1. Application of Lean Thinking to Health Care Development of the “Michigan Quality System” at the U of M Health System John E. Billi, M.D. Associate Dean for Clinical Affairs, Medical School Associate Vice President for Medical Affairs University of Michigan jbilli@umich.edu http://sitemaker.umich.edu/jbilli http://med.umich.edu/i/mqs/ MQS: Quality Safety Efficiency Appropriateness

2. Burning Platform in Healthcare The key is to change before the flames start The gaps at UMHS: –Quality: Not all diabetic patients on statins, aspirin –Safety: Still have wrong site surgery –Efficiency: Days waiting for a PICC IV line; nurse shortage –Appropriateness: generic rate around 55% Bottlenecks at UMHS: –Budgeted 4% activity increase, but only have 0.8% available bed capacity –OR shortage led to elimination of storage and doctor workstations Stress of overwork (muri): –Physicians, nurses, clerks running faster –Payments dropping

3. Crossing the Quality Chasm IOM’s 6 Aims of Health Care Health care should be: Safe Effective Patient-centered Timely Efficient Equitable - not vary due to gender, ethnicity, geography, socioeconomic status Source: Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine, National Academy of Sciences, 2000.

4. Crossing the Quality Chasm 10 Rules 1. Care based on continuous healing relationships 2. Customized based on needs and values, choice and preference 3.Patient as source of control 4.Shared knowledge and free flow of information Patients - their own information & medical knowledge 5.Evidence-based decision making 6.Safety as a system property 7.Transparency - consumers and employers data on systems (safety, evidence-based practice, satisfaction) 8.Anticipation of needs 9.Continuous decrease in waste (the apparent target of “Lean”) 10.Cooperation among clinicians (coordination) Source: Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine, National Academy of Sciences, 2000.

5. What is Lean in Health Care? “The endless transformation of waste into value from the customer’s perspective”. Womack and Jones, Lean Thinking

6. Lean in Health Care? Can healthcare use: - the Toyota Production System - product development- production - supplier management- customer support - planning -to transform waste into value? Can a health system use: - fewer inputs (time, human effort, materials) - than traditional care process - to produce a wide variety of “products” - with fewer “defects” more quickly with less stress? Lean is not about working harder or faster, it is about finding waste and transforming it into value our customers want.

7. Lean = Mean or downsizing or outsourcing or working harder… The Toyota Production System (TPS) –Transform waste to optimize value creation Lean Thinking and the Lean Enterprise –Rethink our entire business –Based on what we do that provides value to our customers What is “lean production”? Source: John Shook

8. The 5 Steps of Lean Can Work in Healthcare Specify value from customer’s perspective Identify the value stream for each product, and remove the waste Make value flow without interruptions from beginning to end Let the customer pull value from our process Pursue perfection – continuous improvement –Do this every day in all our activities Source: Womack & Jones: Lean Thinking

9. The clinic appointment You call the clinic, go through 3 voice prompts, are put on hold, and leave a message The clerk calls you back and sets a date in 3 weeks You arrive for the visit, check in, sit in waiting room You are called into the exam room, wait for doctor The doctor sees you, saying she’s been waiting for you to arrive; diagnoses a URI, and BP is worse The doctor prints an antibiotic prescription, goes to the staffroom to get it. You are allergic to that drug. You wait to pick up the prescriptions. The doctor says she wants to see you back in a week, no appointment is available. The MA does an EKG.

10. The clinic appointment You call the clinic, go through 3 voice prompts, are put on hold, and leave a message The clerk calls you back and sets a date next week You arrive for the visit, check in, sit in waiting room You are called into the exam room, wait for doctor The doctor sees you, saying she’s been waiting for you to arrive; diagnoses a URI The doctor prints an antibiotic prescription, goes to the staffroom to get it. You are allergic to that drug. The MA does an EKG. At check out you ask the cost – clerk says they’ll bill you

11. The 5 Principles of Lean Work Specify value from customer’s perspective –A quick clinic visit Identify the value stream for each product, and remove the waste –Time on hold, callbacks, walking Make value flow without interruptions from beginning to end –No waiting Let the customer pull value from the process –Pull the appointment when you want it Pursue perfection – continuous improvement –Every clerk, doctor and nurse works to redesign for better value to the customer

