2Agenda Topic Duration 10 min Intro to Lean 5 min Project Charter Total: 60 minTopicIntro to LeanProject CharterPlanClarify the ProblemAnalyze the Current StateDevelop GoalsAnalyze Root CausesLean as an Integrated System: Mindset, Management, MethodsWaste Walk Activity should be ~15 minutes
3Learning Objectives At the end of the session you should be able to: Broad understanding of key principles and toolsBe able to use the DOWNTIME model to identify wasteDevelop a project charter with your teamExplain why PDCA is an effective method for problem solvingUnderstand the components of PDCADocument your PDCA process on an A3
4Taking a Different Approach… “I’ve got too much work to do to stop and listen to you”“The Tools Are Available”Use for ice breaker conversation.There are tools to assist us in helping us to more efficiently do our jobs but we must stop to learn.
5Lean Definition What is Lean? Lean is Not: Discuss what is lean A management system and culture designed as a way we work by adding value for our patients and eliminating waste, where every employee is empowered to continuously improve their processesLean is Not:The flavor of the monthConcepts that apply only to manufacturingA collection of tools and methodsTeam DiscussionThis is the first opportunity to break them out into teams so they can begin to get to know each other a little betterLean brings together three inextricable components: mindset, management and methods, with respect for people at the center of everything.Emphasize management system, culture and elimination of waste to deliver value.
6History of Lean Late 1800’s Early 1900’s 1930’s 1950’s 2009 Frank & Lillian Gilbreth(Time & Motion Study/ Process Mapping)Late 1800’sFrederick Taylor(standard Work)1930’sKiichiro Toyoda (Just in Time)1950’sW. Edwards Deming (PDCA)1950’sTaiichi Ohno(Toyota Production System)2009UCLA Operating SystemLate 1800’sEarly 1900’s1930’s1950’s2009Early 1900’sHenry Ford (Flow Production)1950’sJoseph Juran (TQM)1950’sShigeo Shingo(SMED, ZQC)2009Mark GrabanShingo Research AwardLean HospitalsLean is not new. It started a long time ago, in America. Ford took all the elements of a manufacturing system-- people, machines, tooling, and products-- and arranged them in a continuous system for manufacturing the Model T automobile and created the first comprehensive Manufacturing Strategy.Taiichi Ono and Shigeo Shingo studied Ford’s approach and improved it. They incorporated respect for people and the role of inventory, which eventually became the Toyota Production System.Lean has played an integral role in manufacturing, but it’s application in healthcare is relatively new. UCLA wants to position itself as the leading Lean healthcare system and we need your help to do it.
7UCLA Health Operating System Mission - Delivering leading edge patient care, education and researchVision Healing humankind one patient at a time, by improving health, alleviating suffering, and delivering acts of kindnessValues Compassion, Respect, Excellence, Discovery, Integrity, Teamwork
8Lean Benefits How Will Lean Help Me? What are the Benefits of Lean? Facilitator’s Guide – Toyota Business PracticesLean BenefitsHow Will Lean Help Me?Solving problems and recognizing lasting resultsEstablishes an environment that has controlled process, repeatable outcomes and delighted staff/patientsWhat are the Benefits of Lean?Higher quality, safety & efficiencyGiving patients what they want when they want itIncreased staff satisfactionMore time with patients and business growthAsk for examples from audience. . .Eliminates roadblocksReduces errorsReduces wait timesAllows for focus on clinical careAllows for collaborationWhat are some more examples? In your area?
