle of Work / Spaghetti Charts • Lean Tools: TAKT Time • Lean Tools: Push vs. Pull • Lean Tools; 5S and visual controls • Kaizen: Observing the Current Process • Dot Simulation 2 Exercise • Lean Tools: Set up Reduction • Developing the future state • Kanban and Single Point • Dot Simulation 3 Exercise   • Creating a new Standard Work • Error Proofing • Dot Simulation 4 Exercise • Dot Exercise Debrief • Summary and Wrap up  
    3. 3. Session Objectives • Provide an Introduction to Lean • Identify Lean Principles • Define Value, Non-Value Added work and Waste • Identify Lean applications in healthcare • Apply the Lean tools within the Healthcare environment • Provide a description and understanding of Kaizen events
    4. 4. Kaizen Definition Thoughtful Acts of Continuous ImprovementThoughtful Acts of Continuous Improvement To take apart and make new To think about so as to help others Eliminate WasteEliminate Waste Solve ProblemsSolve Problems If the first fix doesn’t work, try againIf the first fix doesn’t work, try again
    5. 5. Lean is ….. • A set of operation concepts • A set of tools used in a variety of industries – including service & healthcare to improve business processes • A philosophy that helps drive efficiency and speed through employee empowerment and change at the grass root level
    6. 6. Benefits of Lean Lean attacks waste in any process or value stream •Higher customer satisfaction •Reduced cycles •Better delivery •More capacity •Better quality and safety •Improved productivity
    7. 7. History of Lean • Lean Manufacturing began as the Toyota Production System (TPS) • Lean came to the US in late 1980’s • Healthcare Providers (Early Adopters) in the US began to embrace Lean Enterprise concepts about a decade ago • Insurance Companies and Insurance Providers demanding that Healthcare Providers embrace Lean Concepts
    8. 8. Kaizen
    9. 9. House of Kaizen
    10. 10. Kaizen Training 10 Do MORE with LESS Waste Productivity Staffing Productivity
    11. 11. Kaizen Training 11 Standards Enforce Inspect . Stabilize Identify Waste Im prove Problem Solve Standardize • Process requires ongoing inspection and enforcement to ensure “Standardized Work” is being followed • Process does not improve automatically - Following standards will only maintain, not improve, the process. - Improvement focuses on the entire process.
    12. 12. Why does Lean apply to healthcare? • Tools easy to learn / teach • Learn by doing • Easier to apply at frontline where work is really happening vs. other methodologies • Improvement occurs with the first application
    13. 13. Lean Opportunities in Healthcare Emergency Reducing Wait Times Surgery OR Throughput Radiology MRI/CT Throughput Admission Bed Turnover
    14. 14. Understand flow of materials, information and people through the hospital, then identify tasks or activities (operations) that improve or hinder flow 1. Understand who the customer is 2. Solve the customers problem completely 3. Understand the value you provide 4. Manage by observation facts...do not make decisions based on reports 5. Involve people closest to the problem…team-based environment 6. Drive to root cause 7. Try storm, take action now!! 8. Standardize – Discipline 9. Sustain through customer focused cycle time & process metrics Lean Principles
    15. 15. Break-out Simulation
    16. 16. The Dot Simulation Demonstrating Basic Lean Principles Background Information You are workers in the Outpatient Radiology department of a hospital. Using colored dots on a sheet of paper, we will simulate the major steps in processing a patient through a radiological exam. Red Dots = Reception Green Dots = Registration Orange Dots = Patient Preparation Blue Dots = Exam Yellow Dots = Check films We will run four round of the simulation. At each stage, you will have opportunities to improve the process, using some of the Lean principles we’ve studies. As you participate in the simulation, think about other hospital processes where these principles might help you reduce waste and improve efficiency; admitting a patient to a nursing unit, coding, documenting a patient’s chart, etc.
