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Lean Healthcare 101

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James Lambert

on 9 August 2011

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Transcript of Lean Healthcare 101

Learning Objectives Understand what LEAN is.... the origins of it

Understand how LEAN is impacted by culture

Understand Value Added versus Non-Value Added

Understand the components (boxes) of an A3

Understand your role in the change process “A systematic approach to identifying and eliminating waste (non–value-added activities) through continuous improvement by flowing the product/service at the pull of the customer in pursuit of perfection.” Definition of LEAN: predictable
performance We must continue to peel that “onion” back layer by layer by challenging the status quo. That means that we are never done. We are constantly seeking better and better ways to deliver care and arrive at good outcomes for our patients Providing products and services to our patients when, where, and how they are needed by the patients. Don't let prefection get in the way of better. Simply put, LEAN is….. a methodology that is all about improving processes and making change for the better. In order to improve, the LEAN system requires that waste within the hospital is constantly sought out and ultimately eliminated. A brief history of waste reduction thinking Poor Richard's Almanac says of wasted time, "He that idly loses 5s. worth of time, loses 5s., and might as prudently throw 5s. into the river." He added that avoiding unnecessary costs could be more profitable than increasing sales: Fredrick W. Taylor said: "And whenever a workman proposes an improvement, it should be the policy of the management to make a careful analysis of the new method, and if necessary conduct a series of experiments to determine accurately the relative merit of the new suggestion and of the old standard. And whenever the new method is found to be markedly superior to the old, it should be adopted as the standard for the whole establishment." Ford, in My Life and Work (1922), provided a single-paragraph description that encompasses the entire concept of waste: I believe that the average farmer puts to a really useful purpose only about 5%. of the energy he expends.... Not only is everything done by hand, but seldom is a thought given to a logical arrangement. A farmer doing his chores will walk up and down a rickety ladder a dozen times. He will carry water for years instead of putting in a few lengths of pipe. His whole idea, when there is extra work to do, is to hire extra men. He thinks of putting money into improvements as an expense.... It is waste motion— waste effort— that makes farm prices high and profits low. Sakichi Toyoda Toyoda developed the concept of 5 Whys: When a problem occurs, ask 'why' five times to try to find the source of the problem, then put into place something to prevent the problem from recurring. The following example demonstrates the basic process:

My car will not start. (the problem)

Why? - The battery is dead. (first why)
Why? - The alternator is not functioning. (second why)
Why? - The alternator belt has broken. (third why)
Why? - The alternator belt was well beyond its useful service life and has never been replaced. (fourth why)
Why? - I have not been maintaining my car according to the recommended service schedule. (fifth why, a root cause)
Why? - Replacement parts are not available because of the extreme age of my vehicle. (sixth why, optional footnote)

I will start maintaining my car according to the recommended service schedule. (solution) Taiichi Ohno While shopping in a supermarket he observed the simple idea of an automatic drink resupplier; when the customer wants a drink, he takes one, and another replaces it. Inspired by how the supermarket only reordered and restocked goods once they had been bought by customers. This would become the precursor of the now-famous Just-in-Time (JIT) inventory system. The Toyota Way
Consists of principles in two key areas:
Continuous improvement
Respect for people Womack, Jones and Roos (1990), coined the phrase ‘Lean Manufacturing’ to describe TPS The problem was one universal voice from doctors and nurses: “we’re caregivers.” The message: don’t try to make me efficient, cost is secondary, “patients aren’t Toyota.” The point completely valid, over the past 15 years, lean in healthcare has primarly focused on patient care. “In the ordinary hospital the
nurses must make useless
steps. More of their time is
spent in walking than in
caring for the patient.
This hospital is designed to
save steps… we have tried
to eliminate waste motion
in the hospital.”
~ Henry Ford 1922 So what is LEAN? LEAN is done by the people who do the work
LEAN is customer/patient value-centered
LEAN is about the process (not the people)
LEAN is about finding waste and solving the problems that caused it
LEAN is a philosophy that must become a part of the culture Culture is a word for people's 'way of life', meaning the way they do things. Organizational Culture is the pattern of behaviors and values that employees create for themselves. It's often made up of tribal knowledge, legends, rituals and stories. The things you pass on to a new employee about how it “works” around here. It can partially be made up legends or the stories of great people, past or present, who have done wondrous things. It is stories told about the organization and passed on from one work generation to the next. A culture has its own language of made up words or phrases. Words like “STAT” or acronyms like “MRI” or “EMT” or “ICU.” If it wasn’t for TV shows about medicine, the public wouldn’t know what many of these terms mean. How do you change something so ingrained in an organization? Shock – We’re going to do what??? You have got to be kidding!
Denial – Not me…not now…I’m way too busy!
Anger – Where do you think I’m going to get the time to do this!
Blame – It’s not my fault, it must be Jim and if it’s not Jim, it’s Ellen…but not me!
Accept – Ok, if we’re going to do this, count me in. Cultural Change Roadblocks Too busy to work on LEAN
A good idea but the timing is premature
Not in the budget
Looks good on paper, but…
It won’t work for us…we are different LEAN is not about less people
LEAN is not a quick-fix; it takes time to change
LEAN is not easy to do
LEAN is not just a something you do once
LEAN is not done in addition everything else
LEAN is not a way to get people to work harder
LEAN is not a “management” program So what is LEAN not? the past should be a springboard not a hammock..... Value-Added vs. Non Value-Added V value-added: Defined by the customer/patient and must meet the following three criteria: The customer must be willing to "pay" for it. Payement is generally thought of in $$ terms, but could also include time or other resources The product or service must be done correctly the first time. The product or service must be transformed. You can easily spot value-added activity:
At the car wash, it's when someone acutally washes the car.
At the hospital, it is when the patient recieves treatment.
On the assembly floor, it's when someone is acutally putting parts together. non-value-added: Any activity, product, or process that does not meet the value-added criteria.