12. Understanding the Root Causes of Waste The simple Toyota approach 1.Go and see 2.Analyze the situation 3.Use one piece flow and problem alerts (andon) to surface the problems (detect abnormal immediately) 4.Ask “Why?” 5 times –Uncovers the root causes of waste and error, not the symptoms –Avoids blame – another form of waste (5 “whos”) –GM: “will not accept, build, or ship a defect” From Liker. The Toyota Way

13. Lean Tools Are Needed in Health Care Standard work – 4 ways lab results get to me Pull systems – no signal (kanban) when OR ready One piece flow – 36 step process to make an orthopedic appointment – PT = 27 min., LT = 23 days; - All patients arrive at 8AM Visual workplace – each exam room has forms in different colored, opaque folders – common ones gone Cellular layout – ORs are mirror images – half wrong Multi-process (cross-trained) operators – RN clean OR Iterative questions (5 “whys”) – patient left without being seen in ER, due to long wait, due to long stay patient, due to lack of inpatient bed, due to gap in discharge planning… Andon cord – “Stop the Line” in surgery

14. Are Lean Tools Needed in University Operations? Standard work – Does each DPS staff follow clearly written standard ops, that they wrote? Pull systems – Can staff pull repairs or supplies JIT? One piece flow – Do budget or capital requests proceed without stopping through campus approval? Visual workplace – Can managers and workers tell at a glance how work flows, current status, problems? Cellular layout – Have we laid out workplace for maximum efficiency, or did it evolve? Multi-process (cross-trained) operators – DPS/OSEH? Iterative questions (5 “whys”) – UM sued, due to ankle injury from visitor tripping, due to a broken step that staff stepped over for a month, due to no easy way to report repair needs and to backlog of repairs Andon cord – How do I report water on parking stairs?

15. Clinical Examples of “Right Every Time” Stephen Spear: Learning to Lead at Toyota –Design and specify process steps well –Embed testing in work: immediately signals a problem has occurred. “Tell normal from abnormal right now” (Toyota President Cho) –Improve work close to problem occurrences in time, place, process and person. Spear: catheter-related sepsis – a lot of little things: –No sink, no soap, no sanitizer, no doormat reminder or buzzer –Gloves missing, wrong size, old and rip, on other side of patient –92% of nurses faced with impediments constructed ad hoc workarounds Laryngoscope that detects misplaced tube, signals the operator, and downloads to QI lead CPR chest cover gives immediate feedback on hand position, depth, ventilation rate and depth, and stores for QI Paul O’Neill – know everything that went wrong, every day

16. Fixing Health Care From Inside, Today – Steven Spear Work is designed as a series of ongoing experiments that immediately reveal problems Problems are addressed immediately through rapid experimentation Solutions are disseminated adaptively through collaborative experimentation People at all levels of the organization are taught to become experimentalists

17. Source: Mike Kaupa, Park Nicollet

18. How is it Harder to Use Lean Thinking in Health Care than Manufacturing? Who is “customer” and what do they value? –Patient/family vs. Employer, Payer, Government –But patient and doctor insulated from cost of choices A “distortion of value” As if the driver didn’t pay for the car Lots of invisible work –Patient encounter often involves a process or decision as the outcome -- not a tangible “product” –Examples: decision to operate, clinic scheduling, lab results ordering & reporting More privacy issues

19. Diversity in Healthcare as a Challenge to Lean Large number of “product lines” –Adult vs. Peds –Specialty vs. Primary Care –Inpatient vs. Outpatient –Surgical vs. Non-surgical –Chronic vs. Acute Care “Each patient is unique” –More like a custom repair (job shop) than an auto manufacturer –Almost infinite variability in mix of diseases and symptoms –Variable: age, family, gender, race, social, insurances factors –Variable: health habits, tobacco/alcohol/drugs, compliance –Mental health as a primary or complicating problem –Patient preferences must be respected

20. How Does Health Care Differ from Manufacturing? Organizational and professional culture issues –Physicians, some world renowned –Nurses, many irreplaceable –Other health professionals Professional autonomy –vs. teamwork and systems thinking Mission-driven (at least some) –Non-profit orientation –Production of social goods

