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© 2008, Park Nicollet Health Systems & John Black and Associates LLC Building a Profound Lean Infrastructure for Durable Success Sam Carlson, MD, FACP.

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Presentation on theme: "© 2008, Park Nicollet Health Systems & John Black and Associates LLC Building a Profound Lean Infrastructure for Durable Success Sam Carlson, MD, FACP."— Presentation transcript:

1 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Building a Profound Lean Infrastructure for Durable Success Sam Carlson, MD, FACP Chief Medical Officer and EVP, Park Nicollet Health Services John Black, John Black & Associates, LLC Revised 2/28/08

2 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Conflict of Interest John Black of John Black and Associates LLC (JBALLC) John Black is President of JBALLC and his consulting firm consults to Park Nicollet Health Systems on Lean, Global Production System. The presentation could be perceived as a conflict as JBA receives payment for services for consulting to Park Nicollet on the Lean, Global Production System principles presented in this presentation.

3 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Park Nicollet Health Services is… Non-profit integrated care system employees 600+ employed physicians Over $1 billion annual revenue

4 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Park Nicollet Health Services is… Park Nicollet Clinic - 45 medical specialties and sub-specialties in 25 clinic locations in suburban Minneapolis 3 million patient visits annually Park Nicollet Methodist Hospital – 426 bed facility 26,000 admissions annually Park Nicollet Institute – Engages in research, education and innovation to improve quality and public and private decision making in healthcare. Park Nicollet Foundation – The fund-raising arm of Park Nicollet Health Services, using philanthropy to build healthy communities by supporting patient care, research and education.

5 © 2008, Park Nicollet Health Systems & John Black and Associates LLC We realized we were far short of where we needed to be We knew we had lots of ineffective, non-value- added processes and activities AND we knew the U.S. healthcare industry as a whole was not world class Prior improvement methodologies werent having traction Why is PNHS Aiming at World- Class Performance?

6 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Because we knew we werent delivering world class health care Because we had heard promising reports about implementation of the Virginia Mason Production System (Lean) at VMs Medical Center in Seattle We were intrigued with its potential, but wanted to do a test run at Park Nicollet before departing from our six sigma improvement strategy Why Did We Take a Look at Lean?

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8 © 2008, Park Nicollet Health Systems & John Black and Associates LLC What Does Infrastructure Mean? Why Is It Important? I35W Bridge, Minneapolis, MN, before and after collapse PROBABLE CAUSE: Federal investigators have concluded that steel plates on the [I-35W] bridge that collapsed last summer in Minneapolis were inadequate to hold the structure together… Design changes in 1977 and 1998 added additional pavement and concrete barriers that increased the weight of the bridge… Gusset plates are flat steel structures used to bolt together the steel girders that carry the weight of a bridge. Bridge engineers typically design the plates to be far stronger than the girders because if one fails, the whole bridge will collapse. In the wreckage of the I-35W bridge, investigators found 16 gusset plates that were fractured… Eight of the plates were in the location on the south side of the bridge where the collapse began… What [engineers] found was that the half-inch thick plates should have been an inch thick – double the size… USA Today, 1/15/08 Construction of the Bridge in 1967.

9 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Creating the Vision Everyone caring every day, creating with the individuals we serve optimal health and greater value

10 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Our Strategic Plan #1 regionally in state of the art measures of quality & safety for high impact conditions Patients respond positively to: I get exactly what I want (and need), exactly when I want (and need) it Reduce total risk-adjusted per capita cost of care relative to other MN care systems to below average Operating margin 3.5% By 2012, # unique patients served grows by 20% 2012

11 Traditional PN Organization Chart

12 Prototype Lean Organization Marketing Facilities Human Resources Purchasing Operations KaizenPromotionOffice Healthcare Lean Organization LeadershipFellows Finance President CEO JBA Consultants JBA Consultants Surgery KOT Hospital KOT Cancer KOT KOT Administration Model Lines Model Lines Special Ops KOT KOT Surgery Cancer KOT Hospital KOT Clinics KOT Service Lines *KOT-Kaizen Operations Team

