Lean Hospital: Creating a Lean Culture of Continuous Improvement Part 3/3


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The PowerHealth OnDemand Webinar Series brings you Leonardo Group Americas LLC (authors of the books Lean in the OR, Supplies Management in the OR, Value Stream Mapping in the OR, Lean Training Games in the OR and Quick Changeover in the OR), who will share their experiences and learnings from working with hospitals across the country to develop a Lean mindset/environment that achieves continuous improvement and sustained profitability. The topics covered in Part 3 include:
1. The Process Improvement database. Is Excel the best option? 2. Building a Kaizen infrastructure: people, systems and improvement processes.
3. Audit Checklist: 10 things to do to create a Lean Culture of Continuous Improvement.

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  • Lean Hospital Roadmap 101
  • We are at a pivotal point in time for hospitals in the US and in the world. Competition is beginning to be a meaningful market force, when it was not a short year ago. Pressure on cost is being brought to the forefront and many times not in the way we would like. Often staff appears to be the target for cost reduction, rather than the many forms of waste that plague the OR. We find ourselves right now where there are only two kinds of hospitals: those who have embraced Lean and those that will. Continuous Improvement is coming to a hospital near you and for your sake and that of your patients, we hope it is your hospital.  
  • This is characteristic 1: Use a Roadmap and have a Master Plan. Let’s define these terms a bit more. By roadmap, we mean a documented and proven series of step to follow, to achieve a desired objective, which in this case is the creation of a high-performing hospital based on Lean principles. The Master Plan defines the who, what, when, where and how to make that happen, in the short term, medium term and long term. Specific projects and resources are assigned in the Master Plan. Let’s take a quick look at each of these.
  • This is the Lean Hospital Strategy roadmap, with the processes for this lesson circled. You can see that we’re just getting started! Remember too that the drill icon means that there is a detailed sub-roadmap for each of these two processes, with additional detail. So this is not as simple as it may look.   We’ll start by describing one of the deliverables of this part of the roadmap, an actionable Master Plan.
  • Do not copy without permission The Japanese word for the Lean planning process is Hoshin Kanri, translated as strategy deployment. This is a big topic, and we’ll only be touching on it here briefly. In this graphic what is communicated is the chain of action starting with the high level vision created by senior management, translated into specific and department-level plans by middle management, and actually done by cross-funtional implementation teams. Each level in the process is linked to the level above and below. Take a look at Hoshin Kanri for the Lean Enterprise by Tom Jackson for a lot more information on this powerful method for creating a Master Plan and strategy deployment.
  • Do not copy without permission Case in Point. We’ll have one of these for each of our 10 characteristics. This is an example of a Hoshin Kanri A3-size worksheet. We are attempting to ensure alignment in our Master Plan by comparing our strategy or vision with our tactics or projects, with our process measurements or metrics, with our quantified results. A strong correlation get a black dot, a medium correlation gets a white dot, and a weak correlation gets a triangle. We also align the people who will be directing these projects, in this section on the right. Done right this is an extremely powerful tool. And if you don’t do this analysis, then how would you ever know if your actions actually match your vision and measurements, using the right people? Again this is discussed in detail in Hoshin Kanri for the Lean Enterprise. That’s characteristic 1. Any mature Lean organization can show you their Master Plan, and are probably using some of the tools we just presented here. Let’s move on to characteristic 2.
  • This is characteristic 1: Use a Roadmap and have a Master Plan. Let’s define these terms a bit more. By roadmap, we mean a documented and proven series of step to follow, to achieve a desired objective, which in this case is the creation of a high-performing hospital based on Lean principles. The Master Plan defines the who, what, when, where and how to make that happen, in the short term, medium term and long term. Specific projects and resources are assigned in the Master Plan. Let’s take a quick look at each of these.
  • Our starting point for a lean transformation is with the tool of Value Stream Mapping, which many of you are already familiar with. The beauty of VSM is that we are documenting not just the work, but the delays in-between processes. These delays are what we are attempting to reduce or eliminate as a part of our Lean efforts. In this VSM shown here, all of the yellow triangles represent delays or queue time. Of course we can’t just wish the queue time to go away. Some work will be needed to improve the process, and create what we call the Future State. The deliverable here is to ensure that every one of our major value streams, i.e. the series of processes through which we deliver value to our patient, or to our customer, is mapped out in this flow-chart format. What you see here is an example of software that will help you develop these flow charts, called iGrafx. We recommend creating them using post-it notes and brown paper, and make them pretty later on. Let’s now talk about standardization.