    17. 17. Intro to Overall Simulation Care Process Templates Dots: Reception Registration Patient Prep Exam Check Films Red Green Orange Blue Yellow Red Green Orange Blue Yellow Completed Care Patient Care process
    18. 18. Roles and Responsibilities Materials manager •Record the time on the batch when the process is started. Move the batch to Reception (Red Operator). Only send one batch at a time to the Reception •Stock Room Management: Give out dots when the process workers come to you. You may only give out one sheet of dots at a time and only when the process worker has a signed requisition form from a VP. Process Workers (1 person per color) •Apply colored dots on the paper as indicated by the customer when a batch is received •Deliver it to the next station. Send only one batch at a time. •Get additional dots from stock as needed. Only one sheet of dots per visit to the stock room is allowed. You must obtain a signed requisition form from a VP to get a new sheet of dots. •Any defective batches returned to your station take first priority. They must be fixed and sent back through the process
    19. 19. Roles and Responsibilities Patient / Inspector •Receives batches from Yellow Operator and inspects for meeting quality requirements. If the batch passes, records the time that a completed batch passed through inspection, places them in the completed bin, and tell the patient it’s ok to leave. (Write the completion time on the unit, fold the unit in half and place it in a location indicating that it has been finished). If the batch does not pass, take it back to the work station responsible for the problem. Keep a record of batches that were sent back to be fixed and batches that were accepted using the inspection sheet. Recorder •On the flipchart, track the Inspection Sheet data and the Process metrics for each of the rounds
    20. 20. Simulation Round 1 • Run for 5 minutes • Colors must be applied in sequence – first Red, then Green, Orange, Blue, and Yellow • No process changes allowed during the round – we want to understand and baseline the current process • If the process workers run out of dots, they must complete a Materials Requisition Form and get it signed by a VP before requesting more dots from the Materials Manager • When Reception (the Red Operator) finishes a batch, he / she must ask the Materials Manager for a new batch Have Fun!!
    21. 21. Report Out
    22. 22. 22 SHIFT MINDSET CURRENT THINKING REQUIRED THINKING WASTE NOT DEFINED REACT TO LARGE EXAMPLES REACTIVE IMPROVEMENT WASTE IS "TANGIBLE” IDENTIFY MANY SMALL OPPORTUNITIES -LEADS TO LARGE OVERALL CHANGE CONTINUOUS IMPROVEMENT WASTE TYPES OF WASTE Correction Processing Motion Waiting Inventory Transportation Over- Production
    23. 23. Value and Waste Value •An activity that the customer is willing to pay for •An activity that physically alters the existing state •Who are your customers •What is “Value” for YOUR customer Waste (Muda) •An excessive or unwanted step, resource, motion, etc. •8 types of Muda – Defects - Waiting – Overproduction - Transportation – Motion - Over processing – Resources (Inventory) - Under utilization
    24. 24. Kaizen Training 24 Some examples NVA Activities: Walking Waiting on test results Transporting parts Generating useless reports THE GOAL IS TO ELIMINATE THETHE GOAL IS TO ELIMINATE THE NON-VALUE ADDED ACTIVITIES.NON-VALUE ADDED ACTIVITIES. Unnecessary motion Unnecessary stock on hand
    25. 25. To determine if a process step or activity is VA, NVE or NVA…. Ask: If we stop doing _____task, would our end customer (patient) care? If “YES”, then it is Value Added (VA) If we stop doing ____task, would our internal customers or key stakeholders (Physicians, nurses, administration, regulatory agencies, etc.) care? If “YES”, then it is Non Value Added Essential (NVE) If the answer to both of these question is “No”, then it is Muda (Waste / NVA)
    26. 26. Kaizen Event Phases PLAN • Business Case Metrics • Scope • Executive Sponsor • Event Owner • Team Leader PREP • Observe Work / Flow • Lean Tools • Team Members • Support Functions • Process Metrics • Finalize Business Case Metrics • Approvals EVENT • Business Case • Training • Current State • Future State • Test / Implement • Action Plan • Communication Plan • Metrics FOLLOW-UP • 30/60/90 Day Plan • Daily Mgmt • Gemba Walks • Measure Impact I II III IV
    27. 27. Kaizen Process • Selecting Projects • Setting Goals • The Team Leader and Team • Support and Infrastructure • The Kaizen Blitz Steps – Set the scene (Document current reality) – Observe the current process (ID waste and countermeasures) – Develop the future state process – Implement the new process (Make & Verify changes) – Report and analyze (Measure results, Create new standard work) • Potential Roadblocks
    28. 28. Scale for rating each criteria 0 if there is no impact 1 for low correlation 3 for medium correlation 9 for a high correlation
    29. 29. Kaizen Process • Selecting Projects • Setting Goals • The Team Leader and Team • Support and Infrastructure • The Kaizen Blitz Steps – Set the scene (Document current reality) – Observe the current process (ID waste and countermeasures) – Develop the future state process – Implement the new process (Make & Verify changes) – Report and analyze (Measure results, Create new standard work) • Potential Roadblocks