13 Implemented Underway Not Started Pat. Returns to Function In Patient Hospital TBD Pre-Op Preparation Pre-visit L/T Day of Clinic Visit L/T Post-Visit L/T Day of Surgery L/T Pre-Surgery L/T Daily Management Boards Materials Flow Use of Non-Surgeon Clinicians Staggered Starts OR Scheduling Process Staggered Starts Case Carts: Standardize, Waste Standardize Rooms Staff Cross Training Visual Control Pull Signals Primary Care 7 days Total Surgical Specialties Patient Lead Time / 208 minutes 8 days TBD 22 minutes Accurate Surgery Times Interoperative Standard Work for MDs Pre-Op Preparation Defining Best Practice Guidelines PICIS: Surgery Information System Instrument room Pre-Op Patient Prep Load Level During Day Load level by DOW Turnover Time Reduced Surg./staff NVA Time OR 21 Standard Rooming Med. Rec. Nurse Post-op Clinics Model Line (Future) – Surgical Specialties

14 Implemented Underway Not Started Pat. Returns to Function In Patient Hospital TBD Pre-Op Preparation Pre-visit L/T Day of Clinic Visit L/T Post-Visit L/T Day of Surgery L/T Pre-Surgery L/T Daily Management Boards Materials Flow Use of Non-Surgeon Clinicians Staggered Starts OR Scheduling Process Staggered Starts Case Carts: Standardize, Waste Standardize Rooms Staff Cross Training Visual Control Pull Signals Primary Care 7 days Total Surgical Specialties Patient Lead Time 208 minutes 8 days TBD 22 minutes Accurate Surgery Times Interoperative Standard Work for MDs Pre-Op Preparation Defining Best Practice Guidelines PICIS: Surgery Information System Instrument room Pre-Op Patient Prep Load Level During Day Load level by DOW Turnover Time Reduced Surg./staff NVA Time OR 21 Standard Rooming Med. Rec. Nurse Post-op Clinics Model Line (Future) – Surgical Specialties

15 Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added) Leveled Production (Heijunka) JUST IN TIME Operate with the minimum resource required to consistently deliver Just what is needed.Just what is needed. In just the required amount.In just the required amount. Just where it is needed.Just where it is needed. Just when it is neededJust when it is needed. Jidoka One-by-one confirmation to detect abnormalities. Stop and respond to every abnormality. Separate machine work from human work. Enable machines to detect abnormalities and stop autonomously. Pull System Production One Piece Flow Production Supermarket System Takt Time Production Andon Operational Availability Standard Work in Process Kanban Standard Work Materials Machines People Park Nicollet System of Care Park Nicollet System of Care To Care for Patients the Right Way © 2008, Park Nicollet Health Systems & John Black and Associates LLC

16 Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added) Leveled Production (Heijunka) JUST IN TIME Operate with the minimum resource required to consistently deliver Just what is needed.Just what is needed. In just the required amount.In just the required amount. Just where it is needed.Just where it is needed. Just when it is neededJust when it is needed. Jidoka One-by-one confirmation to detect abnormalities. Stop and respond to every abnormality. Separate machine work from human work. Enable machines to detect abnormalities and stop autonomously. Pull System Production One Piece Flow Production Supermarket System Takt Time Production Andon Operational Availability Standard Work in Process Kanban Standard Work Materials Machines People Park Nicollet System of Care Park Nicollet System of Care To Care for Patients the Right Way © 2008, Park Nicollet Health Systems & John Black and Associates LLC

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20 Kaizen Office Locations Park Nicollet Methodist Hospital Inpatient and Surgical/Orthopedic Services Visibility Room Park Center Campus Specialty Services (CV/Onc/Medical Specialties); Primary Care Corporate Services KPO Offices Stand-up wall

21 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Strategy and Tactics Kaizen Guidance Team CEO/CEO/CMO/VP and Chief of KPO/Consultants evaluate the overall plan and progress Kaizen Leadership Team All service-line chiefs/VPs with Sr. Leadership and KDs: yearly plan/timeline and progress CEO weekly wall walk and review Progress towards yearly goals Working the visibility room Monthly reviews of corporate health, quality, and access data; setting longer-term strategy

22 © 2008, Park Nicollet Health Systems & John Black and Associates LLC CEO Weekly Wall Walk

23 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Succession Planning and Replacement Tables

24 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Park Nicollet Leadership Fellows at Boeing 777 Factory

25 © 2008, Park Nicollet Health Systems & John Black and Associates LLC

26 Developing Our Own World Class Leaders RPIWs 5S KEEP 3P VSM Daily Management Boards Just-In-Time Jidoka Wall Walk Leadership Fellows KPO

27 © 2008, Park Nicollet Health Systems & John Black and Associates LLC What Does World Class Mean?

