Lean Healthcare & Lean Design


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Lean Healthcare & Lean Design

  1. Lean Healthcare & Lean DesignMark GrabanPresident, Constancy, IncFaculty Member, Lean Enterprise InstituteAuthor, “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction”
  2. What is Lean?•  Management Method •  Design Method –  Best patient care –  Patient/family-focused –  Engaging staff –  Engaging staff –  Minimizing waste –  Minimize waste •  Eliminating barriers –  Right size / resources –  Fit your processes –  Continuous improvement –  Iterative improvement of a •  Better quality at a lower one-time design innovation cost •  Better meets needs at a lower cost, with fewer delays 2
  3. Improving Radiology /MRI Access Time Outpatient Radiology Backlog 14 12Weeks Waiting Time 10 8 6 4 2 0 Source: Children’s Medical Center, Dallas TX
  4. Designing New Workflow 4
  5. “Lean Construction”•  “Lean construction is a new way to design and build capital facilities. It challenges the generally accepted belief that there is always a trade between time, cost and quality.” –  Maximizing value and minimizing waste –  Concurrent engineering of facility and workflow –  Value to owner defined and refined over time –  Continuous flow of work schedules –  Decentralized decision making, transparency, empowerment http://www.leanconstruction.org/about.htm 5
  6. Users of Lean Design•  Riley Hospital for Children (Indy)•  Children’s Medical Center Dallas•  Seattle Children’s Hospital•  Park Nicollet (MN)•  Virginia Mason Medical Center (Seattle)•  Beth Israel Deaconess Medical Center (Boston)•  ThedaCare (WI) 6
  7. Seattle Children’s ResultsSource: Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value By Joan Wellman, Pat Hagan, Howard Jeffries 7
  8. Lean Capital $$ Savings•  Seattle Children’s •  Avera McKennan (SD) –  Avoid $180M construction –  Avoided $1.25M in ED expansion•  LeBonheur Children’s (TN) –  $6M avoidance in new tower •  Florida Health System –  $11M building cost•  Akron Children’s avoidance –  Avoid $3.5M expansion of sterile processing •  Delnor Hospital (IL) –  Defer $80M capital expansion
  9. Lean Benefits All Stakeholders Patients •  Safety & Quality •  Caring Encounters •  Less Waiting and Delay•  Pride in work•  Less frustration People •  Mission•  Job security •  Stewardship•  Career growth Philosophy •  Stability / Growth Caregivers Hospital •  Employees •  Medical Staff •  Administrators 9
  10. ThedaCare Coronary Bypass Improvement 12 1
  11. ThedaCare’s Collaborative Carehttp://www.leanblog.org/foxnewsvideos http://vimeo.com/9967016
  12. ThedaCare’s New Tower 12
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  14. St. Elisabeth Hospital: The Netherlands Dr. Jacob Caron, Orthopedic Surgeon Chairman of the medical staff
  15. “Equally Important Pillars” Continuous Respect Improvement For People 15
  16. The 8 Types of WasteType of Waste ExampleDefects Wrong medication given to patientOverproduction Specimens delivered in huge batchesTransportation Patient walking football fields between oncology clinic and chemotherapyWaiting Patients waiting in E.D. Employees waiting on work to doInventory Expired medications, excess O.R. variationMotion RN’s walking 5 miles per dayProcessing Unnecessary MRI’s when P.T. might workHuman Potential Med Techs recapping specimens 16
  17. The Iceberg of Lean 5S Kaizen VSMs A3 Kanban Std Work Heijunka Culture Management System Philosophy 17 17
  18. Lean Terms•  5S: Workplace organization and reduction of waste•  Kaizen: continuous improvement•  A3: Format for PDSA problem solving, planning, reporting•  Kanban: method for replenishment of supplies•  Heijunka: Level loading of workload•  Standardized work: Creating, managing, and improving processes and protocols•  Value Stream Mapping (VSM) 18
  19. Bad Example of 5S"We were offering suggestions and getting pushback on safe staffing, yet being told to reduce the number of pens and pencils.” – RN (Minnesota)
  20. Good Example of 5S for an MD 670 ft for single procedure prep (pre-Lean walking pattern) Exam Procedure Lab
  21. Reducing Podiatrist Walking Restocking Checklist •  Created standardized cart •  Along with standardized rooms, eliminated the need to leave the room during patient encounters
  22. Engaging EmployeesFrom Locked Box To Visual Idea System
  23. LEAN – the 7 “sees”1.  See for yourself (“go to the ‘gemba’”)2.  See what people do (observe first hand)3.  See how people spend their time (activity follow sheet)4.  See where people go (spaghetti chart)5.  See what really happens to your patients (value stream maps)6.  See who your teammates really are (value stream maps)7.  See the wasted effort (waste / ‘muda’) Applies to design and management
  24. Patient-Centered Care•  “Where care comes to you.”•  In the same room: –  lab draws –  nursing assessment –  physician exam –  IV therapy administration –  Music therapy –  Counseling / spiritual care –  scheduling of future appointments•  “It’s kinda all about you.”Park Nicollet Frauenshuh Cancer Center 24
  25. Lean Design Results – Chanhassen Clinic (PN)•  Decrease walking: –  For patient reduced 27% –  For nurse reduced 27% –  For clinician reduced 42%•  Reduce inventory: –  Reduced 21 exam rooms –  Reduced 1 procedure room –  Reduced construction cost $196,200 –  Total project reduction $357,300•  20% reduction of square footage: –  Created flexibility, team work among disciplines; lean concept of open room; less steps for patient and staff; improved flow and visual control.
