1. Introduction to Continuous Improvement in Healthcare
4/10/2017 9:16 PM
Introduction to Continuous Improvement in Healthcare
Why Lean?
Why Lean in Healthcare?
Lean Philosophy
Seven Wastes
Reliable Methods as Countermeasures
Tell students today’s class is to give them a basic understanding of what lean can do for workers, companies and customers.
They will be introduced to the principles that provide the foundation for all CI, will learn about the kinds of activities that get in the way of work and that customers are not willing to pay for, and then will be introduced to basic best practices that can be used to improve the flow of value to customers.
Let them know that a good portion of the day will be spent running a simulation that shows a company moving from traditional production practices to lean methods through a series of improvements that they will help to effect.

2. Hands-on consulting/training in Continuous Improvement
“I would recommend participation to all healthcare department heads and quality improvement practitioners. GBMP did a great job applying the material to healthcare, "going to the gemba" after learning lean concepts and tools in order to apply knowledge learned in the classroom.”
- Christine McMullan, Director of Continuous Quality Improvement, Stony Brook University Hospital
Our Mission Is Simple: to help companies become more productive and competitive through Continuous Improvement education and implementation.
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3. Introductions Pat Wardwell, GBMP
Chief Operating Officer
25+ years Operations and Improvement Roles
Lean Gold Certified
Shingo Prize Recipient
Shingo Prize Examiner
AME Excellence Award Council and Assessor

4. Why Lean in Healthcare? “While technologies and treatments have made enormous strides during my career, nuts-and-bolts hospital operations haven't.” – Dr. Patricia Gabow.
Errors
Insurance Coverage
National Healthcare
Reform
Work-Arounds
Cost
Reporting Requirements
Payment Systems
Staff Frustration
Waste
Silos
Waiting 4
Desire to Improve Quality, Cost, Delivery and Safety of Care

5. Lean in Healthcare Affinity Healthcare – A Healthcare Remedy
4/10/2017 9:16 PM
Lean in Healthcare Affinity Healthcare – A Healthcare Remedy

6. Video Essay What Is “Traditional”? 4/10/2017 9:16 PM
Tell students to watch this example of traditional manufacturing and to think about all the things they see that will make it hard to make improvements in this enironment.
Show the video clip.
Ask the following questions:
Is the belt moving too fast or do we need more people?* *this question helps to get students to connect with building to demand
How do you think Lucy and Ethel feel about their work? Why?
Who is the supplier to L&E and do they know they are having any problem? Do they care?
Who is the dept. after L&E and what do you think they are thinking based on what you see?
Does the manager know there are any problems? Do you think they will tell her about problems?
What does a properly wrapped chocolate look like? Did anyone instruct L&E how to be successful?
How many should L&E do? How do they know if they are ahead or behind?
Now think about what the customer of chocolates cares about:
When you are hungry for chocolate and go to the store to buy some, what do you care about?
Quality?
Cost?
Selection?
Availability?
Based on what you saw in the video, how well equipped is this process and these workers to give the customer the things they want? Give me some reasons for your answers? What did you see to support your answers?
Video Essay

7. What Is “Traditional Operating Methods”?
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What Is “Traditional Operating Methods”?
Customer requirements not known
Batch processing
Pacing to “maximize” resources
Processes/Equipment keep running despite defects
Lack of standardization
Questionable quality
Operator’s work out of control
Operators not working together
Limited communication between operators and management.
Management occasionally present
Conclude Lucy video segment by linking to above things that typify traditional work environments and explain that this environment is not favorable to improvement:
Workers are fearful, hiding problems
Supervisor not around and doesn’t see the issues or support the workers
Different departments are spread out, not working together to meet overall customer need and can not communicate with one another easily.

8. What Is “Traditional Healthcare”?
Patient requirements poorly communicated
Batch processing
Unnecessary procedures and tests
Lack of standardization
Long wait times expected
Questionable quality
Staff working out of control
Dr., nurse, and staff not working together
Limited communication between staff and management
Management occasionally present 8

9. What is Continuous Improvement?
Quality – Cost – Delivery - Safety
An approach to healthcare which strives to maximize value to the patient by maximizing the value of employees.
JIT
Autonomation
Standardization
Stability

10. What is Continuous Improvement?
Employees
Patients
Continuous Improvement
Connects employees and patients.

11. Concept of Value and Waste
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Value Added
Activities involved with the direct care of the patient
Activities the customer (Patient or Payer) is willing to pay for
Waste (Non-Value Added)
Activities that do not benefit the patient
Activities that fall under the 7 forms of waste
Activities not performed right the first time
Necessary Non-Value Added (Incidental Work)
Activities causing no value to be created but which cannot be eliminated based on current technology or regulations
Henry Ford was first to articulate the concept of waste and to understand the idea of cutting the time between paying and getting paid.