  • This is a picture of the father of standardization, Frederick Winslow Taylor. We celebrating the 100 th year anniversary of his book Principles of Scientific Management, first published in 1911. He used the term “one best way” to describe the goal of standardization. There may be more than one way to complete a task, so it will be the responsibility of the team to determine the way it will be done. This can be done through experimentation, comparing the various methods, or by consensus by the work group. And, of course, the work can also be further improved over time. We’ll talk about that in a few minutes. In a Lean enterprise, a fairly large part of managements job is to sustain and improve standard work…this is not a minor detail.
  • A primary purpose of documenting Standard Work is to define the relationship of quality to the documented task. If we can define quality checks at the task level and perform those checks while doing the work, we can insert quality into the process, rather than relying on inspection to discover defects, or worse, allowing defects to get through to the customer.
  • Case In Point: at a recent Kaizen event that we conducted, the team not only documented the new and improved process on paper, but they also decided to document the process using an inexpensive video camera and a software package called Camtasia. A separate training video was created for the Surgical Techs, the Turnover Technicians and the Surgical Nurse.
  • Characteristic Three: Mentors in Every Department. The philosophy here is that Lean is not the domain of a few specialists, but rather a democratic movement that needs to involve everyone in the organization. In order to make that happen, people need to be trained and guided, and we are calling these guides “mentors”. These mentors work in their departments, and so are “insiders” rather than “outsiders”, and have a better understanding of the needs of each department.
  • We use the mentoring system in a variety of endeavors: how we train artists, athletes, zen masters and scientists. It is really no different in a hospital, as it applies to creating a Lean culture. The important point about the mentor is that he/she is not a “know it all” who tells people the right way to do things. Rather it is an application of the Socratic method of asking questions, and letting people develop their own critical thinking. Developing a strong group of mentors is clearly not a minor detail. I read recently that Steve Jobs thought that the hiring process was the most important task of all, and cultivating staff members to become mentors is probably one of the biggest challenges in becoming a true Lean Hospital. November 2009 Do not copy without permission 7S for Hospitals
  • Case In Point: Mentors can be trained too, and we’ve developed a number of mentor (here called Lean Specialist) training workshops. A big part of each course of study involves hands-on work, and the entire duration of this course is six months, with 1 week a month dedicated to the training in a number of Lean methods. November 2009 Do not copy without permission 7S for Hospitals
  • Characteristic number four is Staff is Engaged. Engaged is another work for “involved” or “actively participating”. In this case we’re talking about the participation of continuous process improvement, i.e. being willing and able to come up with improvement suggestions on a continual basis. The level of staff engagement is one important measurement of the level of Lean maturity of the hospital.
  • The reference that we use is a book by Norman Bodek titled The Idea Generator, Quick and Easy Kaizen . The focus of this book is on building a Lean culture and maintaining a suggestion system that actually works. The emphasis is on small ideas that are easy to think up, easy to approve, and easy to implement. Many of us have suggestion systems already in place, but the problem is, we don’t get very many ideas. This book describes how to manage the system correctly. Let’s now take a look at what is actually possible, with actual data.
  • The ideas we look for can be big ones, of course, but primarily we’re looking for small suggestions. Here is a suggestion, and then a project, that was able to be completed in about a day, with a team of 4 people working on it. This, need I say, is the before picture.
  • And here’s the space afterwards. The hardest thing about a project like this will be the sustaining of the changes, and having a process in place to make sure it doesn’t backslide to the previous condition. That is an important part of the 7S process (5S + Safety and Security). Imagine hundreds or thousands of small, medium and large projects being conducted continually, and imagine how that could revolutionize patient care and staff satisfaction at your hospital.
  • The next characteristic is what we call Real-Time Performance Tracking. Think about driving a car, or flying an airplane. If the speedometer shows how fast you were going last week, it’s not going to be terribly helpful in driving the car. Or if the altimeter in the plane shows your altitude an hour ago, that could make for a risky flight.
