Mark Graban "How Lean Thinking Helps Hospitals"

“How Lean Thinking Helps Hospitals” For Utah State University Student Lean Group Mark Graban Senior Fellow, Lean Enterprise Institute Author, “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction”

Agenda • Lean in Healthcare – The need for Lean in Healthcare – Principles that apply in Healthcare – Examples • Career Lessons Learned – As an Industrial Engineer – As a Lean Implementer • Q&A

Engineering and Medicine… Surgical Nurse as “Caddy” Frank B. Gilbreth (1868-1924)

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.” 5

Lean is Fundamentally About: People doing People facing People managing work problems other people 6

First Things First… “Start from need.” – Taiichi Ohno, Toyota (1912-1990)

Why Lean for Healthcare? No waiting No waste Zero harm Source: an NHS hospital, UK

Resources are Strained “Every day, we are holding, on average, 12 to 20 admitted patients, who have been in our department for days awaiting hospital beds.”

Employees Are Harder to Find • Medical Technologists – Shortfall of 10,000 per year – 40% eligible to retire between 2005 and 2010 • Nurses – 100,000 vacant positions in the U.S. – 4x that many expected by 2020 • Pharmacists – 7.4% vacancy rate per the American Hospital Association Not enough employees or too much waste?

Too Many Errors Occur • Adverse events in 3.7% of hospitalizations(1) – 13.6% of those led to death(1) – 53-58% are preventable(2) • Death resulting from preventable error occurs in 1 of 400 hospitalizations • (1): Brennan, Leape, et al, New England Journal of Medicine • (2): To Err is Human, Institute of Medicine One per week in a typical hospital

Many Errors are Preventable • Nosocomial Infections – a.k.a. “Hospital-Acquired Infections” (HAI) – 5 to 10% of hospitalizations • 10% of these are serious bloodstream infections • 87,000 to 350,000 die annually – “Can be prevented through improved hygiene and proper line insertion standards” (1) • Allegheny: reduced bloodstream infections by 68% through standard methods and supplies • (1): U.S. Centers for Disease Control

Remember This: The problem is the process (or lack thereof)… not the people

Applications of Lean in Healthcare • Laboratories (Core Lab, Blood Bank & AP) – Reducing Turn Around Times and Errors • Operating Rooms – Reducing changeover times, increasing utilization • Inpatient Care – More time for patient care, fewer falls & infections • Outpatient Cancer Treatment – Reducing patient delays, increasing capacity • Pharmacies – Reducing errors, improving response • Emergency Departments – Reducing diversions, improving flow

Lean Methods that Apply • Identifying and • Quick Changeover eliminating WASTE • Employee Involvement & • 5S and Visual Engagement Management • Heijunka • Kanban • Improving Flow • Standardized Work (Reducing Batching) • Kaizen • Value Stream Mapping • “5 Whys” Problem Solving • Flow layouts • Error Proofing • “Go to Gemba” • Spaghetti Diagrams • Time Studies

The Iceberg of Lean

“Equally Important Pillars” 17

“Gemba”: The Actual Place “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 18

“Gemba is for Everyone” “…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 19

Patients (Gemba) Walkway over tracks Parking Garage Executive Offices 20

“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.” 21

The Quaid Case – Heparin/Hep-Lock Hospital CMO: “This was a preventable error, involving a failure to follow our standard policies and procedures, and there is no excuse for that to occur at Cedars-Sinai.” Was this the first time the policies and procedures were not followed?

The Quaid Case – Heparin/Hep-Lock New Design Old Design

Case Example • Virginia Mason Medical Center (2004) – Mary McClinton died after cleaning solution was injected (not dye) – Identical looking clear syringes together on tray • “Mistakes will happen,” he said, sadly. “We are exceptionally human.” – Knew about same color syringes 2 YEARS before fatal error occurred • Had switched from brown cleaning solution to clear – Radiology tech MENTIONED the problem to a supervisor 2 MONTHS before the fatality • Why does this happen? How can we prevent this?