28 © 2008, Park Nicollet Health Systems & John Black and Associates LLC World Class Companies Excel in Five Areas

29 © 2008, Park Nicollet Health Systems & John Black and Associates LLC What Does World Class in Health Care Mean? Safe Effective Patient Centered Timely Efficient Equitable

30 © 2008, Park Nicollet Health Systems & John Black and Associates LLC The Importance of Going to Japan Understanding the possibilities Seeing with new eyes

31 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Learning from Manufacturing Companies in Japan

32 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Yamatake Corporation Isehara Plant Shonan Plant Toyota Motor Corporation Kamigo Plant(Engine) Motomachi Plant(Assembly & Welding) Tsutsumi Plant(Assembly & Welding) Toyota Boshoku Kariya Plant Denso Takatana Plant The Yokohama Rubber Co. Ltd. Hiratsuka Plant Aisin Nishio Plant Yamaha Motor Co. Ltd. Yamaha Learning from Manufacturing Companies in Japan

33 © 2008, Park Nicollet Health Systems & John Black and Associates LLC The Infrastructure Must Be in Sync with the Improvement Plan Improvement efforts must not get ahead of infrastructure Model lines should be an inch wide and a mile deep

34 Taiichi Ohnos Seven Wastes MUDA Time on Hand (Waiting) Transportation Defective Products Processing Movement Stock on Hand (Inventory) Overproduction © 2008, Park Nicollet Health Systems & John Black and Associates LLC

35 The Seven Flows of Medicine Flow of patients Flow of clinicians Flow of medication Flow of supplies Flow of information Flow of equipment Flow of process engineering

36 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Surgical Services Case Study Background Approximately 17,000 surgeries performed at Methodist Hospital in 2006: Each surgery requires multiple instrument trays with potentially hundreds of instruments/supplies Multiple surgeons means multiple instrument/supply preferences Techniques and instruments added over time, but many old instruments remain unused in trays, demonstrating both reprocessing and inventory waste: Range for unused instruments has been 22-50% Mean score for unused supplies is 25% (but as high as 88% for certain procedures) 16 RPIWs done over 2-year period to reduce unused instruments/ supplies across all surgical specialties.

37 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Surgical Services Case Study RPIW Methodology Standard Work Each team included a circulating nurse & a surgical scrub tech Makeup of Teams RPIW target: Reduction of unused instruments/ Supplies across all surgical specialties Baseline for change5 weeks prior to RPIW: *Scope & procedure/case types selected * Product quantity analysis (PQA) data collected *Supply pick lists color-coded to identify utilization *Instrument counts/tray compiled During Prep Weeks: *Data collected on instruments (used vs. nonused) by following trays after surgery * Cycle times for tray processing & supply picks measured *Surgeon-unique additional instrumentation evaluated Surgeons used as content experts to RPIW teams Surgeon meetings during RPIW week; discussed: *Display of new recommended trays & supplies by procedure *Consensus on standardization

38 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Surgical Services Case Study Results at End of 2006 % of Case Volume% of Unused EvaluatedInstrumentsDifference ( )(Pre- vs. Post-Standardization) 18% reduction in processed instruments (translates to 79,530 fewer instruments handled & processed per month)

39 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Follow-up/Implications: Follow-up Audits 30/60/90/120 day audits in place to maintain gains. Each RPIW audits previous case cart standardizations. One instrument tray is evaluated for compliance with standard. Standard work is in place for surgeons to reintroduce an instrument. (To date, no surgeons have utilized this process.) Time Savings Reduction of instruments significantly affects workload of scrub tech & instrument room staff 79,530 fewer instruments processed per month = 2,615 fewer instruments per day Time savings per day: 20,917 seconds (349 minutes, or 5 hours, 50 minutes) *Assuming 3 staff members touch each instrument for 2 seconds (scrub tech touches them twice) Surgical Services Case Study

