Introduction to Lean Principles Planning of your work processes to improve flow Amy Hodgkinson and Trevor Taylor National Improvement Leads, NHS IQ Presentation from the Productive Endoscopy Workshop, Tuesday 15th October 2013 at Ambassadors Bloomsbury , London, WC1H 0HX This meeting brought together teams from around the country, and embarked on creating and testing the productive endoscopy toolkit. The aim of the day is to allow time with your team for sharing of experiences and exchange of good practice, learn how to apply lean techniques and hear the impact of successfully implemented case studies.

1. Introduction to Lean
Principles
Planning of your work processes to improve flow
Productive Endoscopy Workshop
Tuesday 15th October 2013
Amy Hodgkinson and Trevor Taylor
National Improvement Leads, NHS IQ

2. Simulation exercise
“The current state”

3. Simulation Exercise
• Practical simulation designed to introduce
Lean principles
• 2 teams - all team members with a role
• 2 rounds with different focus

4. Simulation Exercise
1. Simulate the process within healthcare from end
to end
2. Observe the process and capture key metrics to
identify the key waste areas
3. Brainstorm improvements to the process
4. Try the key improvements and capture key
metrics to measure the success of the changes

5. Teams
1. Operator #1 (at step 1)
9. Metrics/Time Keeper
2. Operator #2 (at step 2)
10. Finance Manager
3. Operator #3 (at step 3)
11. Observer
4. Operator #4 (at step 4)
12. Observer
5. Operator #5 (at step 5)
13. Observer
6. QA Inspector
14. Observer
7. Porter 1
8. Porter 2

6. Simulation One
Objective:
• Produce 40 Endoscopy reports for scoped
patients

7. Simulation Rules
Each Operator:
• Collect lego pieces from stock room
• First operator ONLY - place sticky 1 on piece
1, sticky 10 on piece 10, 20 on piece 20, 30
on piece 30, 40 on piece 40
• Build as fast as you can
• Build according to batch size
• Call a Porter once batch size completed
• Porter will pass to next operator
• No pre-assembly
• No helping slower teammates

8. Simulation Rules
QA Inspector:
• Check report by report – confirm pass / fail
• Inform Metrics/Time keeper
• when 1st, 10th, 20th, 30th and 40th report is
completed
• when sticky numbers 1, 10, 20, 30 and 40
arrive
• how many reports are correct (pass) /
incorrect (fail)

9. Simulation Rules
Process Observers - closely observe for the
following:
• How the piece moves from step to step
• How many times the operator collects stock
from the stock room
• Where work builds up
• Movement of people and pieces
• Other aspects you feel are important

10. Simulation Rules
Leadership Observers - closely observe for the
following:
• What do you observe about leadership in this
process?
• How do the “staff” feel about their work?
• What leadership behaviours are missing?
• How productive would this team be over the
long term?

11. Simulation Rules
Porter:
• When called by operators 1-5, collect pieces
and transport to next operator or to the QA
Inspector

12. Simulation Rules
Metrics / Time keeper:
• Start the process (start the stopwatch)
• Do not stop stopwatch until end of game
• Record time when 1st, 10th, 20th, 30th and 40th
reports are received by QA Inspector
• Record time when sticky numbers 1, 10, 20, 30
and 40 are received by QA Inspector
• Stop the stopwatch when 40th report and sticky
40 have been received
• Record pass/fail rate, no. of staff and cost
(request cost figures from Finance Manager)

13. Simulation Rules
Finance Manager:
• Calculate profit and loss results and unit cost
per report
Correct Final Report
£25
Incorrect Final Report
£100 penalty
Inventory
£5 per WIP piece
Staff & Equipment
£1 per person per minute