21. How is Health Care Similar to Manufacturing? Process dependence Huge variability, often unjustified –Aversion to standardization Pressure to innovate and use new technology Need for high reliability systems (patient safety leaders learn from airlines, nuclear power industry) Lack of embedded testing –No “instant awareness of every error” Trillion dollar industry Continuous Quality Improvement orientation

22. What Advantages Does Lean in Health Care Have Over Manufacturing? We expect change: new treatments, drugs, devices We have scientific literature to guide us We accept standardization in research protocols We (mostly) accept standardizing treatment of common conditions: –“evidence-based medicine” and practice guidelines We accept standardization to improve patient safety We use root cause analysis in safety and quality We are working on transparency to improve safety We have external pressures for efficiency, safety and quality –Pay for performance –Public reporting

23. Use Lean tools to transform waste into value from the customer’s perspective. Is There Waste (Muda) in Health Care? Defects in products Overproduction of goods Inventories of goods awaiting future processing or consumption Unnecessary movement of workers Overprocessing Unnecessary transport of goods Waiting (for process equipment to finish or on an upstream activity) Design of goods and services which do not meet users’ needs

24. Muda in Health Care Impacts Quality, Safety, Efficiency & Appropriateness Quality and Safety Defects in products Appropriateness Design of goods and services which do not meet users’ needs Efficiency Overproduction of goods Inventories of goods awaiting future processing or consumption Unnecessary movement of people Overprocessing Unnecessary transport of goods Waiting (for process equipment to finish or on an upstream activity)

25. Do the Eight Forms of Waste Make Sense in University Operations Overproduction/Production of Unwanted Products: Material Movement and Worker Motion: Waiting: Over-processing: Inventory: First Time Quality Problems: Defects requiring correction: Wasted Creativity of Employees:

26. Eight Forms of Waste in Healthcare Overproduction and Production of Unwanted Products: The most important form of waste – leads to all the others. Any health care service that does not add value to the patient Antibiotics for respiratory infections CT screening for coronary disease Medication given early, testing and treatment done ahead of time to suit staff schedules and equipment use Appropriateness – the key dimension of QI in health! Material Movement: Moving patients, meds, specimens, samples, equipment Worker Motion: Searching for patients, meds, charts, supplies, paperwork Long clinic halls No printer in exam room for prescriptions, patient education Adapted From Long, Mersereau, Billi

27. Eight Forms of Waste of Healthcare Waiting: ER staff waiting for admission, can’t see next patient Waiting for test results, records, information Nurse waits for med, blood draw, transport, OR cleaning Over-processing: Bed moves, retesting, repeat paperwork, repeat registration, multiple consent forms, logging requests Inventory: Bed assignments, pharmacy stock, lab supplies, specimens awaiting analysis Patient waiting for anything – tests, visits, discharge, phone cues Correction of defects: Medication errors, wrong patient, wrong procedure, missing or incomplete information, blood re-draws, misdirected results, wrong bills Adapted From Long, Mersereau, Billi

28. Genesis of Lean Thinking at UMHS 1.Why Lean? 2.“Michigan Quality System” concept 3.GM Agreement 4.Two tracks: Model lines Internal awareness and training programs 5.Coordination across UMHS units

29. Why Lean? Best way to: –Transform waste into value –Reduce errors and quality problems –Decrease our stress Defines value from the customer’s perspective Focuses on processes that add value Helps us improve our way of doing work by understanding the root causes of waste A learning approach –“Work as learning” –Not just process improvement Aligns the organization from top to bottom Includes philosophy, people, problem-solving

30. Principles of the Toyota Way - Jeff Liker 14 Principles in 4 Categories Philosophy (1) Process (7) People (3) Problem solving (3) Source: Liker: The Toyota Way

31. “Michigan Quality System” MQS Concept Create –a health system-wide –consistent approach –to quality and process improvement –adapting the principles of the Toyota Way –building on CQI base Incorporate 4 goals of Michigan Value : –Quality –Safety –Efficiency –Appropriateness

