Erie st. clair graban sept 27 2010


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  • So why are we talking about this today? Leadership presence at the front line – a very underappreciated topic and practice. When people become a manager often they think that they've graduated away from having to be at the front line… and their executive position means that they have people to do that for them that they are world now it's all about meetings and conference rooms that become disconnected from the work that's done if they were ever connected to it in the first place. The biggest complaint is – “we don’t have time” or that the executives have staff and other managers to do that for them!
  • Lean principles don’t change anything about our values or goals
  • This isn’t about tools – it’s about defining an ideal condition and working tirelessly to close the gap between current state (ACCURATE version) and the ideal state. Can we challenge assumptions? Test – first day on your job--- ask why something is done or why can’t we do it a better way? How does the organization respond? Start from need…
  • These problems are from 1944. Hospitals have tried virtually everything from other industries in their efforts to improve: Scientific ManagementTraining Within IndustryBenchmarkingCost CuttingTotal Quality ManagementDr. Deming / PDCA / PDSARe-EngineeringSix SigmaBest PracticesFunctional Expert ConsultantsJoint Commission & AccreditationsTargets and Goals
  • Waste reduction is not traditional cost cutting
  • 1 in 350 cases in 2009 (full year)
  • We didn’t even do a formal VSM here, made a change almost immediately (Within a week) as opposed to doing nothing but mapping over 5 days… Laboratory – need to take an end-to-end view. Same is true at Radiology
  • Guideline = 120 min “door- to-balloon” – 70% success“Did not have a clear, standardized response to heart attacks.”Now 100% success against 90 minute targetFocus on the patient as customerRespect the patient’s timeIdentify systemic causes of patient waitingStandardized workVisual managementStaffing levelsScheduling practicesLook across the entire “value stream”Minimize delays from handoffs
  • Erie st. clair graban sept 27 2010

    1. “How Lean Thinking Helps Hospitals” Mark Graban Senior Fellow, Lean Enterprise Institute Author, “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction”
    2. ? ?
    3. St. Elisabeth Hospital: The Netherlands Dr. Jacob Caron, Orthopedic Surgeon Chairman of the medical staff
    4. Henry Ford - 1922 “In the ordinary hospital the nurses must make useless steps. More of their time is spent in walking than in caring for the patient.” 4
    5. Fast Forward to 2005-2008 What % of time do “med/surg” unit RNs spend directly with patients? A: 21% B: 33% C: 50% D: 65% New Zealand: 33% VMMC: 32% UK: 34% Illinois: 31% Cinci Children’s 29% It is possible to double this time with patients More time to do the “right things” 5
    6. 6 • Deliveries of supplies delayed because of improper ordering • Articles returned by other departmentsbecause they were not made correctly • Employees have difficultyin handlingnew-type equipment • Limitedstorage space (linen and supplies) not properly used • Safety equipmentnot being used • Correct procedures not followed • Employees leave to go to other hospitals
    7. 77 *Warning: requires effort and leadership (not a silver bullet)
    8. The Iceberg of Lean 8 Culture Management System Philosophy 5S Kaizen StdWork Heijunka VSMs A3 8
    9. Pitfall – Focus on Implementing Tools "We were offering suggestions and getting pushback on safe staffing, yet being told to reduce the number of pens and pencils.” – RN (Minnesota)
    10. Continuous Improvement Respect For People “Equally Important Pillars” Eliminate Waste 10
    11. Identify Causes of Walking (Primary Care) • MDs, PA, RNS: – Poor organization – Supplies in inconvenient locations – Missing information • The system causes this 670 ft for single procedure prep (pre-Lean walking pattern) Exam Procedure Lab
    12. Reducing Podiatrist Walking • Created standardized cart • Along with standardized rooms, eliminated the need to leave the room during patient encounters Restocking Checklist
    13. Quality and Cost • “Lean is a quality initiative, it isn’t a cost-cutting initiative. But the end result is, if you improve your quality, costs will go down.” – Bill Douglas, CFO of Riverside Medical Center (IL) • Allegheny Medical Center: – Reduced central line infections by 95% – Hospital lost $26,839 per case (~16 cases/yr) = ~$500k/year • Beth Israel Deaconess Medical Center: – Avoided 300 V.A.P. cases in one year – $12M cost savings
    14. • 90% reduction in CR-BSI in MICU and Oncology • Saved $1.7M • Saved 17 days L.O.S. per case 14 Source: Dr. Richard Shannon
    15. ThedaCare Coronary Bypass Improvement 12 1
    16. Case Example: MRI Suite
    17. Reducing MRI Waiting Time 0 2 4 6 8 10 12 14 Weekswaitingforappt Outpatient Radiology Backlog Source: Children’s Medical Center, Dallas TX
    18. Typical Department Silos Oncology Clinic A Oncology Clinic B Oncology Clinic C Chemotherapy Treatment Radiation Treatment
    19. Patients Scheduled 5/2/06 0 2 4 6 8 10 12 14 16 18 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 Start running out of chairs Idle Time Oncologist Schedule Look Across the Value Stream - Oncology
    20. ThedaCare Code STEMI • Starting Point 2002 – “Did not have a clear, standardized response to heart attacks.” • Studied each process step in detail • Posted standardized work in each room