12. What is Continuous Improvement? What is CI in Healthcare?
The primary focus of lean or CI is in developing people as problem solvers and participants in process improvement.
CI or lean is the creation of value for the customer through the relentless and iterative elimination of waste (muda), variation (mura) and strain (muri).
Value is defined as any action or process for which the customer would be willing to pay.
In Healthcare, value is defined as any action or process that directly contributes to the care of the patient.
“Care that is patient-focused, with less waste and cost and better medical outcomes” - John Toussaint, On the Mend

13. Lean – The Big Picture 10% Techniques & 90% People
4/10/2017 9:16 PM
Lean – The Big Picture 10% Techniques & 90% People
Before strategy there is Philosophy.
Techniques are the means, not the ends
Management must lead.
At the center is Human Development.
Techniques
Management
How can CI thinking counter the problems with traditional business practices?
CI is a business strategy for the long term, founded on principles about developing processes that serve customers by allowing workers to focus on the things that add real value and take advantage of the knowledge and creativity of people, our most valuable asset.
It must be supported by a strong management system that creates a favorable environment for people to practice and learn, and give them the skills and time to solve problems that crop up.
The Technical aspect, or the tools of lean, are used as countermeasures to the problems that get in the way of real work.
It is 90% about people, however, because it is the people who know where the waste and problems are. The more people learn and practice, the better they get at it, the more complex the problems they can solve and the more capable the organization becomes. Managers exist in a lean environment to help develop people!
Human Development
Philosophy

14. Lean Philosophy Patient is First . . .
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Lean Philosophy Patient is First . . .
Patients expect zero errors
At an affordable price
With no waiting.
Old Thinking
New Thinking
Errors Expected
Zero Defects
There are 4 key philosophies upon which CI is founded:
The first is “customer first thinking”.
Explain the difference between old and new thinking about customers and explain that the focus is on building processes that only do what the customer is willing to pay for.
Price = Cost + Profit
Profit = Price - Cost
Maximize for Physician
No Patient Waiting

15. Lean Philosophy Employees are the most valuable resource.
4/10/2017 9:16 PM
Lean Philosophy Employees are the most valuable resource.
People want to make valuable contributions to the world.
Dissatisfaction is a normal and necessary condition for improvement.
95% of objection is cautionary.
If employees truly understand value, they will gladly provide it.
People have limitless capability.
Second philosophy is the embodiment of the “people are our most valulable resource” statement. We must value our workers and create an environment favorable to CI and learning.
Learning never ends and people have the ability to keep learning and applying that learning throughout their lives.

16. Lean Philosophy Direct Observation
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Lean Philosophy Direct Observation
Direct observation on regular basis is critical to understanding.
Best information for continuous improvement comes from direct observation and involvement with the people who do the work.
Workplace is dynamic.
Go to Gemba often!
The third philosophy says that if we wish to know what is getting in the way of customer value we must become skilled and practiced at “direct observation”, going to where the work is done and watching with an eye for improvement.
Introduce the term “GEMBA” (real place), where work is done, whether it is factory, office, hospital, bank or retail store. The best info. about problems and how to improve will always come from facts gathered from the work place!

17. 4/10/2017 9:16 PM
Lean Philosophy Kaizen (continuous improvement) is for everybody, everyday.
Kaizen is small changes for the better that come from the common sense and experience of the people who do the work.
The more employees learn and use CI the better they become at problem-solving (tacit learning.)
Continuous improvement never ends.
The final philosophy is about making CI part of every work day: everybody, everyday.
Talk about the word “Kaizen” and how each worker should feel the responsibility to find problems and come up with ideas to improve as part of their daily jobs.
Ask: “when do you think we are done with CI?” Answer: never! Then talk about perfection, or True North and explain why we always continue to head in that direction but will likely never get there and that is to be expected.
What is not acceptable is to stop trying to move ahead!

18. Toast Kaizen Current and Target 4/10/2017 9:16 PM
Tell students: “Now we have a chance for you to practice some direct observation.”
Explain that they should watch for problems in the short video of making toast.
Watch the before condition segment, then stop and ask them to tell you all the problems they saw.
Walking
Searching
Wrong toast made (defects)
Waiting
Hard butter/excess butter
Congratulate them on there ability to “see” problems.
Now ask them for ideas on how to solve the problems they observed.
Then show them the after condition clip.

19. Toast Kaizen Event Metrics
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Toast Kaizen Event Metrics
These are the measurable outcomes of the before and after condition in toast.
Talk about how no new toaster was needed and why adding a new toaster is not a good solution.
Talk about how this is how a typical kaizen happens:
Observe/collect the facts
See the problems
Come up with ideas for improvement
Try them out
Did they work? If so, standardize and sustain
Look for more improvements.
Make the link to the Scientific method and running “experiments”. This is how kaizen works!
Many small changes to toast process and worker, customer and business are happier.
Small changes from the common sense and experience of the people who do the work.