14. On your marks…..

15. Results

16. What are the
principles of Lean?

17. What is Lean?
• Perfected by Toyota – from 1928 (Deming & Ford)
• ‘Lean’ coined by Jones & Womack in 1990s
• Lean is about improving flow and eliminating waste
– getting the right things,
– to the right place,
– at the right time,
– in the right quantities,
• while minimising waste and being flexible and open to
change.
• Customer at heart of the process
• Driver for Quality and Safety

18. Lean Thinking…
It is –
• A way of thinking
• A philosophy
• A mind set
• An approach
• A new culture
It is not –
• A management fad
• Rocket science
• A cost cutting exercise
• About making everyone
work faster
• A magic wand
• Just for manufacturing

19. NHS Change
Model
Lean principles
support the
capability to
deliver the new
NHS Change
Model

20. The 4Ps of Lean
Problem
Solving
Solve problems using Root Cause Analysis,
‘Go See’ and data
People &
Partners
Respect, challenge & grow them - become a
learning organisation
Process
Eliminate Waste
Right process will deliver the right result
Philosophy
Long-term Thinking and
Continuous Improvement
Ref: Liker 2004

21. Lean Principles
Define value from the
customers perspective
and express value in
terms of specific
requirements/measures
1
Specify Value
2
Map the
Value Stream
3
Establish
Flow
5
Work to
Perfection
The complete elimination
of waste so all activities
create value for the
customer
Map all of the steps…
value added & non-value
added…
4
Implement
Pull
The continuous movement of
patients, samples, request
cards, reports from end to
end through pathways
Nothing is done by the upstream process until
the downstream customer signals the need

22. Lean “Tools”
• Voice of the customer
•
•
•
•
• Work Combination
Sheets
• Total Productive
Maintenance
• Mistake Proofing
Standard work
Data and Measures
Visual Management
5S
•
•
•
•
• Value Stream
Mapping
• Process
sequence charts
• Spaghetti map
• Handoff diagram
• A3 thinking /
problem solving
(PDCA)
• Root cause
analysis
• One piece flow
Kanban
Demand smoothing
Load levelling
Takt time

23. Lean Principles
Define value from the
customers perspective
and express value in
terms of specific
requirements/measures
1
Specify Value
2
Map the
Value Stream
3
Establish
Flow
5
Work to
Perfection
The complete elimination
of waste so all activities
create value for the
customer
Map all of the steps…
value added & non-value
added…
4
Implement
Pull
The continuous movement of
patients, samples, request
cards, reports from end to
end through pathways
Nothing is done by the upstream process until
the downstream customer signals the need

24. The Customer defines Value Added
A visit to the Doctors
Where is the added value?
• Making the appointment
• Registration
• Waiting
• Diagnosis
• Treatment
• Who is your
customer?
• What do they need /
want?
• How do you know?
• Do you understand
the ‘voice of your
customer’?

25. Lean Principles
Define value from the
customers perspective
and express value in
terms of specific
requirements/measures
1
Specify Value
2
Map the
Value Stream
3
Establish
Flow
5
Work to
Perfection
The complete elimination
of waste so all activities
create value for the
customer
Map all of the steps…
value added & non-value
added…
4
Implement
Pull
The continuous movement of
patients, samples, request
cards, reports from end to
end through pathways
Nothing is done by the upstream process until
the downstream customer signals the need

26. Understanding Value & Waste
Value Added Activity
Any activity that changes the
form, fit, or function of a
product/transaction
— OR —
Something customers are
willing to pay for
Eliminate
Non-Value Added Activity
Any activity that absorbs resources
but adds no value is a Waste
Minimize
Unnecessary
Waste
Necessary
Waste
Value
Maximize

27. Types of Waste - Simple Mnemonic
• Doesn’t add value to the patient, healthcare provider or staff
– Transport
– Inventory
– Motion
WASTEcosts
– Automating an inefficient process
money and
– Waiting
adds time!
– Overproduction
– Over processing
– Defects
– Skills appropriate to task

28. ‘Old’ process
NEW Process

30. Spaghetti mapping

31. Things to think about…
• Focus on 80% of the time (green stream)…people will always
remember the exceptions
• Look for bottlenecks & “batching” (Triage, vetting,
authorisation) – what stops flow?
• Look for “work arounds”… often duplication
• Focus on what “adds value” from the patient perspective
• Is unpredictable demand really unpredictable?
• Where are you losing capacity?
• Is everyone following the same system / protocol ? (standard
working)
• Could visual display help save time?