  • A lean term that we should know it pitch , and it’s not even Japanese! That’s a change, right? From a metrics or data collection point of view, the pitch will be the reporting frequency. For example, we may have a production line with a takt time of 5 minutes. We may have an electronic system for tracking completions, in which case the pitch might be 5 minutes. If we are reporting progress manually, however, we don’t necessarily need to know how we’re doing every 5 minutes. We just need feedback often enough to make course corrections in time, and not wait until the end of the day (or tomorrow) to find out we didn’t meet our production target for the day. Let’s take a look at an actual performance board, being used to display OR status. This will probably be familiar to many of you, and I know some of you have electronic versions of this board as well.
  • This is just one example among many. Another term that is used these days is “dashboard”, that we use to steer the organization. What data do we need to record, and how often should we record it? And one final point: most mature Lean organizations (even those that can afford any fancy system they might want) record and display this data manually. Why manually? Because it’s immediate, you don’t need a computer to enter the data or see it, and staff has direct ownership of the numbers.
  • Characteristic number nine is: there is a high level of 5S.
  • November 2009 Do not copy without permission 7S for Hospitals
  • November 2009 Do not copy without permission 7S for Hospitals
  • We now come to the question of management’s role in this system of continuous improvement. There is a parallel set of habits or disciplines related to being a manager November 2009 Do not copy without permission 7S for Hospitals
  • In a traditional hospital, managers and supervisors are expected to manage and supervise. November 2009 Do not copy without permission 7S for Hospitals
  • November 2009 Do not copy without permission 7S for Hospitals
  • November 2009 Do not copy without permission 7S for Hospitals
  • November 2009 Do not copy without permission 7S for Hospitals
  • November 2009 Do not copy without permission 7S for Hospitals
  • November 2009 Do not copy without permission 7S for Hospitals
  • There are only two kinds of hopsitals: those who are pursuing a Lean strategy, and those who will.
  • Lean Hospital: Creating a Lean Culture of Continuous Improvement Part 3/3

    1. 1. Creating a Lean Culture of Continuous Improvement Part 3
    2. 2. • Principal, Leonardo Group Americas LLC. • Co-Author of Fundamentals of Flow Manufacturing, Aerospace Flow, In the OR series of Lean HospitalGerard books. • Vice President of Technology, JCIT.Leone • Trained over 5000 manufacturing professionals seeking improved performance over his tenure at JCIT and CSU. • Adjunct Instructor of Manufacturing Management at Colorado State University. • Implementation Leader in over 150 businesses of various sizes. • Lean Hospital work since 2002. • In charge of the Lean Healthcare practice at LGA. • Bilingual Spanish-English. • 12 years of manufacturing management and teaching at university level prior to consulting career.
    3. 3. Webinar OverviewThe principles and tools of Lean thinking are changing the lives of Healthcare professionals by allowing them to devote more of their time to caring for patients. This is possible through the elimination of wasteful activities and the participation of all staff in a culture of Continuous Process Improvement, following a Lean Roadmap.
    4. 4. Learning Objectives: Part III of III Building a Kaizen infrastructure: people, systems and improvement processes. Audit Checklist: 10 things to do to create a Lean Culture of Continuous Improvement. The Process Improvement database. Is Excel the best option?