    30. 30. Pre-Event Preparation 1.Describe the opportunity A. Stakeholder analysis B. Define scope C. Planning 2.Team selection and training 3. Have your targets set 4. Select Team leader 5.Set event objectives tied to your company’s goals 6. Complete Kaizen Event Charter
    31. 31. Lean Six Sigma Project Charter Title: Reduce Scrapped Cookies in NW Region BB/GB: B. Thornton Business Gap Defects & Metrics Problem Statement Team: B. Thornton (BB), A Yamoto (Process Owner), W. Houston (SME), P. Smith (SME), G. Hines (SME), L. David (SME) Champion: T. Wong Project Scope/Boundaries: Process Start: Mix Ingredients Process Stop: Bake Cookies In Scope: Chocolate Chip Cookies in all NW Bakeries Out of Scope: Packaging Milestones/Timeline: Scheduled Actual Define Tollgate Review: June 4, 2007 6-4-07 Measure Tollgate Review: July 9, 2007 Analyze Tollgate Review: August 13, 2007 Improve Tollgate Review: September 10, 2007 Control Tollgate Review: September 24, 2007 Customer Objective Statement Our bakeries scrap approximately 25% of all cookies baked. Scrapped cookies limit our ability to remain profitable while we are being pressured to reduce prices by our competitors. Scrapped cookies have always been an issue and it has become worse since new ovens were installed. Based on a Pareto Analysis we will focus initially on the NW Region. External: Grocery Stores, Consumer Internal: Regional General Manager Defects: Scrapped Cookies Primary: Scrap Rate for Cracked Chocolate Chip Cookies (CCCC) Secondary: Returns dues to CCCC’s Consequential: Taste, Chewiness The scrap rate due to cracked chocolate chip cookies in the NW bakeries was 15% for the past 12 months based on daily scrap reports. Reduce the scrap rate due to cracks from 15% to 8% by 11/12/07 as measured by the daily scrap report Financial Impact $204,400 in direct savings based on current production rates © BMGI. Except as may be expressly authorized by a written license agreement signed by BMGI, no portion may be altered, rewritten, edited, modified or used to create any derivative works.
    32. 32. Problem vs. Goal Statement The purpose of the Problem Statement is to describe what is Wrong The Goal Statement defines the Team’s Improvement Objective
    33. 33. Kaizen Process • Selecting Projects • Setting Goals • The Team Leader and Team • Support and Infrastructure • The Kaizen Blitz Steps – Set the scene (Document current reality) – Observe the current process (ID waste and countermeasures) – Develop the future state process – Implement the new process (Make & Verify changes) – Report and analyze (Measure results, Create new standard work) • Potential Roadblocks
    34. 34. Forming a Kaizen Team Team member considerations: • Effective problem solvers • Team players • Open minded • Be aware of: – CAVE
    35. 35. Kaizen Teams Skeptics vs. Critics (CAVE)Skeptics vs. Critics (CAVE)
    36. 36. Kaizen Training 36 Steps on Team Development FormingForming This is the development of a multi-functional team with a variation of backgrounds and knowledge NormingNorming Stage where the group agrees how to operate as a team StormingStorming Open & honest discussion, also brainstorming PerformingPerforming Agreement on solutions & taking action AdjourningAdjourning Closing on the continuous improvement process after 30 days
    37. 37. Document Reality 37 Kaizen NewspaperKaizen Newspaper Add problem when youAdd problem when you find themfind them Responsibility listResponsibility list Due dates forDue dates for completioncompletion Use as a to-do list during eventUse as a to-do list during event
    38. 38. Kaizen Process • Selecting Projects • Setting Goals • The Team Leader and Team • Support and Infrastructure • The Kaizen Blitz Steps – Set the scene (Document current reality) – Observe the current process (ID waste and countermeasures) – Develop the future state process – Implement the new process (Make & Verify changes) – Report and analyze (Measure results, Create new standard work) • Potential Roadblocks
    39. 39. Go to the Gemba Managers Must Not Must Do Give Up Flex Muscles Throw Fits Blame the workers Blame the measures Show boat Cover Up Game the measures Throw people at problems Stress out Hide in the office Create smoke screens Grovel Be clueless Think of at least 7 ways to do better Kaizen your standard work Observe the process Find the waste Have a vision Provide the right tools Set goals Communicate direction39
    40. 40. Kaizen Process • Selecting Projects • Setting Goals • The Team Leader and Team • Support and Infrastructure • The Kaizen Blitz Steps – Set the scene (Document current reality) – Observe the current process (ID waste and countermeasures) – Develop the future state process – Implement the new process (Make & Verify changes) – Report and analyze (Measure results, Create new standard work) • Potential Roadblocks
    41. 41. LEAN EXAMPLE START