40 Goal: A Model Line Line Improvements Line Vertical development (Link processes to create a cell) Change production method from Push to Plan for Leveling Pull Develop Standard Operations Quickly Solve Flow Problems Practice Visual Control Plane Improvements Plane (Link cells to produce a product) Goal: Spread Across Plane Years Years Critical Transition from Point to Line 5-10 Years 5-10 Years Point (Eliminate waste at source - Just start somewhere) Point Improvements Goal: Flow vs. Batch Years Years Height 3rd Dimensional (Link all elements from concept to customer) Goal: Raise to Other Planes Spatial Improvements Other processes make point and line improvements based on the model line Where Does PN See Itself Now? © 2008, Park Nicollet Health Systems & John Black and Associates LLC

41 Pat. Returns to Function In Patient Hospital TBD Pre-Op Preparation Pre-visit L/T Day of Clinic Visit L/T Post-Visit L/T Day of Surgery L/T Pre-Surgery L/T Daily Management Boards Materials Flow Use of Non-Surgeon Clinicians Staggered Starts OR Scheduling Process Staggered Starts Case Carts: Standardize, Waste Standardize Rooms Staff Cross Training Visual Control Pull Signals Primary Care 14.8 days Total Surgical Services Patient Lead Time minutes15.1 daysTBD43.8 minutes Accurate Surgery Times Interoperative Standard Work for MDs Pre-Op Preparation Defining Best Practice Guidelines PICIS: Surgery Information System Implemented Underway Not Started Instrument room Pre-Op Patient Prep Load Level During Day Load level by DOW Turnover Time Reduced Surg./staff NVA Time OR 21 Standard Rooming Med. Rec. Nurse Post-op Clinics 5 Year Block (Point): Surgical Specialties

42 Pat. Returns to Function In Patient Hospital TBD Pre-Op Preparation Pre-visit L/T Day of Clinic Visit L/T Post-Visit L/T Day of Surgery L/T Pre-Surgery L/T Daily Management Boards Materials Flow Use of Non-Surgeon Clinicians Staggered Starts OR Scheduling Process Staggered Starts Case Carts: Standardize, Waste Standardize Rooms Staff Cross Training Visual Control Pull Signals Primary Care 7 days Total Surgical Services Patient Lead Time 208 minutes8 days TBD 22 minutes Accurate Surgery Times Interoperative Standard Work for MDs Pre-Op Preparation Defining Best Practice Guidelines PICIS: Surgery Information System Implemented Underway Not Started Instrument room Pre-Op Patient Prep Load Level During Day Load level by DOW Turnover Time Reduced Surg./staff NVA Time OR 21 Standard Rooming Med. Rec. Nurse Post-op Clinics 10 Year Block (Line): Surgical Specialties

43 © 2008, Park Nicollet Health Systems & John Black and Associates LLC Dramatic Improvement in Health Care is Possible Through Lean! It was exciting to see the chance for making changes, since there is no time in our typical day to make the changes we would like to make. Also, this process was good because we didnt have to talk it to death. It was fun, and a good experience. (Clinician, RPIW team participant) I was struck by the complexities of our systems, and how presumably small changes in a process can have such an important impact on the work of others in the system. It is a challenge to develop new procedures in a way that benefits all the participants on the clinical side, and keeps focus on the ultimate goal – doing what is best for the patients. (Clinician) This was the best RPIW ever! I finally feel as though someone actually cares that I work at home until 12:30 many, many nights. This has changed my life! Please keep the DA!!! (Clinician) The improvements will have a great impact to the amount of time saved preparing for a case. This saved time will be directly shifted to the patient, increasing the amount of time the RN will have for patient care. (Clinician) I never felt like I was at a hospital, because having worked at the Marriott for over 20 years, I felt that the Park Nicollet staff totally embodied the service philosophy and took care of my father-in- laws needs. (Patient, RPIW team participant)

44 © 2008, Park Nicollet Health Systems & John Black and Associates LLC QUESTIONS?


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