Minimally Invasive Lean Six Sigma 7 2012

®

www.AptoLean.com
Adaptive Lean Six Sigma

 Introduction

John Muka, Ph.D
June 14, 2012
609-238-3360
johnmuka@aptolean.com

© 2012, AptoLean LLC All Rights Reserved 1

The Waste and Delay Organization

The Official Organization
Admit Test Treat Discharge Bill

Injuries

Healthcare isn’t just business --- it’s personal!


 “…with so many different kinds of employees and
so many interrelated systems and functions, it is a
small wonder that hospitals work at all, much less
as well as they do. With the multitude of tasks
performed every day by the hundreds of employees
in a busy hospital, misunderstandings and
information breakdowns in patient care are
inevitable…”
Healthcare USA, page 85
Textbook often used in Hospital Administration Courses


http://www.hospitalcompare.hhs.gov/ Nurses "Always" communicated well.
Survey of
Doctors "Always" communicated well.
Patients’
Hospital "Always" received help as soon as they
Experience wanted.
pain was "Always" well controlled
HCAHPS: staff "Always" explained about medicines
before giving it to them
Hospital
Consumer room and bathroom were "Always" clean.
Assessment of "Always" quiet at night
Hospital Given information about what to do
Providers and during their recovery at home
Services Overall rating of 9 or 10 on a scale from 0
(lowest) to 10 (highest).
“Definitely recommend the hospital.”


‘…Jefferson Regional Medical Center in RWJUH PHCS Virtua
Pittsburgh expects all employees, from
maintenance workers to doctors, to respond Nurses "Always" communicated well. 75% 73% 76%
to a patient’s call light or find someone to
Doctors "Always" communicated well. 77% 80% 72%
offer assistance. In Los Angeles, Cedars-
Sinai is testing new patient call buttons that "Always" received help as soon as they 60% 56% 61%
ring directly to nurses’ cellphones. If the wanted.
nurse’s line is busy, the call automatically pain was "Always" well controlled 68% 68% 70%
rolls over to another worker’s phone.
Many hospitals have devised detailed scripts staff "Always" explained about medicines 58% 56% 55%
before giving it to them
that doctors and nurses follow when
interacting with patients, telling them what to room and bathroom were "Always" clean. 63% 62% 69%
expect and often extolling the care they are
"Always" quiet at night 49% 49% 45%
getting. This fall, the University of Toledo
Medical Center launched an internal “iCARE “Always” given information about what to 82% 82% 78%
University” dedicated to training employees do during their recovery at home
on improving patients’ experiences. …” rating of 9 or 10 on a scale from 0 67% 61% 63%
Test for Hospital Budgets: Are the Patients (lowest) to 10 (highest).
Pleased? NYT, 11-8-2012
definitely recommend the hospital. 75% 69% 71%


Choose the statement in each row that best describes what you are used to:
My work is frequently interrupted There are large blocks of time when I am not
OR
interrupted
I frequently have to invent new ways to OR Most issues are covered by an understood
handle an issue or keep the work going procedure and exceptions are infrequent
The same problems come up over and over OR Most problems are solved permanently
again
I’m never sure what my work load will be OR Usually work arrives at an expected rate

Priorities change continually Priorities are set and then the work proceeds
OR
consistently toward accomplishing the tasks
needed


Choose the statement in each row that best describes what you are used to:
I often don’t know if the results of the work The criteria for completing the work are clear
OR
are what is really wanted
Meetings often waste a lot of time OR Meetings are usually valuable
The emphasis is on getting results The emphasis is on strong processes focused
OR
toward results
When the work backs up its up to me to When things get busy there is an accepted
deal with it OR way to get help
Stress is usually high There is a sense of urgency but usually not an
OR
overly stressful environment


Define and Ideal
Measure: Challenge Behaviors

Sustain Control
Current
Behaviors Analyze &
Invention
Improve

 Invention:
 Challenge: ◦ Deeply understand the problem
◦ List Issues ◦ Identify Root Causes and Obstacles
◦ Prioritize what to work on ◦ Develop and Test Countermeasure
◦ Breakdown the Problem Sets
◦ Investigate and Survey ◦ Pilot and Prove the best
◦ Create a well defined Challenge Countermeasures
description
◦ Authorize Invention Phase  Sustainment
(Charter) ◦ Implement Countermeasures
◦ Update Standardized Work
◦ Train
◦ Monitor Process Closely

Build on the Toyota Production System
 …The Toyota Way is not a natural behavior.
The Toyota philosophy relies on the
“system”, and adhering to its concepts will
force people supporting the system into
uncomfortable situations. The choices
presented then are to either remove the
obstacles or to fail.”

Jeffrey Liker and David Meier,
The Toyota Way Fieldbook, p307

 Make Problems Visible:
◦ Visually Improve Service by
◦ Immediately Preventing “Work-Arounds”
◦ Urgently
 Activate short term mitigation
 Trigger 2nd Level Problem Solving (Prevention)
 Continually Develop People as Problem Solvers


All work shall be highly specified as to content, sequence, timing and
Activities outcomes
All Supplier-Customer connections shall be direct, one-to-one, with
Connections unambiguous ways to send requests and receive responses

Process flow will include all necessary steps and no un-necessary
Pathways steps

Any improvement will be done using the Scientific method, under the
direction of a Teacher, as close in time and location to the problem
Improvement as possible.