    42. 42. Document Reality Verify how are the processes done todayVerify how are the processes done today – What’s really happeningWhat’s really happening – See it for yourself (Walk the Gemba)See it for yourself (Walk the Gemba) – Target sheets, area profilesTarget sheets, area profiles – 5S Audits, Safety Audit5S Audits, Safety Audit How does it work todayHow does it work today – Spaghetti Chart, Standard WorksheetSpaghetti Chart, Standard Worksheet – Layouts, DocumentsLayouts, Documents What happens in this processWhat happens in this process – Photos, Time ObservationsPhotos, Time Observations
    43. 43. Document Reality
    44. 44. Circle of Work – Process Analysis Circle of Work analysis is crucial 1)to establish your baseline for the Lean project and 2)quantify improvements after change have been implemented. Key points to remember •Make sure all key elements of the process are included and a representative, reasonable time period observed •Ensure the observer is familiar with the process and can identify all activities •Use observation for single workers, work sampling for multiple workers and overall worker / equipment utilization
    45. 45. Spaghetti Chart An important aspect of the Circle of Work analysis is to visually depict the flow of work from the perspective of the worker and / or product. The standard sequence of work chart, also know as the “Spaghetti” chart, accomplishes this objective. Key aspects of the Spaghetti Chart are: •A diagram that shows the motion of the patient / family / caregiver / supplies throughout the course of care. •A visual representation of the amount of travel involved for an activity to be completed and the number of locations involved •A Spaghetti chart will include the total distance traveled (in feet) •Spaghetti charts are created BEFORE and AFTER improvements are made in order to document success.
    46. 46. Document Reality Standard Work SheetStandard Work Sheet (Spaghetti Chart)(Spaghetti Chart) • Operator path in RED • Material path in BLUE • Safety YELLOW • Quality GREEN 46 Be consistent with colors and symbolsBe consistent with colors and symbols
    47. 47. Kaizen Training 47 What is TAKT Time? TAKT is used to “set the pace” of the operation such that it takes place at the rate at which the customer “PULLS” from you. By determining TAKT, you can adjust your offerings so as to add or reduce capacity.
    48. 48. Kaizen Training 48 Single Piece Flow Single piece flow is the basis of TAKT time Single piece flow: Completing the process from start to finish continuously Batch Process Single Piece Flow How many do you have? You have only one. Where are they in the process? You know where it occurred. What is the root cause? Resolve the root cause immediately. The next process step is the customer……. …..never send defects!!
    49. 49. Kaizen Training 49 TAKT Time Calculation Available Time (seconds) / Period Total Units of Customer Demand / Period TAKTTAKT Available Time / Period (one shift): Breaks - 2 @ 15 minutes Shift Time ( 8 hrs. ) Total Time Available: - 30 mins. 480 mins. 450 mins. Units Required / Period (one shift): 10,500 Units Sold Monthly 21 Working shifts / month or 27,000 secs. 500 Required units / shift TAKT Time:TAKT Time: 27,000 secs / shift 500 units / shift 54 secs.
    50. 50. Kaizen Training 50 Line Balancing By redistributing some of the tasks in Step D to A, B, and C… …we can easily identify our target for Improvement. If we reduce the cumulative cycle times for all the steps by 12 seconds, we can potentially reduce from four steps to three. Takt Time
    51. 51. Flow Movement of patients / products, services and information down the value stream. Objective is a continuous flow as patient / product, service and information is transformed by continuously adding value. Flow is created by eliminating queues and stops, and improving process flexibility and reliability.
    52. 52. Pull End customer pulls product / transaction through the value stream. Each step pulls the product / transaction when needed from the preceding step. Only the amount required is taken. No action is taken until the downstream process initiates it.
    53. 53. Push vs. Pull A Fundamental Lean Principle Push Principle – Admitting or feeder units say: “We have a patient and need a bed” Pull Principle – Floor Nurse says: “We have a bed and we need a patient” We always seek to eliminate waste, establish flow and create a pull system
    54. 54. 5S System and Visual Management Maintain and improve sort, set-in-order, shine, and standardize SortSort Separate the needed items from the un-needed items which are then removed to a "red-tagged" location Set InSet In OrderOrder Arrange remaining items in the way in which they will be used ShineShine Maintain the work area for the already sorted and set-in- order items StandardizeStandardize Ensure sort, set-in-order, and shine are consistently followed across all users SustainSustain 5S5S
    55. 55. Sort When in doubt, remove it! • Segregate what is needed and what is not needed, discard what is not needed. • Use “Red Tags” to make it easy to reduce clutter. • Note that “remove” does not mean dispose of. Unneeded items that may have some value are moved to a holding area for disposition. STEP 1: Clarify what is needed. STEP 2: Dispose of things that are not needed. STEP 3: With items that are needed, segregate according to frequency of use.