Willingness to Pay
Correct the First Time Too Add Value or Not to Add Value, That is the Question? From a customer perspective what is non-value-added:

At the carwash, it's the order-taker, the car-mover, the cashier, the queuing time, the excess water, and the customer waiting lounge.

At the hospital, it's the check-in time, filling out forms, inconclusive test, and hospital food.

On the assembly floor, it's the parts bins, the travel time, the setup time, the inspections and testing, the conveyors, the supervisors, the bad parts reject basket. Wait a minute, you say?
Some of those things are important, even necessary? The customer lounge is nice, but it doesn't transform the prouct.

Filling out forms may get you admitted to the hospital, but it doesn't directly contribute to your treatment.

The reject basket means you caught the failures that were not done correctly the first time. What steps in your process are Value Adding? Two good questions to ask yourself as you look at each step in your work process are:

1." If a customer/patient saw me doing this step woud he or she be willing to pay me for it?"

2. "If I did this step twice, would the customer/patient pay be twice as much?" Wait a minute, didn't you say that some of those things are improtant and even necessary? The time spent in direct care of a patient or patients.

This is most any activity performed in the room of the patient (e.g., treatment, documentation, checking vital signs, administering medication etc.).

What % of time do Med/Surg RNs spend providing direct care? Toast Video In an ER visit, value-added activity would be registering the patient, having a nurse triage the patient, the doctor making the diagnosis. Waiting in the waiting room or in a patient room is a non-value-added activity about 80% of a patients time is waiting. a clear concise description of the issue(s) that need(s) to be addressed by a problem solving team. It is used to center and focus the team at the beginning and keep the team on track during the improvement event. A3 Thinking –
More than Just the Paper Size The name comes from the 11 x 17 inch paper size, which is also called A3. When Toyota first started driving for concise problem-solving documentation, the widest paper that could be transmitted electronically through a fax machine was 11 x 17 inches. Hence, the name A3 became synonymous with the problem-solving document. The real power of the A3 is in the “thought process” it is intended to drive. It is laid out to essentially force the Problem-solver to follow the Scientific Method: Problem, Cause, Solution, Action, & Measure.

You are not allowed to go directly from Problem to Solution, as we do routinely in our jobs every day. A man working on an oil platform in the North Sea awakened suddenly one night by an explosion. Amidst the chaos, he made his way to the edge of the platform. As a plume of fire billowed behind him, he decided to jump from the burning platform even though jumping is a risky option for the following reasons:

It was a 150-foot drop from the platform to the water.
There is debris and burning oil on the surface of the water.
If the jump into the 40°F water did not kill him, he would die of exposure within 15 minutes.

Luckily, the man survived the jump and hauled aboard a rescue boat shortly thereafter. When asked why he jumped, he replied, “Better probable death than certain death.” The point is the literally “burning” platform caused the radical change in his behavior. Burning Platform Depicts things as they currently are: Mapping
Descriptive Words
Pics (Story Board) Depicts an improved view: The improved condition for a process with all possible flaws and errors eliminated
Improvement Goals
This is the foundation for our planning activites
Snapshot of where you want to go “The core problem with most companies is the administration of sophistication. When you have a complicated system, complicated solutions do not work! The more complex the problem the simpler the solution.”
Eli Goldratt Employees have the Answers Define the barriers between current state and future state Gap Analysis can be completed utilizing a cause and effect (fishbone) diagram This diagram is also know as an Ishikawa Diagram, named after Kaoru Ishikawa, who first applied them in the shipyards of Kobe, Japan, in the 1940s. Based on the Gap Analysis if we make these changes..... We expect these results.... 30/60/90 Tracking Med/Surg Door Flags
Shift Handoffs
Report @ Bedside
Side-Effects on MAR
Visual Management
6S Events
Up-Front Collections
Correct Information
Turn-Around-Times Aha Moment - an instant at which one recieves clarity or wisdom Change is easier when we understand why
Seeing the process on paper is overwhelming!
What a great oppurtunity for us to make a difference
I need my own office
I leaned my toast this morning WHAT.. WHO.. BY WHEN...
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