9How we teach lean at UCLA Health Understand Value, Waste, & PDCACurrent State AnalysisRoot Cause AnalysisImplement & Sustain ImprovementsSIPOCEffective SolutionsParetoProcess MappingStandardWorkFishboneLast week we learned about:Understanding Value vs. WasteWhat does Value-Added mean? Why is it important?What is the difference between Non-Value Added and Incidental Work? Why is this important?Should Non-Value added or Incidental Work be eliminated first? Why?Categorize WastePresent your homework (choose the best examples for each category). What did you learn?How was it useful to categorize waste?Would it have been different if we had just asked you to find waste?5SRemind us what the 5S’s are, what order we do them in, and why?How is 5S different than housekeeping or cleaning?How is 5S related to the Waste Categories?Why is 5S foundational to the improvement process?Standard WorkWhat is standard work?What do we do after the work is standardized? Are we finished?What happens if you don’t standardize an improvement?Present and explain the chart from training.Time Obs.Active DailyManagementDaily HuddlesOperationalPlanningChange MgmtPDCA / A3 MethodologyDoCheckActPlanSpaghettiDiagram5 Why
10Seeing With New EyesLean helps us to question and take a deeper look at the situation at hand.Lean helps us to see beyond the immediate.As mentioned earlier, when we apply the tools and approaches of Lean to our work, we begin to see and understand our world in new and different ways, and begin “seeing with new eyes.” Let’s explore this concept using some other examples of how things we see and think are correct turn out to be something very different when we have additional information about the situation at hand.Example #1Click to display the Panda Bears picture.Ask: “What do you see in this picture?”Likely Responses:2 pandas eating bambooAsk: “Please look more closely. Are there just two pandas?”There seem to be panda faces embedded in various places in the pictureAsk: “How many pandas do you see now? And why did we miss the other panda images initially?”Like Responses:We missed the other images initially because they were not as obvious and were “embedded” in other parts of the picturesomewhere between 2 and 9 totalSay: “Lean provides us the tools and approaches to help us see situations from a different point of view. It gives us the tools to strip away waste that prevent us from seeing the true picture.”Example #2Click to bring up the second picture.Ask: “From a distance, and at first glance, what do you see in this picture?”A female figure reading a book- she could be pregnant and a drape in the backgroundThe profile of a man with a mustache and goatee that looks kind of sinisterBoth of these responses are correct. We may see either image depending on our perspective.Say: The mind, through prolonged inspection of a subject, becomes bored with it and will explore alternative ways of perceiving it by decomposing the whole into parts and looking for the interesting parts. In the early steps of this process, the effects of these changes remain below the level of awareness. After a while, you become aware of them.Lean helps to see our world differently. 5S provides a system and tools for literally stripping away what’s not adding value, what’s not being used, to see what lies below. And when we do that, we lay the groundwork for applying an array of other Lean and tools. In the end, we are striving for Visual Management, i.e., knowing that when we look at something, we’re seeing the truth or reality as we know it at that point, and whether or not we’re on track to achieve our goals.
11Seeing with new eyes requires an understanding that activities either add value or waste… Waiting in generalWaiting for orders to be writtenLate/missing callback for testsClinical or operational errorsUnnecessary documentationUnnecessary approvalsWhy?Activities that are Wasteful (any can be true)The patient is not willing to pay forThat do not move the care process forwardThat are not done right the first timeWASTEThis allows you to focus your resources (to eliminate waste, increase value, or support value)VALUEWork motion exampleMain point:Why do we concentrate on waste? Because we want to eliminate anything which does not add value to the product.Within any process there are three components:A) Waste - is within every process we see (man or machine), for example: unnecessary motion, obvious waste, waiting, searching etc..B) Incidental Work - is work that is required based on the way the current job is done but adds no value to the customer, for example: the loading or unloading of a part into a machine, or positioning of a part into a fixtureC) Value Added - it is often the smallest component of most processes.By identifying and eliminating waste we can reduce costs, increase quality and productivity.Tip: Know the audience’s work environment and provide examples of waste within their own work environment or daily life (ie. Standing in lines at the supermarket or in traffic, waste of waiting). Give one example for each of the three components of work motion.Comforting a patientExamining a patientDiagnosing a patientTreating a patientEducating a patientActivities that add Value (all must be true)The patient is willing to pay forThat moves the care process forwardThat are done right the first timeIntroValue AnalysisWaste AnalysisRCARCA - CausesRCA – ParetoRCA – Cause & EffectRCA – 5 Whys