The Need for Lean Problem Solving

By Adopting the Lean Approach • Asked Key Questions: – Whose responsibility is it to stock supplies? • Add standardized work • Establish kanban system – How do we make it obvious something is missing? • Visual management – How do we manage the system and hold people accountable to the standardized work? • Lean management system

Toyota’s Chairman Fujio Cho Three Keys to Lean Leadership • Go See – “Senior Management must spend time on the front lines.” • Ask Why – “Use the “Why?” technique daily.” • Show Respect – “Respect your people.” 27

It’s The System “You respect people, you “Human error is listen to them, you inevitable. We can work together. You never eliminate it.” We don’t blame them. can eliminate problems Maybe the process was in the system that make not set up well, so it it more likely to was easy to make a happen.” mistake.” – Gary Convis, President TMMK – Liam Donaldson, WHO World Health Alliance for Patient safety 28

“I’ve worked here for six years and this is the first time anyone has asked me what I think about anything.” Registered Nurse 15 yrs experience 29

Engaging Employees From Locked Box To Visual Idea System

Kaizen “Wall of Fame” Area: STL Kaizen Wall Date: 5/31/07 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: Old Style Container New Container 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 Source; Children’s Medical Center, Dallas 31

ThedaCare’s Lean Leader Traits • For ThedaCare’s “steady state” – Patient – Inquisitive – Keenly interested in problem solving – Good communicator – Mentor who likes to see people success and wants to be in the middle of the action, not behind a desk – Calm, deliberative problem solver • Source: On the Mend (2010, Lean Enterprise Institute) • Fox News Videos: http://lnbg.us/1D0 32

Lack of Lean Leadership “This [lean] is not the standard model executive being produced by U.S business schools, much less American medical schools.” – Toussaint and Gerard, On the Mend 33

ThedaCare’s Results • True North: – Customer Satisfaction, Safety/Quality, People, Financial Stewardship • Saved $27M in first four years • Increased margin from 2% to 6% • Improved “door-to-balloon” time 92 min to 37 min • Lower cardiac surgery mortality • Fewer babies born pre-term • Higher staff satisfaction 34

The Working World Technical Content Relationships Lean Tools Communication Change & Results • Cannot communicate enough • “Show, supervise, set free”

Mark’s Lessons Learned (1) • Don’t be the lone “Expert,” get everyone involved • Great ideas don’t matter if people can’t agree • Understand an organization’s capacity for change – “Have the right amount of impatience” • Observe first, then propose solutions • Solving problems rather than “doing stuff” – Choose the right problem and define it properly – Numbers and results for your resume

Mark’s Lessons Learned (2) • Lean is a management system and philosophy, not just “tools” • Does your employer really want to “be Lean”?? • Don’t rely just on “events” • Get direct supervision experience early (but not first)

Why Work in Healthcare? • Less likely to be “offshored” • As a “Lean” person, you can make a difference • Incredibly interesting, rewarding work • Impact people’s lives – Patients – Hospital Staff – Medical Professionals • Help solve a high-priority societal issue

Q&A • Email: – mgraban@lean.org • Lean Enterprise Institute: – www.lean.org • Healthcare Value Leaders: – www.healthcarevalueleaders.org • Blog: – www.leanblog.org • Twitter: – www.twitter.com/LeanBlog 39

About LEI • Lean Enterprise Institute, Inc. (LEI) is a nonprofit education, publishing, conference, and research organization founded by James Womack, Ph.D. in 1997 to promote and advance the principles of lean thinking in every aspect of business and across a wide range of industries. • Through its publications, summits, conferences, workshops, webinars, online forums, and website resources, LEI helps organizations transform themselves into lean enterprises, based on the principles of the Toyota Business System. 40

Mark Graban "How Lean Thinking Helps Hospitals"

by Mark Graban on Apr 14, 2010

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Mark Graban "How Lean Thinking Helps Hospitals" — Presentation Transcript