    5. 5. Implementation ModeFoundational Elements for a Kaizen Culture
    6. 6. Preparation Step 1 Use a Roadmap andHave a Master Plan
    7. 7. Lean Hospital Implementation Roadmap Train Leadership Team in the principles of To support the Hospital’s Lean A Lean Hospital embraces a An initial assessment of current hospital Hoshin Kanri (Goal Deployment) and formalize journey, Leaders must participative model of Continuous operations, including future vision and level internal process. Use A3-X chart and Team understand the tools and Improvement. All Lean Hospital of process improvement maturity. Includes Charter forms for all Master Plans. culture of Continuous Process employees must be trained to be a analysis of potential benefits. Improvement. part of this culture. Conduct Value Stream analysis for each unit and department to identify 1 3 TRAIN 6 opportunities for improvement. Create a START LEAN HOSPITAL ASSESS O.R. TRAIN TRAIN unit-level Master Plan. START LEAN HOSPITAL ASSESS O.R. LEADERSHIP TRAIN TRANSFORMATION OPERATIONS LEADERSHIP HOSPITAL STAFF TRANSFORMATION OPERATIONS TEAM HOSPITAL STAFF TEAM The Lean Hospital Master Plan includes a definition of identified 2 VALUE STREAM 4 7 8 Formalize the VALUE STREAM SET UP SET UP IMPLEMENT IMPLEMENT improvements, resources DEVELOP UNIT DEVELOP UNIT process of soliciting, ANALYSIS AND ANALYSIS AND PERFORMANCE PERFORMANCE GOAL DEPLOYMENT GOAL DEPLOYMENT required, implementation MASTER PLANS MASTER PLANS receiving, MASTER PLAN MASTER PLAN DASHBOARD DASHBOARD TOOLS TOOLS timeline, estimated benefits, and evaluating, andROI for the selected value streams. implementing process Establish lean performance metrics improvement and method for reporting, analysis, suggestions for the 5 and follow-up. CONDUCT CONDUCT entire hospital. PILOT PROJECTS PILOT PROJECTS Select highly visible areas for proof 9 10 SUSTAINED of concept and buy-in. Follow CONDUCT INITIAL IMPLEMENT KAIZEN SUSTAINED Roll-out unit and department CONDUCT INITIAL IMPLEMENT KAIZEN PERFORMANCE Kaizen methodology to achieve KAIZEN EVENTS SUGGESTION SYSTEM PERFORMANCE process improvement KAIZEN EVENTS SUGGESTION SYSTEM results in less than 5 days. activities per the Lean Certify all Internal Lean Hospital Master Plan. Mentors through completion of actual projects and 15 14 IMPLEMENT Knowledge Checks. ROADMAP IMPLEMENT ROADMAP SUSTAINABILITY COMPLIANCE AUDIT SUSTAINABILITY COMPLIANCE AUDIT ROADMAP ROADMAP 13 12 KAIZEN MENTOR 11 KAIZEN MENTOR KAIZEN MENTOR INSTITUTE KAIZEN MENTOR CERTIFICATION INSTITUTE CERTIFICATION CERTIFICATION UNIT CPI TEAM Conduct a comprehensive, lean- CERTIFICATION TRAINING UNIT CPI TEAM TRAINING focused audit, with the objective of advancing the Lean Culture at the Hospital. Each team leader presents the status of Organize a local Continuous completed Kaizen projects to ensure Train a team of Hospital Staff Process Improvement Team to results and sustained performance. to become internal Lean identify, evaluate, and Mentors. implement improvements.
    8. 8. Hoshin Kanri: Goal Deployment
    9. 9. A3-X “X-CHART”
    10. 10. Preparation Step 2Value Streams are Mapped and Standardized
    11. 11. Value Stream Mapping
    12. 12. THE ONE RIGHT WAY  If only one way is right, document that one right way  If there is more than one right way, agree on the way the work will be done, and do it that way  Staff is trained and certified in Standard Work  Management’s Job: SustainFREDERICK W. TAYLOR and Improve Standard Work
    13. 13. CHECK - DO - CHECK Build Quality into the Work Check the work coming to you Do Standard Work Check your work before moving it to the next step
    14. 14. VIDEO TRAINING Case in Point
    15. 15. Implementation Mode10 Points to Creating a Culture of Continuous Improvement
    16. 16. Point 1:Mentors In Every Department
    17. 17. THE MENTORING PROCESS Similar to Master-Novice Relationship in the Arts, Religion, Science, Sports Goal of Mentor is not Problem Solving But Employee Development Big Challenge = Cultivation of Mentors
    18. 18. Case in Point
    19. 19. Point 2:Staff Is Engaged
    21. 21. before state Case in Point
    22. 22. after state Case in Point
    23. 23. Point 3: Real-TimePerformance Tracking
    24. 24.  Pitch = how often work is released and monitored.  Pitch = frequency of reporting key performanceReal-time metricsFeedback  As an organization matures in its Lean journey, the pitch gets smaller
    25. 25. REAL-TIME O.R. STATUS Case in Point
    26. 26. Point 4:Every Process has a Target Condition
    27. 27. • It is called Continuous It’s like Improvement for a reason. Pushing a• There is no such thing as a Rock “Stable Process”.• A Process that is not Improving is Degrading.• The question is “What’s Next?”
    28. 28. How?