12Value-Added & Non-Value Added Example Value-added Actions138Pt receives AVS and schedules f/u appt if necessaryPt checks in, pays co-payMA takes vitals and rooms pt5MD completes consultPt waits in waiting areaPt waits for MD in room6Pt waits nurse/MA to come and complete visit247Pt waits to checkoutNon-Value-added Actions
13Waste models can help you identify/find waste For “non-value added” activities, next you find/identify waste; this is made easier by using a model such as DOWNTIME*Mistakes, errors, resulting rework -D efectsO verproductionW aitingN ot utilizing TalentT ransportI nventoryM otionE xtra ProcessingProducing too much, too soon, or excessive setup -Actual downtime (patient, service, or production) -Poor use of skills and talents, knowledge loss -Moving things around -Work motion exampleMain point:Why do we concentrate on waste? Because we want to eliminate anything which does not add value to the product.Within any process there are three components:A) Waste - is within every process we see (man or machine), for example: unnecessary motion, obvious waste, waiting, searching etc..B) Incidental Work - is work that is required based on the way the current job is done but adds no value to the customer, for example: the loading or unloading of a part into a machine, or positioning of a part into a fixtureC) Value Added - it is often the smallest component of most processes.By identifying and eliminating waste we can reduce costs, increase quality and productivity.Tip: Know the audience’s work environment and provide examples of waste within their own work environment or daily life (ie. Standing in lines at the supermarket or in traffic, waste of waiting). Give one example for each of the three components of work motion.Too much inventory, or too little -People moving around, searching, etc. -Duplication, unnecessary: refinements, approvals -*Different systems classify wastes into different amounts of categories. Most use 7 (same as above but without N) or 8 but some use up to 11!** There are different types of waste – Type 1 and Type 2. Type 1 adds no value and can be removed easily. Type 2 adds no value but is necessary in the current system and/or is very difficult to remove. This distinction will become more important when focusing on solutionsIntroValue vs WasteWaste AnalysisRCARCA - CausesRCA – ParetoRCA – Cause & EffectRCA – 5 Whys
14Eight Wastes in Ambulatory Processes… 14DefectsOverproductionWaitingNot Utilizing TalentIncomplete Specialty referralsFull sheet of labels printed when only one is neededPt waits in exam room for MDNumerous ideas are “lost” only to be rediscovered laterMD/Nurse time spent on clerical tasksTransportInventoryMotionExtra-ProcessingPatients are taken from waiting room -> vitals intake -> waiting room -> exam roomExpired supplies because of excess orderingMA/Nurse spends time looking in multiple places for a particular supplyPatients asked the same questions multiple timesOPTIONAL PAGE: If the option has had a hard time coming up with specific examples for the 8 wastes, you can show this page and show additional examples. This page also offers examples from different areas of the hospital, which might be useful if most of the examples brought up are from the same area of the hospital (e.g. if only the OR or ED folks have been vocal during the discussion)Discuss the examples of each muda’s and have audience add their own
15Waste WasteHave someone in the audience read this cartoon. What is there thoughts?
16A3s and A4s are used to communicate progress A4 Problem-Solving (8.5 x 11)A3-Problem Solving (11 x 17)Everyday problem-solving, consensus & communication tool used by staffComplex problem-solving, consensus, communication toolKnown root-causes and solutionsUnknown root-causes and solutionsQuick and easy to useRequires Planning (PDCA) and usually dataExample: Peanut butter and jelly sandwiches in the RR.Example: A unit wants to improve poor patient satisfaction scores but they do not understand why the scores are so poor or how to improve them
17We will be working with A3s today A4 Problem-Solving (8.5 x 11)A3-Problem Solving (11 x 17)Everyday problem-solving, consensus & communication tool used by staffComplex problem-solving, consensus, communication tool and project management toolKnown root-causes and solutionsUnknown root-causes and solutionsQuick and easy to useRequires Planning (PDCA) and usually dataExample: Peanut butter and jelly sandwiches in the SMH.Example: A unit wants to improve poor patient satisfaction scores but they do not understand why the scores are so poor or how to improve them
20PDCA – Continuous Improvement A structured guide and method for problem solvingThe way by which we should be practicing continuous improvement in our daily workDoCheckActPlanPlanDoCheckActAsk if anyone knows what PDCA means?*click* (Plan, Do, Check, Act appears)Ask what stands out? What do they notice?-Planning has the most steps, otherwise there will be rework in DCAStep 1Clarify the ProblemStep 2Analyze Current StateStep 3Develop GoalsStep 4Analyze Root CauseStep 5Implement SolutionsStep 6Evaluate ResultsStep 7Adjust, Standardize & Sustain