Lean in Hospitals

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  • Other important points we must consider: focus on what the customer wants, and the align all our processes to deliver collect best practices and develop standard processes use teams to execute use all of the brains in the company establish flow; eliminate the barriers to flow (causes of waste) rework is not value-added, need quality built into products/processes understand customer demand reward LEAN thinking and LEAN behavior reward problem solving rather than work-arounds make every process visual multi-skill everyone
  • Other important points we must consider: focus on what the customer wants, and the align all our processes to deliver collect best practices and develop standard processes use teams to execute use all of the brains in the company establish flow; eliminate the barriers to flow (causes of waste) rework is not value-added, need quality built into products/processes understand customer demand reward LEAN thinking and LEAN behavior reward problem solving rather than work-arounds make every process visual multi-skill everyone
  • Other important points we must consider: focus on what the customer wants, and the align all our processes to deliver collect best practices and develop standard processes use teams to execute use all of the brains in the company establish flow; eliminate the barriers to flow (causes of waste) rework is not value-added, need quality built into products/processes understand customer demand reward LEAN thinking and LEAN behavior reward problem solving rather than work-arounds make every process visual multi-skill everyone
  • Respect for humanity includes the following concepts (this terminology comes from noted lean author Norman Bodek), including 1) jidoka (separating people from machines and empowering employees to stop production) 2) People working in teams, and 3) people contributing improvement ideas (kaizen)
  • All of the eight types of waste can be found in a laboratory environment. A big challenge in a lean transformation is learning to SEE waste, then having the courage to call it waste, then having the drive to actually reduce the waste.
  • All of the eight types of waste can be found in a laboratory environment. A big challenge in a lean transformation is learning to SEE waste, then having the courage to call it waste, then having the drive to actually reduce the waste.
  • Let ’ s look at a typical non-LEAN lab. If you trace the flow of a product (such as a tube of blood) or the path an operator walks during a shift, the resulting picture is what we call a “ spaghetti diagram. ” This usually results when we organize the lab without thinking about product or operator “ flow ” . “ Flow ” is another key lean word that we ’ ll hear a lot today. When a lab (or a factory) is organized with similar machines grouped together, the resulting workflow ends up looking like this. All the wasted steps and wasted time involved in moving product (and people) such a long distance. Before lean concepts are introduced, is this even seen as a problem? Do we just put up with this as “ the way we ’ ve always done it? ”
  • Other important points we must consider: focus on what the customer wants, and the align all our processes to deliver collect best practices and develop standard processes use teams to execute use all of the brains in the company establish flow; eliminate the barriers to flow (causes of waste) rework is not value-added, need quality built into products/processes understand customer demand reward LEAN thinking and LEAN behavior reward problem solving rather than work-arounds make every process visual multi-skill everyone
  • Ford examples – announcing 30,000 layoffs but CEO Bill Ford says he wants a “ risk taking ” and “ innovative ” culture…. How will people do that if they ’ re afraid? Merck announced “ lean ” is about cutting heads at their factories, including 25% of the staff at their first “ lean ” factory…. I ’ m sure the other factories are sure excited about lean coming to them. It ’ s basic human nature…. Fear does not lead to creativity and risk taking. People will look to protect their own job and keep their heads down. It ’ s takes very rare and outstanding leadership to keep people on board when layoffs are going on.
  • Respect for humanity includes the following concepts (this terminology comes from noted lean author Norman Bodek), including 1) jidoka (separating people from machines and empowering employees to stop production) 2) People working in teams, and 3) people contributing improvement ideas (kaizen) Add in example about Gary Convis and “ servant leadership ” Coach Carter: the best way care for someone is to have high expectations The “ if the operators would learn to read english ” story
  • Other important points we must consider: focus on what the customer wants, and the align all our processes to deliver collect best practices and develop standard processes use teams to execute use all of the brains in the company establish flow; eliminate the barriers to flow (causes of waste) rework is not value-added, need quality built into products/processes understand customer demand reward LEAN thinking and LEAN behavior reward problem solving rather than work-arounds make every process visual multi-skill everyone
  • Toyota continues to allow TPS to evolve and grow LEAN often involves balance – there is a balance between being so flummoxed as to be overwhelmed, versus being flummoxed enough to get create and solve problems “ Fat dumb and happy ” is not a term Toyota would ever want. They want a “ healthy stress ” or “ healthy pressure ” that drives improvement.