    56. 56. Set in Order A place for everything, and everything in its place. • Clearly mark and arrange everything neatly so what is needed can be easily found. • With unnecessary clutter removed, the team determines appropriate locations for items that are needed to “add value”. • After repositioning items and tools, the team applies temporary labels, signboards, and positions. STEP 1: Decide place for storage STEP 2: Set up markings (Boundary Lines) for storage locations STEP 3: Mark items to be placed for storage STEP 4: Use ingenuity to make maintenance easy
    57. 57. Shine Clean to inspect, inspect to detect, and detect to correct. • Clean up personal and working environment so there are no areas untidy with dirt or other clutter. • Top to bottom cleaning and inspection. • By touching and observing equipment as they clean, team members can spot early signs of trouble before they cause break downs, accidents, and defects. STEP 1: Conduct overall ‘Shining’ STEP 2: Maintain cleanliness STEP 3: Improvement plans to prevent dirtiness STEP 4: Efficiency plan for sustained improvement
    58. 58. Standardize You can see the perfection ! • Maintain the conditions of Sort, Set-in-Order, and Shine • Turn proven temporary methods for keeping the work place uncluttered into permanent “VISUAL” methods that make new standards obvious to everyone.
    59. 59. Sustain Sustain the Gain. Pride of ownership! • Adhere faithfully to the decisions that have been made. • Communicate and maintain practical approaches for improved workplace conditions. • Spread the activities and pride of ownership to all levels and areas of the company.
    60. 60. What is Visual Control? • The visual control method is based on the 5-S System • Order is established with visual control • Because it impacts us directly, a visual control is considered aggressive in its approach to adherence • Visual controls can be very important as a tool for error proofing and should always be considered in a brainstorming effort
    61. 61. Examples of Visuals Status Board Work Group Display Boards OR in Use Prep Next Patient OR Ready Indicator Lights Direction of Flow Indicators Gages showing Normal Operating Range Fluid Markings Process Control Boards Color Coding of Patients
    62. 62. Standards not followed are not standards. the lean proverbs
    63. 63. Kaizen Process • Selecting Projects • Setting Goals • The Team Leader and Team • Support and Infrastructure • The Kaizen Blitz Steps – Set the scene (Document current reality) – Observe the current process (ID waste and countermeasures) – Develop the future state process – Implement the new process (Make & Verify changes) – Report and analyze (Measure results, Create new standard work) • Potential Roadblocks
    64. 64. Waste can multiply itself like rabbits. the lean proverbs
    65. 65. Identify Waste • Remember the 8 Wastes – Anything that doesn’t add value to the customer • Once identified make sure event scope is correct – Ok to change, make sure everyone knows 65
    66. 66. 5 Whys • When problems are found – Find the root cause by using the 5 whys
    67. 67. Asking why opens the mind to new causes. the lean proverbs
    68. 68. Countermeasures • Solutions need to be implemented during the week • Try it out – action versus analysis • Creativity before capital • Continuous strive to reduce waste, no matter how small it is • Attack items that impact – Process flow – Material flow – Information flow • Solutions strive for – Takt – Flow – Pull – Lower Inventory
    69. 69. Kaizen • Just do it! – Action over analysis • Improving specific piece – The Value Stream – Company goal • Manage to completion
    70. 70. Spirit of Creativity - A “McGyver” Capability
    71. 71. Symptoms to solve is little to resolve. the lean proverbs
    72. 72. Section Review • Value • 8 types of Waste • Kaizen Process • Problem Statement • Selecting Team • Process Mapping – Spaghetti Map • Takt Time • Single Piece Flow • Push vs. Pull • 5S • 5 Why’s
    73. 73. Break-out Simulation
    74. 74. Simulation Round 2 • Run for 5 minutes • Colors must be applied in sequence – first Red, then Green, Orange, Blue, and Yellow • You may redesign the work layout – you will have 10 minutes to do this. Work layout changes must be approved by a VP. Flipchart your changes to facilitate approval by a VP • You may not change the job descriptions of any of the process workers
    75. 75. Report Out
    76. 76. Examples of Set-up / Changeover Activities There are numerous examples of set-up / changeover activity in healthcare, primarily for procedures and treatments: •Starting / Removing IVs for patients •Transporting patients in and out of rooms •Verifying MD orders •Staff understanding what procedure needs to be done and how to do it •Placing/securing/aligning patients on a table/bed and then removing them •Ensuring supplies and instruments are available and ready before procedure or treatment begins •Equipment readiness •Interviewing patients regarding H&P information
    77. 77. Reducing Set-up Time Set-ups are categorized in four phases •Preparation •Change / loading or unloading •Adjustment / Alignment •Inspecting and / or securing Set-up reduction minimizes the amount NVA time devoted to these activities
    78. 78. Set-Up Reduction As previously indicated, the set-up / changeover would include: •Any preparation •Tearing down or cleanup of previous job, patient, procedure, etc. •Searching for equipment, supplies, information •Moving/transporting •Testing/calibrating equipment •Performing trial runs •Making further adjustments Setup Finish “A” - - - - - - - “A” Begin “B” - - - - - - - “B” Set-up time is the time from the last step of the previous item, service or run to the first step of the next.