20. Lean Summary Everybody, everyday! Patient focused.
4/10/2017 9:16 PM
Lean Summary
Everybody, everyday!
Patient focused.
10% techniques & 90% people.
Is taken in small steps.
Produces orders of magnitude benefits.
Is not consistent with traditional approach.
Simply summarize: “so this is what we mean by CI” and it is very different than Lucy and Ethel and the environment they work in. The results can be very striking if they foundation, management systems are in place to encourage problem identification and the proper use of lean tools to make improvements.

21. Benefits of Lean Highest Quality Lowest Cost Shortest Time
Safer for Patient
Least Strain for Caregiver
Greatest Productivity
Better use of Space
Greatest Margin Flexibility
There are no limits to improvement!
Connects Patient to Staff

22. Process - Operation Model
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Process - Operation Model
Operation
Feedback
Process
Reading
Screening
Admissions
Main Reception
We need to learn to “look” for these wastes in our processes. If we can’t identify them we can’t reduce or eliminate them. Often we need to look between the “cracks” to find them.
Explain the difference between process and operations and link to what the customer cares about—the correct output, quickly and at a reasonable price from the process.
Patient A
Patient B
Patient C

23. Process - Operation Model
4/10/2017 9:16 PM
Process - Operation Model
Admissions
Main Reception
Screening
Reading
Feedback
Unfortunately a great deal of time in unimproved processes is consumed by waste or NVA.. The typical quoted value is 95% is waste!
Cite an example:
Order takes 8 weeks to ship to customer, but the product is built, tested and packaged in 2 hours.
Waste
95% of process is waste.

24. Seven Wastes 1. Inventory 2. Transportation 3. Waiting 4. Motion
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In patient rooms
In stockrooms
Between departments
In hallways
1. Inventory
Patients and providers
Information
Supplies
2. Transportation
3. Waiting
To get in
To get out
For results
For medication, for food
Searching, walking, backtracking, reaching, bending, climbing, taking eyes off of work
4. Motion
These are the 7 deadly wastes that we always look for in our processes—things the customer is not willing to pay for.
Ask them to take a few minutes and suggest examples from their own workplace of each on the slide.

25. Seven Wastes 5. Processing 6. Defects 7. Over-production
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Patient being asked the same questions, unsafe or strain producing, Unnecessary, irrational
5. Processing
Infections, wrong site surgeries, medication errors
6. Defects
Excessive tests, unnecessary treatment
7. Over-production
Worst Waste
Continue from prior slide, give some examples.
Ask them why Overproduction is the worst waste? Be sure they understand and remind them this is why lean always seeks to get to JIT production.

26. Reliable Methods 5S - Workplace Organization
4/10/2017 9:16 PM
Reliable Methods
Identify reliable methods.
5S - Workplace Organization
Problem Solving for CI Teams
Value Stream Mapping
Continuous Flow
Standardized Work
Kanban/ Pull Systems
Visual Control Systems
Set up Reduction
Poka-yoke/ Error Proofing
Heijunka/ Level Scheduling
10%
Create a favorable environment.
40%
Keep all employees practiced.
50%
Here is a list of some of the reliable methods that fall under the CI umbrella. There are others but these are the ones that we will discuss during this course and/or see today as our simulation unfolds.
Most are simple in concept, but without the proper environment or getting the right people involved, it can be difficult to implement them.

27. 5S - The First Improvement
4/10/2017 9:16 PM
S1 – Sort Out
S2 – Set Locations
S3 – Shine
S4 – Standardize
S5 – Sustain
5S, or workplace organization, is typically one of the first reliable methods implemented in lean. This is because it is a tool to help create stability and standardization in the workplace. It is also necessary to be successful with every other lean tool that you may apply in your lean journey.
It must involve the people who do the work—only they know what they need and where they need it!
It is focused on allowing workers to have everything they need to do their jobs at their fingertips, in a well organized manner, minimizing searching and motion and helping workers make the right decisions every time the job is done.
The office picture here shows how sales binder literature has been organized and color coded to make it easy to create two different kinds of sales binders (as denoted by the two different color dots). All items needed to build one type binder have a green dot on the folders that contain the proper literature for the binder. If you start at the left of the drawer and pick one sheet from each folder with a green dot you will have the materials for a complete binder, in the correct order.