  • This is a very Toyota-like philosophy. People WILL make mistakes because they are human. Certain circumstances make it MORE likely to make errors. Management has a responsibility to help improve the system so it ’ s harder to make mistakes. Deming, who deeply influenced Toyota, liked to say 94% of errors were management ’ s responsibility (meaning the system).
  • Lean in Hospitals

    1. 1. “Introducing Lean to the Hospital” Peter D. Schellinck Partner SHConseil +32 496 386 437 www.shconseil.fr www.schellter.eu
    2. 2. Agenda The Crisis of Waste in Healthcare Lean Thinking Principles in Healthcare Benefits for:  Patients  Employees  Hospitals
    3. 3. Hospitals Are Dangerous… CDC 1998: 90,000 killed and 2,000,000 injured from hospital-caused drug errors & infections
    4. 4. Preventable Errors Abound… “… 3 to 5% of specimens taken each year are defective… blood that isn’t drawn correctly… mix-up with another patient’s sample”
    5. 5. Preventable Errors Abound…
    6. 6. Preventable Errors Abound…
    7. 7. Mass Production or Healthcare? Large batches  Automation is the answer Sub-optimizing one  Lack of standard processes resource Lack of employee input  Not communicating metrics One-person/One-machine  Lack of leadership Quality through inspection  Constant fire fighting
    8. 8. Non-Lean, Current Thinking1. Specify value in the eyes of the provider (or the payer)1. Identify your department and sub-optimize it1. Make patients wait for the convenience of the system1. Ignore some employees and devalue others1. Continuously fight the same fires in the pursuit of surviving the day
    9. 9. Applications of Lean in Healthcare Laboratories  Reducing Turn Around Times and Errors Emergency Departments  Reducing diversions, improving flow Outpatient Cancer Treatment  Reducing patient delays, increasing capacity Operating Rooms  Reducing changeover times, increasing utilization Pharmacies  Reducing errors, improving response Food Service  Reducing wasted food, improving quality
    10. 10. Why LEAN Works in Healthcare LEAN is not a list of tools that applies only to factories LEAN is a philosophy of management that applies to any system LEAN rallies people around goals we can all agree on:  Patients and Employees for Quality
    11. 11. Not About Cutting Heads Shortages of skilled employees  51% of hospital med techs greater than 45 years of age, vacancy rate at 11%  Shortfall of 65,000 nurses expected by 2012 Do more…  With the same  Eventually, with less
    12. 12. Not Only About Cutting Costs Hospitals are using lean as a Business Strategy  Improving quality  Improving service  Improving employee satisfaction  Growth strategies  “Un-outsourcing” testing work
    13. 13. Principles of LEAN Thinking1. Specify value in the eyes of the customer. – The customer must be willing to pay for the activity – The activity must change the form, fit or function of the product or service – The activity must be done right the first time Who are the “customers?” Source: LEAN Thinking, Womack and Jones 1996
    14. 14. Principles of LEAN Thinking 1. Specify value in the eyes of the customer. 2. Identify the value stream and eliminate waste.13% of hospital costs are due to controllablewaste. Source: Zuckerman, Hadley, and Iezzoni, 1994
    15. 15. Treatment CenterTypical Organization is Silo-ed Treatment Clinic Check-In Pharmacy Laboratory Testing Phlebotomy Physician Clinic
    16. 16. Value Stream – Anatomic Pathology Patient & MD I Transcriptionist I PathologistSpecimen ICollection Send to Grossing I Embed Slide I Grossing Processing & Cut Staining Making I I I I
    17. 17. Types of Waste – Lab Examples Defects  Label on the wrong tube Overproduction  Drawing all blood at 4 AM Transportation  Long walks, multiple handoffs Waiting Time  Tube waiting on centrifuge to fill Inventory  50 weeks of supply Motion  Tech walking 80 ft to the printer Processing  Time/Date stamps added, not used Human Potential  Administration not listening to Med Techs or ideas for improvement
    18. 18. Are We Tolerating Waste? Healthcare = Workarounds  Professor Steven Spear  “Decoding the DNA of the Toyota Production System” (HBR)  “Fixing Healthcare Today From the Inside” (HBR) Case Example:  10-20% of MD orders are missing EVERY DAY  Call and get the order – done?  Tomorrow, we’ll do the same Problems need to be seen as opportunities
    19. 19. Laboratory Layouts Drive Waste Layout is driven by departmentsBenches interfere withstraight-line walking, encourage batches
    20. 20. Clinical Laboratory Product Flow
    21. 21. Clinical Laboratory Timeline Total CT = 5.44 hours
    22. 22. Layouts Drive Waste of Motion Med Tech Walk Pattern Pharmacist Walk PatternKms per Day! Cancer RN Walk Pattern
    23. 23. Typical 5S Baseline Unorganized Workbenches  Poor Utilization of Space Product Flow not Obvious  General Clutter Time wasted looking for things  Supply Shortages and Hoarding of supplies “Hidden” Inventories
    24. 24. 5S Improvement Examples
    25. 25. Principles of LEAN Thinking1. Specify value in the eyes of the customer.2. Identify the value stream and eliminate waste.3. Make value flow at the pull of the customer.