    79. 79. Process for Set-up Reduction Analysis The process for analyzing set-up (or changeover) reduction analysis is as follows: 1.Identify all tasks associated with the set-up or changeover 2.Classify activities as happening while a process 3.Record the time associated with set-up activities 4.Associate all tasks with the four categories previously stated – preparation, changeover (loading/unloading), adjustment/alignment, inspection or securing 5.Brainstorm ideas to eliminate NVA time (i.e., maximize room or equipment utilization) and minimize overall set-up activity 6.Quantify the improvements 7.Develop new standard work (SOPs) for the implemented changes
    80. 80. Set-up / Changeover Improvement Ideas When examining the categories of set-up / changeover (preparation, changing, adjusting, secure/inspect), there are several common flags or opportunities to look for: •Alignment / Adjustment time: any type of alignment or adjustment of patients or equipment should automatically be considered a flag for evaluation, since they are typically non-valued added tasks. Analysis of equipment options (e.g. guide pins, blocks, scales) or some 5S type controls for patients could provide viable solutions. •Securing / Inspection time: regarding equipment, consider available options (e.g. Velcro vs. screw type restraints), while with patients evaluate repeatable or duplicative tasks (tests, vital signs, etc.). Multiple approvals or assessments should also be evaluated. The goal should be to maximize room and/or equipment utilization.
    81. 81. Kaizen Process • Selecting Projects • Setting Goals • The Team Leader and Team • Support and Infrastructure • The Kaizen Blitz Steps – Set the scene (Document current reality) – Observe the current process (ID waste and countermeasures) – Develop the future state process – Implement the new process (Make & Verify changes) – Report and analyze (Measure results, Create new standard work) • Potential Roadblocks
    82. 82. Make Changes • Make the changes – NOW! – Don’t get stuck waiting for a better time – Make the changes then observe them • Pre-plan for large moves before the event • Everyone needs to contribute – Don’t dictate, build teamwork • Make sure you update the newspaper
    83. 83. Verify Changes • Verify with new observations • If it’s not easier, make more changes • Goal is to put new process in place and verify it – Do this early in event to allow time for more changes – Make sure a better process is working at end of event
    84. 84. Kaizen Process • Selecting Projects • Setting Goals • The Team Leader and Team • Support and Infrastructure • The Kaizen Blitz Steps – Set the scene (Document current reality) – Observe the current process (ID waste and countermeasures) – Develop the future state process – Implement the new process (Make & Verify changes) – Report and analyze (Measure results, Create new standard work) • Potential Roadblocks
    85. 85. Kanban Definition A Japanese work that means “signboard” •In a Lean enterprise, it’s a signal authorizing production or delivery of required materials. The signal is initiated by consumption from an upstream process •Allows a just-in-time (JIT) environment to be set up but it requires: – Level Production – Pull – Defect Free Products •A Kanban is a high-level tool that is implemented after solving many problems Kanbans route information in a pull system Supermarkets provide material for a pull system
    86. 86. Measure Results • Compare results with baseline data – Did we make it better? – Was waste removed? • Did we achieve what we wanted to? Not all changes are successful.Not all changes are successful. Don’t worry.Don’t worry. Learn from what we’ve done!Learn from what we’ve done!