  26. Staff Engagement to Reduce Waste (Riverside Lab) Final Layout Core Cell Processing Chem/Hem/+ Manual Lean Team, Analysis DrivenComparing Alternatives For Flow and TAT 26
  27. Riverside ResultsMetric Before AfterPotassium IP TAT 74 min (June 06 avg) 48 min (Nov 06 avg) (35.1% reduction)Troponin ER TAT 54 min (June 06 avg) 34 min (Nov 06 avg) (37.0% reduction)% of Results on 62% (10/10) 85% (Nov 06 avg)Chart < 7 AMSpecimen Travel 146 feet 67 feetDistance Chemistry (54% reduction)Hem. Tech Walking 1620 to 2028 feet/ 500 to 800 feet/hour (estimated based on std work)Distance per Hour hourSquare Footage 228 sq ft freed up (behind manual area, to side of special chemistry)
  28. 8 Flows of Lean1.  Flow of Patients2.  Flow of Families3.  Flow of Providers4.  Flow of Medications5.  Flow of Supplies6.  Flow of Information7.  Flow of Equipment8.  Flow of Instruments/Processes
  29. Typical Department SilosOncology Clinic A Chemotherapy TreatmentOncology Clinic B RadiationOncology Clinic C Treatment
  30. Look Across the Value Stream - Oncology Patients Scheduled 5/2/06 Oncologist Schedule Start running18 out of chairs16141210 8 6 Idle Time 4 2 0 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00
  31. Seattle Children’s Bellevue•  32% reduction in original space estimate Recovery•  Opened on time•  $3.5M under the $70M budget O.R.•  “Frankly this is the best “one piece flow” for ambulatory surgery I Induction Induction have observed anywhere in the world.” –  John Toussaint, MD 31
  32. Iterative DesignSeattle Children’s BIDMC 32
  33. Riley Design Process•  Their lead architect: –  “Building design is often a reaction to their current state” •  Too much equipment – more space --- not the best answer –  “Taking those extra months to understand what they really wanted and what their ideal state was going to be was very helpful.” –  Telling architects to not draw anything for 2 sets of user meetings – strange to them 33
  34. Understanding Current State•  3-day workshops –  NICU –  Burn unit –  Oncology•  Structured observation by staff members –  Qualitative –  Quantitative 34
  35. Spaghetti Diagrams 35
  36. Layouts Drive Waste of MotionMed Tech Walk Pharmacy TechPattern (5.1 miles/day!)Miles per Day! Cancer Center RN
  37. Activity Follow•  Shadowing a person –  Focus on the process, not finding fault w/ person•  Identifying tasks / activities done each minute•  Tracking interruptions•  Do spaghetti diagram in parallel
  38. Activity Follow
  39. Activity Follow (3)
  40. Activity Follow (2)
  41. Activity Follow (1)
  42. Summary “A3” 42
  43. Current Condition - Burn 43
  44. Envisioning Future State•  Current: Transporting patients in the burn unit –  Wouldn’t it be great to have a procedure room in the unit? –  Avoid having to go all the way to the O.R. –  “Not dragging that child all the way across the hospital.” 44
  45. Future Condition 45
  46. “Whenever there isCARE for aPATIENT, there is avalue stream. Thechallenge lies inseeing it.” Paraphrasing Rother & Shook
  47. What is a Value Stream? Supplier Customer Request Made Product or Service or Need Identified PROCESS STEPS Delivered Reception Prep Procedure Recovery Reports & Invoice VALUE STREAMValue Stream: All steps, both value creating and non value- creating, required to complete a service from beginning to end. 47
  48. This is a Value Stream Problem This is Not Always an “ED Problem” •  Beds unavailable •  Admission delays •  Discharge delays Building a bigger ED might not help 48
  49. What is a Value Stream Map?•  A diagram of a process from beginning to end at a level that people can see interactions between departments, floors and processes. Information Registration Referring Lab Dept MD Work Scheduling Patient Assessment Dept Dept Product/Patient Check Pre-Op OR PACU Recovery Go In Prep Home
  50. The Mapping Team•  Create a Cross Functional Team Consisting of: –  VSM Facilitator •  Responsible for leading the team through the VSM process. –  Process Experts •  People who have in-depth knowledge of the Value Stream you are mapping. –  Process Neophytes •  People who are not familiar with the Value Stream you are mapping.
  51. Go to the “Gemba”•  Cannot be a conference room exercise•  Three versions of a process: 1.  What should happen 2.  What we think happens 3.  What actually happens•  “Gemba” = “actual place,” where the work occurs
  52. Value Stream Map – Chemo Admin Patient Flow 52
  53. Closer Look 53
  54. Current State D/C Process Issues 54
  55. Types of Future States•  “Ideal” Future State –  Long-term vision –  Dream big – don’t worry about constraints•  “Practical” Future State –  What is achievable in the short to mid-term
  56. D/C Future State 56
  57. Chemo Future State 57
  58. Ideal v. Practical 58
  59. After the VSMs•  Architect: •  Apply VSM to adjacencies and set based design •  React to what they wanted their ideal state to be, not just problems in their current state 59
  60. Iterations at Riley•  Architect: –  “Use PDCA thinking throughout” –  More detailed room design through each iteration –  Started mockups before we drew anything, based on the ideal state (the tub room) 60
  61. Lean Design Summary•  Goals: Best patient care; best workplace•  You will come up with the best design for your own Institute•  Time investment –  Staff time –  More planning, longer iteration time•  Payoff –  Faster build (less rework and less cost) –  More likely to have best outcome (from iterative learning) 61
  62. Next Steps•  Discussion•  Q&A 62