32. Perceived (and Real) Barriers to Application of Lean in Health Care (Add your barriers here)

33. Perceived (and Real) Barriers to Application of Lean in Health Care “Just the Management Flavor of the Month – this too shall pass.” –Must show it is a learning approach, not just some projects “We’ve done well, why change?” “The autos had to do it” –Lack of a burning platform/overriding reason to change (national v. personal) “Let each unit choose QI process it finds most useful.” –Some see no value in uniform QI approach; miss the synergy “Who can lead this?” –Lack of expertise/clinical champions “I’ll join when I see that the leaders are on board.” –If not led from the top, many will not engage “How much are we spending on this new program?” –Will the “return on time invested” be there? “A 3 day workshop??!!” –They’ll spend 3 days over 3 years and not change anything

34. Perceived (and Real) Barriers to Application of Lean in Health Care “Is this cost cutting disguised as QI?” –The term Lean is misunderstood –1990s CEP (Cost Effectiveness Program) = lay offs “I can’t do this on top of my day job.” –Isolated projects will not change the corporate culture – it will never become management’s job I can’t risk my area’s performance to optimize the whole product line throughput –Accountability, teams, and incentives must cross silos and levels of the organization –Evaluation of middle management must match corporate goals –The Peace Health example “Creativity is our most important asset – standard work will stifle creativity.” –Can you innovate if you have not first standardized??? –Do you want your cardiologist innovating or giving you statins and aspirin?

35. Perceived (and Some Real?) Barriers to Application of Lean in Health Care OR, People are not automobiles…

36. Michigan Quality System: The Value Proposition Uniform process improvement across UMHS –Across missions: education, research, clinical/service med students in clinic flow –Across goals: -Quality - Efficiency -Safety - Appropriateness A VSM created to improve “efficiency” can be used to improve “safety” (root cause analysis following an adverse event) –Spread to adjacent areas: merging projects ED => Radiology => OR –Training synergy Transferability of training received for one project when working on other projects

37. Model Line Projects What are they? Why use them? –Institutional examples of lean in healthcare –Proof of concept at UMHS –Can expand upstream, downstream and laterally Why not train all managers first? –We Learn Lean By Doing –Training long before use is less valuable –“Learn-do-reflect-discuss” cycle of a learning organization

38. Model Line Sequence - through the 3 d workshop phase Vascular access – “Right line at the right time” –Delayed discharge, cross silo (nursing, MD, radiology) –Results: PICCs placed w/i 12h – up 43% w/i 24h – up 40% % needing Interventional Radiology cut by 46%

39. Model Line Sequence - through the 3 d workshop phase Orthopedic consult – from request to scheduling –Chronic problem, delayed appointments, frustrated referring physicians/patients/orthopedists –Results: Pre project process time = 27 min; waiting time = 23 days Post project MedSport = 89% of appointments made on first call (2.5 min) Radiation oncology scheduling and treatment planning –Results: 54% treatment begins day of call (goal was 48h) for brain metastases

40. Model Line Sequence - through the workshop phase Orders Management Project (CPOE) – Medication management end-to-end –Redesign new workflow when implementing new information technology –High institutional visibility and impact Emergency Department – Patient flow (a series of projects for patient journey)

41. Model Line Sequence - through the workshop phase Operating Rooms –Sinus, otology (“decision to incision”) –Scheduling OR, missing consents, pre-op, right site confirmation, delay in surgeon start –Redesign before we move to new Ambulatory Surgery Center Faculty appointment, credentialing, insurance enrollment Care transition – Discharge planning, tracking before RV

42. Model Line Projects underway/planned Radiology and Lab – Misdirected results (ordering clinician does not receive report) Scheduled admissions Wound care CT scheduling and throughput Institutional Review Board

43. Clinic ED Radiology OR Admitting Transition Planning PICC A UMHS Patient Patient Journey

44. Clinic ED Radiology OR Admitting Transition Planning PICC Orders Management Project UMHS Lean “Model Line” Projects Ideal Patient Flow CT Scheduling and Reporting Ortho Scheduling ENT Cases Vascular Access: Order to Line Placement Patient Journey Care Transition Wound Care Misdirected Results Sched. Admits

45. Determining Scope is Not Easy –Emergency Department: Idealized patient flow? Chest pain patients? Observation patients? Patients needing CT scan or MRI? Patients waiting for inpatient beds? Patients needing consults? Non-acute patients – in the wrong place? –Operating Rooms Admission Day Procedure patients? –with one day length of stay (LOS) All sinus surgery? –Including clinic phase? All cases to be moved to new ambulatory surgery center? Room turnover?