    87. 87. Improvement Idea Date: __________ Kaizen Title:____________________ Team #: ____________ Completed By: __________________________ Description of Problem: Description of steps taken: Results: Before Kaizen After Kaizen Remarks: The lift truck cords were continually being left on the floor causing delays and damage. A cord retractor was installed at each recharge station. Prevents damage to plugs Eliminated trip hazard 87
    88. 88. Single Point Lesson Water cooling lines • Mistake proofed fittings • Hoses can only be hooked up one way – Simple fix, no money spent, just switched fitting from hose to fixture 88
    89. 89. Mistake proofed is mistake’s pain missed. the lean proverbs
    90. 90. Section Review • Reducing Set up Times • Making Changes • Verifying Changes • Kanban • Measuring data
    91. 91. Break-out Simulation
    92. 92. Simulation Round 3 • Run for 5 minutes • Colors must be applied in sequence – first Red, then Green, Orange, Blue, and Yellow • You may not change the job descriptions of any of the process workers • The Department Director has decided to institute a Kanban system. The VP or facilitator will explain Kanban • In your group, apply the concepts of Set-Up Reductions
    93. 93. Report Out
    94. 94. Create New Standard • Put new visual standard work in place – Maintain progress made during event – Training tool – Should be understood by anyone observing the process • Post all open action item on the Kaizen Newspaper – Make sure all items have a name attached to them – Follow up to make sure they get completed • Visually display what has happened in the area • New process must be repeatable and sustainable – Try it out during the week!!! Celebrate
    95. 95. Standard Work What is “Standard Work”? •For a given process, it is having every activity done in the same sequence and manner every time with the least possible amount of time in order to meet customer specifications. It is the most effective combination of activities that will minimize non-value-added activities while providing the highest quality of care. •For the process workers, it is knowing what to do, how to do it, and when to do it every time the process cycle occurs •For the process non-labor, it is having the right supplies and equipment available when they are needed and in the right quantity (Just-In-Time). Without standard work, there can be no continuous improvement - it is the basis for Lean transformation
    96. 96. Standard Work – Healthcare Examples • Clinical pathways, protocols, practice guidelines for disease state or DRG management • Standard Operating Procedures(s) for a treatment or case, including patient prep and discharge • Organizational Policy and Procedures – departmental or hospital wide While we can see from the above that standard work has existed to some degree in healthcare (but not necessarily successfully), it is not even remotely close to where it needs to be for us to meet the challenges in the years ahead
    97. 97. Standard Work – Critical Components Implementation of Standard Work involves five steps, all of which incorporate numerous lean tools. The five steps are: •Evaluate the current situation •Identify areas of opportunity •Modify the existing process •Substantiate and enumerate improvements •Implement the new standard work
    98. 98. Standard Work - Evaluation Evaluating the current situation of the process will involve the use of several tools discussed thus far: •Observation – time value analysis (TVA). Note times, dates, and any specific circumstances involved with the observation •Spaghetti diagrams •Forms – time observation sheet •Determine current line balance of the process (Takt time of the process applied for each process step).
    99. 99. Standard Work – Identify Opportunities Examples of the 8 Wastes: Defects: Medication errors, wrong site surgery Over Production: Preparing IV’s ahead of time Transportation: Transporting lab specimens, patients Waiting: Waiting for bed assignments, treatments, discharge orders Inventory: Lab specimens, supplies Motion: Searching for charts / supplies Processing extra: Excessive paperwork, unnecessary tests, using IV over oral meds Under-utilization: RNs doing non clinical paperwork; CPAs doing basic G/L work, idle equipment
    100. 100. Standard Work – Modify the Process In this step, Lean tools are employed to change the process and make improvements: •Brainstorming •5S •Visual controls, indicators, signals, guarantees •Line Balancing •Leveling •Quick changeover – setup reduction
    101. 101. Standard Work – Piloting Process Attempt to conduct a pilot of the process changes first before full implementation in order to demonstrate the feasibility and success of the changes In a Lean Kaizen event, this is normally the “Trystorming” phase. This occurs quickly in the process, and team participants will in real time make whatever changes are needed based upon feedback from workers in the process. If a pilot cannot be conducted and full implementation is required for the process, ensure that careful monitoring exists and that changes can be made to the new process if warranted.
    102. 102. Standard Work – Implement New Standard In order to fully implement new standard work for a process, the following steps need to be taken: •Training of all personnel affected by the changes must take place through formal verbal communication and written documentation. Install as many visual indicators, signals, or controls as possible to help facilitate understanding and compliance. •Objective, quantifiable measures (if not done previously in the project or Kaizen) must be created to monitor worker compliance and to determine if improvement is continuing to occur. Monthly or quarterly reports to management should be a norm.
    103. 103. Error - Proofing A technique for eliminating errors Making it impossible to make mistakes In Japan: Poka-Yoke. Poka means an inadvertent mistake. Yoke means to prevent It is good to do it right the first time: it is even better to make it impossible to do it wrong the first time.
