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Virginia Mason Medical Center CEO (Seattle, WA)
Former President of Virginia Mason Medical Center
Author of book, and former employee of Boeing; now lean consultant. Connection to Mike Rona to start applying Lean to healthcare.
Origin of Lean Production
- -based on Toyota Production System; Post-WWII, pioneered in Japan.
- -Kiichiro Toyoda & Taiichi Ohno.
- -Coined by John Krafcik (1991)
-Strategy focused on eliminating waste while continuously increasing percentage of value-added time.
- -any activity, service, or supply that consumes time, money, and other resources.
- -Creates NO value.
-continuous incremental improvement.
Reasons to embrase Lean (3)
- 1) Patients deserve better
- 2) Employees deserve better
- 3) Nation deserves better
- -personal trainer with the mastery of a body of knowledge.
- -specialist in Lean production.
Two Main Pillars of Lean Production
- 1) Just-in-Time production (JIT)
- 2) Jidoka
Just-in-time Production (JIT)
-consistently delivering only the healthcare service that is needed, in just the required amount, where it is needed, and when it is needed.
- -Intelligent use of both people & technology with the ability/obligation to stop any process at the first sign of an abnormality.
- -Stop the line.
Seven Healthcare Flows
- 1) Flow of pts 5) Flow of info
- 2) Flow of clinicians 6) Flow of equipment
- 3) Flow of meds 7) Flow of process eng.
- 4) Flow of supplies
- -system where parts, supplies, info, and services are pulled by internal and external customers exactly when they are needed.
- -when the pt/customer is ready to receive the next service.
Effects of Waste
- -Risk for pts
- -Increased costs
- -Decreased satisfaction
Seven Wastes of Healthcare
- 1) overproduction 2) Waiting (time on hand)
- 3) Transportation 4) Processing
- 5) Inventory (stock on hand)
- 6) Movement
- 7) Defective Products
Waste of Overproduction
- -redundant activities
- -e.g. Park Nicollet Health Svcs (PNHS) - excessive printing reports; VMMC - repetitive questioning --> EMR.
-the specific activities required to provide a specific service to the pt.
Waste of Time on Hand (waiting)
- -waiting to see physician, early admissions for afternoon procedures, staff waiting for meetings.
- -e.g. VMMC - 20min wait time, improved; PNHS, decrease lead time from 2hrs to 9min.
-a prescribed repeatable sequence of steps/actions that balances people's work to takt time.
- -production time aligned with the rate of demand.
- -time it should take to provide a service to one pt based on the overall rate of demand from all pts.
Waste of Stock on Hand (Inventory)
- -inventory that builds up and requires disposal; takes time and energy to remove/move.
- -e.g. PNHS, implement Kanban to supply items that were high cost, low use so as not to over-stock; VMMC, wasted time moving supplies form closet to POU -- only stock in room at POU.
- -a way of automatically signaling when new parts, supplies, or services are needed.
- -"sign," sign board, billboard, doorplate, poster, or card.
Rapid Process Improvement Workshop
- -aka Kaizen event.
- -team of people who do the work, fully engaged in a rigorous and disciplined 5-day process, using the tools of Lean to achieve immediate results in the elimination of waste.
Waste of Movement
- -lg. part of budget of for wages (70%), thus time is valuable -- optimize use of employees' time.
- -mostly staff trying to find equipment, info or attending meetings farther from dept.
- -e.g. PNHS - Rad techs moving equipment; VMMC - decreased walk time for RNs and PCTs.
-time spent walking from one location to another.
work area (VMMC example)
Waste of Defective Products
- -errors in charting/documentation; VMMC implement PSAs (patient safety alerts).
- -e.g. PNHS - created pt. tracking system, for pre-op pts; andon utilization.
- -a visual control device, usually a light, that alerts supervisors to factory floor needs or problems.
- -green, yellow, red light system for example.
Waste in Transportation
- -movement of supplies, files, equipment
- -e.g. PNHS - vans transferring mail, files, and films; upgraded EMR. VMMC - decreased automated shipment of files not needed (neurology clinic).
Waste in Processing
- -unnecessary tests, repeatedly logging the same data.
- -e.g. VMMC - eliminate MRIs for non-surgical back pain pts. PNHS - eating d/o institute, meet with psych before entering EDI for further eval.
Global Production System or the Lean House
-a generic and graphic representation of the Toyota Production System (Lean).