32. Lean Principles
Define value from the
customers perspective
and express value in
terms of specific
requirements/measures
1
Specify Value
2
Map the
Value Stream
3
Establish
Flow
5
Work to
Perfection
The complete elimination
of waste so all activities
create value for the
customer
Map all of the steps…
value added & non-value
added…
4
Implement
Pull
The continuous movement of
patients, samples, request
cards, reports from end to
end through pathways
Nothing is done by the upstream process until
the downstream customer signals the need

33. Flow
What stops flow ?
• Batching
• Searching
• Variation in way things are
done
Eliminate batching
5S
Standard working
Visual Management
• Poor layout / excess walking
• Variation in demand
• Variation in turn around times
Ergonomic layout
Level demand
Stabilise process

34. Batch production
Operator 3
Batch size 10
Operator 2
Batch size 10
1 min
Operator 1
Batch size 10
10 minutes
20 minutes
3 step process
3 operators
30 minutes
Batch size 10

35. One piece flow
Operator 3
1 min
Batch size 1
Operator 2
1 min
Batch size 1
1 min
Operator 1
Batch size 1
3 mins
4 mins
3 step process
5 mins
3 operators
12 minutes
Batch size 1

36. Lean Principles
Define value from the
customers perspective
and express value in
terms of specific
requirements/measures
1
Specify Value
2
Map the
Value Stream
3
Establish
Flow
5
Work to
Perfection
The complete elimination
of waste so all activities
create value for the
customer
Map all of the steps…
value added & non-value
added…
4
Implement
Pull
The continuous movement of
patients, samples, request
cards, reports from end to
end through pathways
Nothing is done by the upstream process until
the downstream customer signals the need

37. Pull
•
A notification system of requesting either:
• work to be completed, or
• delivery instructions for work completed
•
Nothing is done by the upstream supplier until the downstream
customer signals the need
One more
please!
Okay
supplier
customer
Pull: Customer centric

38. Lean Principles
Define value from the
customers perspective
and express value in
terms of specific
requirements/measures
1
Specify Value
2
Map the
Value Stream
3
Establish
Flow
5
Work to
Perfection
The complete elimination
of waste so all activities
create value for the
customer
Map all of the steps…
value added & non-value
added…
4
Implement
Pull
The continuous movement of
patients, samples, request
cards, reports from end to
end through pathways
Nothing is done by the upstream process until
the downstream customer signals the need

39. What is the point of Lean?
• Improving quality & eliminating defects
– Poor quality costs money in re-work and time
• New future state
– In god we trust, everyone else brings data!
– What are you going to measure to ‘prove’ the
change is an improvement?
• PDCA / A3 thinking
– Structured problem solving & RCA
– Cycle of continuous quality improvement (CQI)

40. Model for
Improvement –
the three questions

41. A3 Thinking
• Structured thinking way - thinking deeply
• Follows a series of standard steps
• Rigorous application of Plan Do Study/Check
Act (PDCA) cycle
• Output is a concise, condensed document A3 Report (11 x 17 inch paper)

42. Version:
Author:
Title: A3 Problem Solving -
Future state:
Current state:
Waste identified:
PLAN
Goal:
Action plan:
Root cause analysis:
Next Steps:
CHECK /
ACT
Results and measures:
PLAN DO
Problem Statement:
Date:
Team:

43. Use data to
establish the
facts

44. Root Cause Analysis
• The cause(s) that, if taken care of, would
eliminate all future occurrences of the problem

45. Cause and Effect / Fishbone

46. Why? Why? Why? Why? Why?
Results are not being reported back to GP in addition to OP
clinic
Why? Results system has not been coded to report to GP
as well as OP clinic
Why? Person booking in did not include GP information
when booking in
Why? Request to report to GP not on request card
Why? OP clinician did not complete the field on
the request card
Why? Process for completing request cards is
not standardised

48. You need data to evidence improvement
“It feels like it has improved…” or
“I think it has improved…”
is not enough

49. Lean “Tools”
• Voice of the customer
•
•
•
•
• Work Combination
Sheets
• Total Productive
Maintenance
• Mistake Proofing
Standard work
Data and Measures
Visual Management
5S
•
•
•
•
• Value Stream
Mapping
• Process
sequence charts
• Spaghetti map
• Handoff diagram
• A3 thinking /
problem solving
(PDCA)
• Root cause
analysis
• One piece flow
Kanban
Demand smoothing
Load levelling
Takt time

50. Visual Management
• The most important step in developing
standardisation.
• Define the ‘normal state’ (standard).
• To visualise deviations from the standard
(problems)
• Indicate if there is a shift from what is expected
• We are visual creatures

51. Examples of
Visual
Management

54. Stop/Start
Audit

55. Lean “Tools”
• Voice of the customer
•
•
•
•
• Work Combination
Sheets
• Total Productive
Maintenance
• Mistake Proofing
Standard work
Data and Measures
Visual Management
5S
•
•
•
•
• Value Stream
Mapping
• Process
sequence charts
• Spaghetti map
• Handoff diagram
• A3 thinking /
problem solving
(PDCA)
• Root cause
analysis
• One piece flow
Kanban
Demand smoothing
Load levelling
Takt time

56. What do these organisations have
in common??

57. Why Standard work?
• Creating the best possible work method, with the least
amount of ‘waste’ to produce the best quality result.
• Maximise quality and safety
• Reduce variation
• Reliable and repeatable process
CONSISTENT METHOD = CONSISTENT RESULTS

59. Lean “Tools”
• Voice of the customer
•
•
•
•
• Work Combination
Sheets
• Total Productive
Maintenance
• Mistake Proofing
Standard work
Data and Measures
Visual Management
5S
•
•
•
•
• Value Stream
Mapping
• Process
sequence charts
• Spaghetti map
• Handoff diagram
• A3 thinking /
problem solving
(PDCA)
• Root cause
analysis
• One piece flow
Kanban
Demand smoothing
Load levelling
Takt time

60. If only
we had
more
space!

61. Is this safe?

64. 5S
•
Sort: Deals with the contents of a workplace and removes all
items that are not needed there.
•
Set in Order: Designating locations to enable easy access to
needed items.
•
Shine: Refers not just to cleaning, but to "being proud" about
the way the workplace is organised.
•
Standardise: Refers to having standards that everyone
agrees & adheres to. Visual management is an important
aspect to facilitate easy understanding of these standards.
•
Sustain: Refers to training of and communication with all
employees to ensure continuous 5S application.

65. Before 5S

66. After 5S

67. A place for everything
and everything in its place

68. Simulation exercise
Designing your
“future state”

69. Designing your “Future State”
• 5 mins - What waste exists in the
“Current State”?
• 5 mins - Discuss and agree what
changes you will make to improve your
process
NEW Objective:
• Produce 40 Endoscopy reports
in 5 minutes

70. On your marks…..

71. Results

72. Success
•
•
•
•
•
•
•
•
Understand the principles
Processes not people
Accept all aspects (challenge the status quo)
Implementation (not recommendations!)
Implement carefully (ever mindful of VOC)
Systematic implementation (not just 5S)
Leadership
Communication

73. Thank you
@NHSIQ
enquiries@nhsiq.nhs.uk
www.nhsiq.nhs.uk
www.england.nhs.uk/ourwork/qual-clin-lead/nhsiq/