    104. 104. Poke Yoke Poke-Yoke (pronounced Po-Ka Yo-kay) – stands for mistake –proofing Usually the physical alteration of a devise or process so as to guarantee only one way (the right way) to carry out a task. •Electrical sockets – only one way to plug in •Petrol vs. diesel spouts at a gas station – a diesel nozzle will not fit into a petrol gas tank Medical examples of Poke-Yoke: •Anesthesia gas equipment – port valves only designed for correct gas tubing (e.g. oxygen tubes can only fit on oxygen ports of the anesthesia equipment)
    105. 105. Error-Proofing Techniques Technique Prevention Detection Control (Shut Down) An error is impossible Defective item can’t move on to the next step Warning An error is about to be made An error has been made Errors may either be prevented or detected
    106. 106. Why Do Errors Occur? • Incorrect or non-existent procedures • Overly complex processes • Excessive variation in the process • Excessive variation in the inputs • Inaccurate measuring system • Human error
    107. 107. Human Error Provoking Conditions 1. Adjustments 2. Unclear or no instructions 3. Undefined process 4. Many units/mixed units 5. Multiple steps 6. Infrequent production 7. Ineffective or lack of standards 8. Multiple handoffs 9. Hand processing 10. Rapid repetition 11. High volume demand or deadline pressures 12. Environmental conditions Robust processes reduce Human Errors!
    108. 108. Three Inspection Methods • Traditional inspection (end of the process) – discovers defects – Sort “good” from “bad” at the end of the process – Measure “Y” into categories (good/bad) • Informative inspection (during the process) – reduces defects – Use process data to control/correct the process (e.g. Statistical Process Control Charts) – Measure “Y” for variables information to control “Y” • Source inspection (before the process) – eliminates defects – Inspect for error producing conditions in the process. – Measure and control “X’s” to create good “Y’s”
    109. 109. 7 Steps to Error Proofing 1. Create a process map and identify the locations at which the defects are found and made 2. Evaluate current procedures for adequacy and determine if they are being followed 3. Identify defect provoking conditions at each process step 4. Identify the root cause(s) (error) of each type of defect and in which process step it occurs (FMEA, 5 Whys, Cause & Effect Diagram) 5. Identify the type of error-proofing device or process required (Brainstorming) 6. Create the device or process and try it 7. Measure for effectiveness
    110. 110. Section Review • Standard Work • Error Proofing • Poke Yoke • Inspection Methods • Visual Controls
    111. 111. Break-out Simulation
    112. 112. Simulation Round 4 • Run for 5 minutes • Colors must be applied in sequence – first Red, then Green, Orange, Blue, and Yellow • Great news! The hospital has gained such a reputation for efficient and patient friendly operation that the department’s volume is expected to increase sharply. Your VP will tell you what volume you will need to handle during this round • The Department Director recognizes that in order to meet the increased demand without adding staff, the department will have to operate more efficiently. She suggests that you may want to make additional improvements by redesigning the job descriptions. You will have 10 minutes to redesign the jobs, train everyone and rearrange the work layout as needed to accommodate the new roles. • In your group, apply the concepts of Standard Work and error proofing to your simulated process
    113. 113. Dot Exercise Debrief • What are the “Lessons Learned”? • Can you Apply these “Lessons Learned” to your area?
    114. 114. Kaizen not maintained dissipates like smoke. the lean proverbs
    115. 115. Lean Summary • Linking value stream map, cycle time analysis and value analysis creates a compelling business case for change • Making the process visible highlights potential problems and sources of variation • Evaluate the flow through the operations to determine what hinders the flow • Use the best tools available to help identify solutions / improvements (e.g., process maps, C&E diagrams, brainstorming, etc.) • The leveled schedule and process sequencing should allow for the process flow to be paced according to customer demand • TAKT is used to set the pace of the process step • Use Lean and Six Sigma tools in combination and / or alone to solve your process problems
    116. 116. Websites Performance Excellence Website (go live 8/20) Free Lean Six Sigma & Kaizen forms / images: www.bmgi.org http://www.youtube.com/watch?v=wfsRAZUnonIhttp://www.youtube.com/watch?v=lwWI-3z1wPull system Total Productive Maintenance Total Preventive Maintenance Value stream analysis in healthcare Push system Gemba kaizen Continuous Improvement Kanban and Pull systems Kanban Lean kaizen Lean six sigma 5S Lean Visual Controls Problem solving Value stream analysis 5S visual controls OEE PEx Website (Online 8/20) http://inside.uams.edu/performance-excellence
    117. 117. The End What questions do you have?

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