    21. ThedaCare “Door to Balloon” Time 91 65 52 37 0 10 20 30 40 50 60 70 80 90 100 2005 2006 2007 2008 Minutes 21
    22. Need to Stop Blaming People "[The CEO] said the technician responsible for the mix up also no longer works there."
    23. A Different Hospital Lab… “It’s OK, my people are very careful!” 3 Different Patients - Batched
    24. Toyota’s Chairman Mr. Cho • Go See – “Senior Management must spend time on the front lines.” • Ask Why – “Use the “Why?” technique daily.” • Show Respect – “Respect your people.” 24 Three Keys to Lean Leadership
    25. “Gemba” “Toyota managers should be sufficiently engaged on the factory floor that they have to wash their hands at least three times a day.” Taiichi Ohno 25
    26. “…Kaplan tours the hospital daily looking for problems and solutions. Everyone is encouraged to look for changes to make work more efficient.” - Virginia Mason CEO Gary Kaplan 26 “Gemba is for Everyone”
    27. Patients (Gemba) Walkway over tracks Executive Offices Parking Garage 27
    28. “Convis became the first North American to head a Toyota manufacturing plant when he was put in charge of the Georgetown facility. He responded to the promotion by moving his office from the admin building adjacent to the Georgetown plant to the center of the factory floor.” 28
    29. Six Sigma Adapted from: “The Toyota” Way Fieldbook, Liker and Meier Very few Large problems Few Medium problems Many Small problems Mgmt Kaizen Kaizen Event Daily Kaizen Different Types of Kaizen
    30. Chemistry: Before Chemistry: After CA Core Manual Lab Layout: Before & After
    31. Metric Before After Potassium IP TAT 74 min (June ’06 avg) 43 min (May 07 avg) 42% reduction Labor Productivity 0.14 WHPUOS 0.12 WHPUOS 14% reduction % of Results on Chart < 7 AM 62% 92% Square Footage 228 sq ft freed up (behind manual area, to side of special chemistry) Initial Improvement
    32. Lab Improvement (3 years) 32 30 35 40 45 50 55 60 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 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Troponin TAT (in minutes)
    33. Lab Improvement (3 years) 33 75% 80% 85% 90% 95% 100% 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 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 % tests by 7 AM
    34. Lab Improvement (3 years) 34 0.100 0.110 0.120 0.130 0.140 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 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Labor Productivity (Worked Hours per Unit of Service)
    35. The Problem with Ignoring “Respect for Humanity” Found posted in a hospital lab (during Lean assessment)
    36. Engaging Employees From Locked Box To Visual Idea System
    37. One Idea Card Format FRONT BACK
    38. Documenting & Celebrating Improvements • What was the problem? • What was changed, improved, or implemented? • What were the benefits? • Who was involved? Kaizen Wall of Fame What was the Problem? For disposal of pipette tips, the only containers we had were “sharps” containers. This Adds extra disposal cost, as the tips are not sharp. The container hole was also Hard to get tips into. What was changed, improved, implemented? Create biohazard bag holders out of urine jugs, cut the tops off. Photo/Diagram: What were the benefits? Safety? Quality? Time? Waste? Cost? Reduces cost since we aren’t doing unneeded sharps disposal and we aren’t throwing the containers away each time. No safety risk. Easier to get tips into container (less motion and less arm strain, since the Container is lower and easier to get into). Tips can be dumped into a larger Biohazard bin or we can replace the bag. Who was Involved? Gretchen, Beth, Janie, Franke Date: 5/31/07 Area: STL Old Style Container New Container
    39. Kaizen Wall of Fame – Core Lab
    40. Value of Kaizen in a Hospital? • $4,000 per employee (Toyota) – Just the quantifiable benefit • What about benefits from: – Better Quality – Morale – Patient Satisfaction – Less Waiting Time = $$ ?
    41. Employee Quote “This is the best thing we’ve done in my 20 years. We’re finally fixing things.”
    42. Data From Children’s Medical Center Dallas Before Lean 12 Months After Starting 3. I have the opportunity to do what I do best every day. 3.11 3.92 8. I feel free to make suggestions for improvement. 2.84 3.48 10. I feel secure in my job. 2.32 3.42 13. Stress at work is manageable. 2.43 3.23 17. I am satisfied with the lab as a place to work. 2.51 3.43 18. I would recommend my work area as a good place to work to others. 2.38 3.46 Grand Average 2.96 3.69
    43. Lean Benefits All Stakeholders Patients Caregivers • Employees • Medical Staff • Administrators Hospital • Safety & Quality • Caring Encounters • Less Waiting and Delay • Mission • Stewardship • Stability / Growth • Pride in work • Less frustration • Job security • Career growth Philosophy People 43
    44. Q&A • Email: • Lean Enterprise Institute: • Healthcare Value Leaders: • Blog: – • Twitter: – – 44