28. 5S Video Essay

29. CEDAC Team Based Problem Solving Technique

30. Good Process Good Result
Value Stream Mapping
Good Process Good Result

31. Continuous Flow (Cells)
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Continuous Flow (Cells)
Reorganizing physically and organizationally for improved flow.
All steps used to complete a prcess are placed in sequence of production. No space between steps.
No material build-up between operations.
One piece flow.
A key goal of CI is to improve the flow of value to customers. Processes set up in Continuous Flow reduce the time between paying and getting paid.
Getting all operations in order, close together, typically cuts down on space, WIP, mistakes and other wastes, and improves communication and productivity.
Spaghetti Diagram Lab Flow

32. Standardized Work
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Best (current) combination of people, machines and material to complete process for patient demand.
Takt Time – time allowed by customer to complete the process
Cycle time - time to perform the process, including machine and manual time
Work Sequence - order of operations to complete the process
Stock on Hand – inventory required to maintain flow
Key safety and inspection points
Ask: Whether they under produced or over produced in round tow ask, “How can we ensure we make exactly the amount the customer wants and that we use the right amount of resources to do so?”
Introduce Standardized Work as the countermeasure that allows us to create a repeatable, predictable outcome every time the job is done --- in other words, a known amount of output using a known amount of resources—people, equipment, materials---in a known amount of time.
Explain the three components of Standardized Work: Takt time, work sequence and std. WIP
Point out that standard work must always be safe and run through an example to help them calculate takt time for a process and number or required workers.
Takt time = Work day time/amount of units required in the work day to meet customer demand
Number of workers required = total cycle time to do the work/takt time

33. Kanban Kanban eliminates overproduction.
4/10/2017 9:16 PM
Kanban
Kanban eliminates overproduction.
Kanban re-integrates inventory data with material.
Number of kanban cards controls level of inventory.
Delays (unavailable kanban) are highlighted immediately.
Kanban is like money, always try for less money in system.
Kanban helps to ensure that only work that is really needed is done. It is a rules based system that will fail if people don’t follow the rules.
Kanban is “waste by design”, a system that puts inventory in place to allow customers to pull and accounts for the problems that keep the process from being in continuous flow.
Tell students that our goal should always be to reduce the amount of inventory in a pull system—heading more and more toward JIT, single piece flow. Other countermeasures such as SMED, poka-yoke, etc. are used to help remove the process problems that drive kanban levels.

34. Visual Control Systems Letting the Process Speak
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Visual Control Systems Letting the Process Speak
Visual
Indicator
Visual
Control
Visual
Signal
Visual
Guarantee
Various examples of visual systems.

35. Reducing Interruptions and Improving Patient Safety
A study involving nine San Francisco Bay Area hospitals focused on improving accuracy in administering drugs - with particular emphasis on reducing interruptions that often lead to mistakes - resulted in a nearly 88 percent drop in errors over 36 months at those hospitals.

36. Set-up Reduction Reduce every set-up by “59/60th’s”
CI Briefing
4/10/2017 9:16 PM
Set-up Reduction
Reduce every set-up by “59/60th’s”
Separation of external from internal tasks
external = process running internal = process stopped
Convert internal to external tasks
Minimize adjustments
Improve overall set up
Focus on waste, not operation
Equipment
Patient
Room
Operating
Room

37. Kayem Foods Top Management CI Briefing
Poka-yoke
Defects = 0
Poka-yoke means to avoid (yokeru) inadvertent errors (poka).
“Preventing the act of forgetting what you have forgotten” Shigeo Shingo.
Respect the intelligence of staff by taking the judgment out of repetitive tasks where errors are likely to occur.
Cannot connect to the wrong tank!
Wednesday, December 15, 1999

38. Quality – Cost – Delivery -- Safety
Continuous Improvement Summary
Quality – Cost – Delivery -- Safety
Develop from Need
90% People (Patients and Employees)
Focus on Workplace
Create Kaizen Way
Incremental use of reliable methods to counter 7 wastes
Pull Systems
Standardized Work
Continuous Flow
5S and VSM

39. Key Points Create a favorable environment: 90% people,10% methods!
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Three aspects to TPS
Technical – tools like 5S, Kanban, Set Up Reduction
Philosophy (see below)
Management – new strategy, policy and organization
TPS (Lean) Philosophy:
Patient First
Employees most important resource
Direct observation. (Go see!)
Kaizen – small changes for the better, everybody, everyday
7 Wastes
Storage
Transportation
Overproduction
Processing
Motion
Defects
Waiting
Basic hierarchy of improvement
JIT
Autonomation
Standardization
Stability
Review the key points from day 1 as an exercise with the group:
Ask the group to tell you what the key points are from day 1—write them on the flip chart.
Then press the enter key to show the key to have the key points appear on the screen.
Stress human development, problem identification, waste identification, then use of countermeasures to reduce/eliminate flow productions.
Create a favorable environment: 90% people,10% methods!

40. Thank you! Questions