Components of Lean House
- -Foundation = goal of lean (eliminate muda).
- -Floor = leveled production (heijunka).
- -Columns supporting roof = JIT production & Jidoka.
- -Columns within house = Left (people, materials, & machines), Middle (standard work, kanban, & andon), Right (takt time, one-piece flow, & pull production).
Columns within Lean House
- LEFT = Necessary resources
- MIDDLE = Lean Methods
- RIGHT = Outputs
-scheduling products and services in such a way as to eliminate bottlenecks and maximize throughput.
Stop the Line
-where any staff member can stop any process or procedure if that staff member believes proceeding would adversely affect pt safety or negatively impact efficient operations.
Key Principles within the Lean House (3)
- 1) Takt-time-paced Production.
- 2) One-piece Flow
- 3) Pull Production
- -providing services/products at the overall rate of demand from the pts.
- -e.g. total hrs/mins in a work day for a # of pts.
- -all equipment, other supplies, and information are physically grouped together to enable one person to perform all the steps necessary to complete a process or action.
- -opposite of batching work.
-system where parts, supplies, info, and services are pulled by internal and external customers exactly when they are needed.-when the pt/customer is ready to receive the next service.
- 1) people
- 2) materials
- 3) machines
Appropriate & Efficient Use of People's Skills
- Method: standard work; prescribed, repeatable sequence of steps/actions.
- Principal output: take-time production.
Appropriate & Minimal Use of Materials
- Method: standard work-in-process (SWIP) and kanban.
- Principal output: work with takt-time management to enable one-piece flow.
Appropriate & Optimal Use of Machines
- Method: operational availability/andon.
- Principal output: pull production.
-the availability of healthcare equipment when needed.
-the amount of work-in-process inventory on the floor to provide pt care for the day.
Standard Work Sheet
- -a document identifying the steps necessary to complete a task, who should perform each step, and the reasonable (repeatable) amount of time to complete each step.
- -e.g. PNHS & blood pressure work sheet.
Three-legged Stool of Standard Operations
Made up of standard work, takt time, and standard work-in-process.
5S Process to Organize the Workplace
- 1) Sort - the unnecessary
- 2) Simplify - organize
- 3) Sweep - identify unsafe conditions
- 4) Standardize - define and communicate
- 5) Self-discipline - hold everyone to same standard
Value Stream Map
-a pictorial representation of the steps in a value system, either as a current or future (desired) state.
Preparation for Lean Action Plan
- 1) get rid of competing strategies
- 2) Find outside Sensei
- 3) No shorter than 5 yr contract
- 4) Develop a sense of urgency
Elements of Action Plan
- 1) Identify your business & its scope.
- 2) Est. a Kaizen Promotion Office & Kaizen Operations Team.
- 3) Begin with a model line an inch wide and a mile deep.
- 4) Implement your waste-elimination strategy via workplace Kaizen events & Kaikaku.
- 5) Map value streams/disrupt organization.
- 6) Focus on cutting lead time/cycle time.
- 7) Reorganize by service lines & value streams, flatten the organization.
- 8) Develop internal leaders.
- 9) Deal with excess people at outset.
- 10) Implement world-class management system.
- 11) Link pay to value creation and elimination of defects.
- -combination of Lean and budgeting ideas from Jeremy Hope & Robin Fraser.
- -based on key performance indicators.
- -e.g. PNHS - cost per unit of svc, and units of svc per full-time equivalent.
Kaizen Promotion Office (KPO)
- -develop lean action plan.
- -work with managers & CEO on day-to-day basis.
- -edu/development of Lean leaders.
- -2-5% of work force.
Kaizen Operations Teams (KOTs)
- -for each major svc. line.
- -PHNS, each ran by Lean leader having completed 18mo. training in lean/kaizen.
- production preparation process.
- a new facility or process.
- an established facility or process.
- The amount of time it takes to complete a task or process.
World-Class Management System
- 1) Daily management, management by policy (MBP), determine improvement priorities.
- 2) MBP - opposite of management by objective. How goals are determined, plans made to achieve goals, and ensure progress.
- 3) Cross functional management - major management system for implementing breakthrough improvements across organizational lines.
Management by Policy (MBP)
- -a catch-ball process. Meaning where goals are proposed and discussed by people all the way down and up the chain of command.
- -aka hoshin kanri
- -quality, cost, delivery, safety and morale.
-where the work gets done, e.g. the factory floor or hospital floor.