    26. 26. Reducing Patient Wait Times Mass Production Thinking Utilization  Keep expensive assets heavily utilized  Machines Doctors  The tradeoff is waiting time  Cars Patients Lean Thinking Flow  Focus on reducing Patient Waiting time
    27. 27. Outpatient Oncology Patient “Flow” Value AddedA • Blood drawn • MD consult • Needle into Port NVA But RequiredB • Check In / Check Out • Moving from room to room ARRIVAL TO LATENESS FOR NVA, “Pure Waste” TREATMENT TREATMENT PATIENT (HOURS) (HOURS) • Waiting for Check In A 2,5 0,42 • Waiting for MD B 3,5 1,08 • Waiting for Treatment AVG 3,0 0,75
    28. 28. Re-Work Loops Cause Delays
    29. 29. Batching Prevents Flow
    30. 30. Batching Hurts Quality  Lack of “standard work” and opportunity for “error proofing” – Anatomic PathologyBatch of slides made, 3 2nd histotech labels onepatients, risk of mixup? slide at a time
    31. 31. Batching Hurts Quality Lack of “standard work” and opportunity for “error proofing” – Pharmacy
    32. 32. Flow You can’t have flow without some amount of “leveling” in the system “Leveled Production:  You won’t be Happy without it”  From Toyota publication
    33. 33. Typical Hospital Lab  Not Level39% of Samples Arrive in Just 3 Hours of the Day TAT expectations are constant
    34. 34. Leveling Reduces Peak Costs Shift Shift Shift
    35. 35. Principles of LEAN Thinking1. Specify value in the eyes of the customer.2. Identify the value stream and eliminate waste.3. Make value flow at the pull of the customer.4. Involve and Empower employees.5. Continuously improve in the pursuit of perfection.
    36. 36. Pre-Lean Med Tech Quote: “With all of the automation, I feel like a robot.”
    37. 37. The “Thinking Production System”“Perhaps the greatest strength of theToyota Production System is the wayit develops people.This is why the T actually stands for‘Thinking’ as well as for ‘Toyota.’”  Teruyuki Minoura, Toyota
    38. 38. What Mistake-Proofing Means toHealthcare The Global Goal: Reduce Medical Errors “Human error is inevitable. We can never eliminate it.” ….. We can eliminate problems in the system that make it more likely to happen.” Source: USA Today Liam Donaldson August 24, 2005 WHO World Health Alliance for Patient safety
    39. 39. Lean Requires a Cultural Shift Traditional Approach:  “Naming, Shaming, and Blaming” Lean Approach:  Supports open reporting of mistakes  Root cause problem solving process  “Anyone can make mistakes”
    40. 40. Error Proofing Example Micrograms or Milligrams? A medical mistake waiting to happen when written by hand
    41. 41. Error Proofing Example Confusing Unambiguous (Lean)
    42. 42. MD Resistance to Standard Work Which is More effective? “… some surgeons make a tiny, mole-sized mark on a patient instead of a big, bold "X”…. I call them passive- aggressive marks…”  USA Today, 4/18/06
    43. 43. Lab Benefits from Lean Productivity improvement >30% Space savings of >250 sq m Standardized work practices Reduction in Errors and Error Potential Test Turnaround Time (CT) reduced by 50%
    44. 44. Reflections on Year’s in Healthcare Lean is a powerful methodology People are people Healthcare people have incredible intrinsic motivation Humility and asking questions is better than being a know-it-all Coaching the team to “do lean & be lean” is the only sustainable route

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