    29. 29. Casein Point
    30. 30. Point 5: ManagementUnderstands Lean and Leads
    31. 31.  Lean is Democratic Hard to sustain if not understood What does it mean to “understand”? Management Team must have It Must Start some intensive training from the Top Managers must participate in Improvement Projects Managers must audit sustainability Continuous Improvement becomes part of Managing
    32. 32. • Manager ≠ Has all the answers• “I don’t know” is OK How?• Figure it out as a Team• Know your Lean tools• Make friends with the Lean Mentors• Try it, then Try again• Think PDCA, teach PDCA• Budget staff time for Kaizen• Round with intent
    33. 33. Casein Point
    34. 34. Point 6:Formal Kaizen Processes
    35. 35. Formalization Checklist• Kaizen Management training and certification for supervisors and managers.• Cloud-based Kaizen Management System.• Formal but easy process for submitting ideas.• Kaizen dashboard and metrics.• Daily/weekly team meetings focused on Kaizen.
    36. 36. 1. Sort: Remove unneeded items2. Shine: Keep the work areas spotless, and maintain all Formalization equipment rigorously Example3. Set in Order: Organize those items which remain4. Safety assessment of new setup5. Security assessment of new setup6. Standardize: Create and follow rules and standards7. Sustain: the disciplines above
    37. 37. Casein Point
    38. 38. Point 7: Embed ContinuousProcess Improvement Habits
    39. 39. The PDCA Cycle CPI
    40. 40. 1. What is the target condition?2. What is the actual condition now?3. What problems or obstacles are now preventing you from reaching the target condition? Which one are you addressing now?4. What is your next step?5. When can we go and see what The we have learned from taking Coaching that step? Cycle - Toyota Kata by Mike Rother
    41. 41. Point 8:Management = Process Improvement
    42. 42.  Common View: Managers Are Responsible for Management Duties  Progressive View: Managers Are Responsible for Management Duties Plus The Continuous ImprovementManagement  Lean View: Management = Habit Managing and Improving Processes
    43. 43. Point 9:ImprovementsHappen Locally
    44. 44. Does The Org Chart Matter? Organize By Value Stream? Goal: Smooth Sailing Ship Organizational Structure Not That Important More Important: Mentor- Student Relationships Toyota is Organized Traditionally and Functionally All hospitals in the US are organized functionally
    45. 45. Point of Leadership
    46. 46. Small Ideas Versus Projects 10% 90%
    47. 47. Managing the Lean Transformation  Coordination of improvement activities is necessary  Promoting staff ideas helps develop Kaizen Spirit  Nurses and Techs are already busy and time-constrained, and are attending to patients  Management and Kaizen Leaders dedicate 50%+ of their time to mentoring and projects  What about physicians?
    48. 48. Point 10: Use A KaizenManagement System
    49. 49. Kaizen DatabaseExcel-Based System Home-Grown System• Easy to set up. Low cost. • Access / Sharepoint / Other• Rely on single point manual • IT involvement needed. data entry. • Can be very expensive.• Security is a concern. • Long-term maintenance• Backup is a concern. needed.• Capacity is a concern. • No leverage for system improvement.
    50. 50. Cloud-Based System Kaizen OnDemand Flow• Easy to set up. Low cost.• Minimal IT maintenance needed.• Benefit from system improvements.• Access benchmarking data from multiple hospitals.
    51. 51. A Call to Action
    52. 52.  Start with Assessment Value Stream Mapping is a good start How? Where to start Fishbone, 5-Why tools. Develop a Database Pursue Relentlessly Improvements happen locally Who is in Charge?
    53. 53.  Lean is not a technique, it’s a philosophy of continuous improvement (Kaizen). Kaizen needs to be learned Webinar and practiced. It won’t Series happen by itself. Summary Without Standardization there is no Kaizen. Needed: training, management leadership, formalization.
    54. 54. Lean Introduction series has ended so what now?1. View February’s Demo on Kaizen OnDemand Management System2. Sign up for a 1:1 live demo with Gerard3. Sign up for As little as $2/month per user 1st 10 signups receive 60 days risk-free AND 1 hour free Quickstart Implementation training from Leonardo Group (8 spots left)
    55. 55. Thank you for joining us!Leonardo GroupPrincipals: Gerard Leone & Richard D Rahn303-494-4404Boulder, Co 80303 PowerHealth OnDemand Scott Calvert VP Business Development 303-683-8239 Greenwood Village, Co 80111