Spear and Bowen: Decoding the DNA of
the Toyota Production System
Kenagy: Designed to Adapt

Category Delay & Waste Defects and Variation
Ideally,
What we
expect is:
But what
we have
is:
Therefore,
the next
steps are:


 Cardiac Catheterization
◦ Increased effective capacity by over 25%
◦ Reduced Post-Procedure Holding time by 35%
◦ Reduced First Procedure delays to 5 minutes or less

 ED Radiology: X-rays “Order to PACS”
◦ % in 30 min. or less: from under 45% to over 70%


1. Observe the actual work for at least 1 hour
◦ Do not make any changes
◦ Observe carefully
2. Team with people who do the work
3. Start with small glitches, workarounds,
do-overs
1. Apply the 4 Rules of Process Design
2. Eliminate one or two issues
3. Use Sustainment to make the changes permanent
Build toward Supportive Observation

• Key Questions:
• What is important about what you do?
Build • How do you know what to do? When to start?
toward • How do you know you are finished?
Supportive • What problems do you have?
Observation • What do you do when you have a problem?
• Where does your work (and information) come from?


Start on
time Room
First Turnaround Second
First Procedures
Procedures
Start Procedure Procedures “Cold Table” Start
Start Prep Time End Time

Setup Patient Clean Setup,
Room in Room Restock Next
Patient
Move out Patient
Move Patient On Table
Patient
Nursing
Bed
Arrive Patient Doctor Holding Unit
Availability
Ready in in
on Time Holding
Doctor
called
Discharge

Focus Countermeasures
Start on Pre-mixed Heparin flush; Co-ordinate with Doctors’ offices to get all needed tests and
documentation; Smooth Patient Check-in; Improve handoffs from Admitting to Prep Unit; Improve
Time handoffs from Prep to CathLab; Express labeling for LabTests; Traveling Patient Checklists;
Improve In-Patient prep; Improve CathLab shut down process; Notify Doctors of Patient ready;
Arrange staff schedule to support startup;

Room Arrange lead aprons; arrange most frequently used supplies and equipment in or near rooms;
Arrange less frequently used supplies to be easy to find; Re-stock rooms between cases; Co-
Turnaround ordinate room cleaning; Document Roles and Responsibilities for Room Turnaround and post in
area; Staff involvement in improving methods.

Nursing Unit: Designate “Interventional Beds”; insure 10 empty beds every Monday AM; Discharge 2 patients
every 2 hours throughout the day; Reduce delay on reporting “bed empty”; Eliminate un-
Increase rate necessary electronic documentation; Reduce time for MedRec; Discharges by APN; Doctor
of Discharges availability for Discharges; Improve Nursing routines;


Focus Countermeasures
Delay in Improve Gowning and “Jewelry” routines; Unit clerk sets EDIM flag for transport; Clarify Location
Signage; Improve signal to nurse that study has been ordered; develop transport rules based on
Patient Prep Acuity Level; train nursing on new routines;
and “Flags”

Delay in Assign dedicated Transport instead of from pool; Adjust number of Transporters to match
demand; upgrade to cell-phone based dispatch; Patient Ready flags visible on Large LED screen
Transport in the ED;

Delay in Move ED X-ray to CT area; add improved Portable X-Ray machines; improve charging routines;
Install EDIM on Radoilogy PC’s; improve CT to X-ray flow; “Save a minute” urgency; Daily
Radiology Accountability routines; Expediter/Value Stream Leader; Acuity Level transport rules; Surge
Response routines; X-Ray room organization; Start of shift outreach to ED.


Do the study as fast as safely and
Humanly possible.


Service 95% in 30 min. or less from “Patient Ready” Flag
Level (Acuity 1,2,3)
Slack Normal Surge
“Save a • Practice Routines • Monitor Flag Set • Call “Code Surge”
• Cross-Train • Check Queue • Pull in offline staff
Minute” • Start of Shift Huddle • Co-Ordinate with ED • Teamwork to maximize
Routines • Review Performance • Co-Ordinate with Throughput
• Outreach to ED Transport

Prevent • Improve Layout • Equipment Down • Anticipate special needs
• Maintain Equipment • Transport missing • Open up additional
Failure • Restock Supplies • CT Handoff equipment:
Modes • Handoffs • Stop Out-Patient
Routines Services


 Team Leader Role constantly assigned
 Visual Controls, Key Metrics, Workplace Organization (5S)
 Continuously improved Standardized Work and Training
 Immediate Response to problems and short term mitigation
 Second Level Problem Solving: Prevention
 Bundle for Kaizen Events and Projects
 Accountability Routines:
◦ Team Leader
◦ Area Supervisor
◦ Value Stream Manager
◦ Executives


®


 Select Model Line or Area
 Team Leader Role: select, train, coach
 Solve small glitches and problems permanently
 Increase scope and support with resources:
◦ Move from activities, to connections, to pathways
 Implement Visual Controls
 Implement Daily Accountability routines
 Use Value Stream analysis to focus on key bottlenecks
 Bundle issues for Kaizen Events and Projects


®

www.AptoLean.com

John Muka, Ph.D
AptoLean, LLC
609-238-3360


Minimally Invasive Lean Six Sigma 7 2012

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