46. PICC order written in patient’s chart PICC nurse travels to patient unit Locate chart and confirm order Locate and confirm patient Notify patient of procedure Obtain patient consent Review labs & previous records for contraindicat ions / Assess need for PICC Place PICC Review VAS history. Review Care Web for meds, allergies, dx, care plan, location Order CXR (includes order routing, transport, imaging, Radiologist read, MD request for adjustment ) Complete document ation in Mediserv e and VAS web site. VAS nurse P/T: W/T: FTQ: 100% VAS nurse P/T: 5 min W/T: 1 min FTQ: 100% VAS nurse P/T: 3 min W/T: 2 min FTQ: 80% VAS nurse P/T: 8 min W/T: 0 min FTQ: 90% VAS nurse P/T: 3 min W/T: 1 min FTQ: 85% VAS nurse P/T: 2 min W/T: 0 min FTQ: 93% VAS nurse P/T: 30 min W/T: FTQ: 78% VAS nurse P/T: 5 min W/T: FTQ: 78% VAS nurse P/T: 5 min W/T: FTQ: 100% VAS nurse P/T: 2 min W/T: 1 min FTQ: 98% To IR queue Referral entered into VAS website Results posted to VAS website PICC Current State Map – V.A.S. (Part 1) For patients with hx of IR PICCs For patients with inaccessible veins PICC Nurse unable to insert PICC For PICCs requiring adjustment 14 hour delay if no order 4-14 hr delay if patient not in room 4-18 hr delay if patient has concern 2-12 hr delay if patient won’t consent 12-36 hr delay if change in patient status or hold per service request 5 min – 5 hrs Up to 1 hr delay if at the end of VAS nurse shift, battery dies, etc. Up to 2 hr delay if tube lines full and can’t send order Total process P/T: 63 min W/T: 39-97 hr FTQ: 34%

47. 1. Determine that case should be referred to I.R. Set ‘transfer to IR flag’ on web 2. Complete transfer info in VAS web. Note any lab issues / sedation / … 3. Decide whether PICCs can be done today 4. When IR room becomes available, determine priority of patient for PICC 5. Contact Floor/unit to determine patient status & notify of time for PICC placement 6. Request transport via page (or SWAT via phone– only 7a- 9p) 7. Patient arrives in IR holding area / IR room 9. PICC line placed. VAS nurse P/T: W/T: FTQ: VAS nurse P/T: W/T: FTQ: Primary MD P/T: W/T: FTQ: Transport P/T: 30 min W/T: FTQ: PA / Fellow P/T: 45-60 min W/T: FTQ: Lead tech / RN P/T: 1 min W/T: FTQ: IR Lead tech P/T: 2-5 min W/T: FTQ: 50% IR Lead tech P/T: 1 min W/T: FTQ: From VAS queue PICC Current State Map – I.R. (Part 2) Results posted on VAS website 8. Obtain consent (pediatrics, if anesthesia needed) Tech P/T: 10-15 min W/T: FTQ: Tech 10. Room turnover / clean up. P/T: 20-30 min W/T: FTQ: 100% Total process P/T: W/T: FTQ:

48. PICC order written in patient’s chart PICC nurse travels to patient unit Locate chart and confirm order Locate and confirm patient Notify patient of procedure Obtain patient consent Review labs & previous records for contraindicat ions / Assess need for PICC Place PICC Review VAS history. Review Care Web for meds, allergies, dx, care plan, location Order CXR (includes order routing, transport, imaging, Radiologist read, MD request for adjustment ) Complete document ation in Mediserv e and VAS web site. To IR queue Referral entered into VAS website Results posted to VAS website PICC Brainstorms – V.A.S. For patients with hx of IR PICCs For patients with inaccessible veins PICC Nurse unable to insert PICC For PICCs requiring adjustment 5 min – 5 hrs To IR queue Dr. order form should include what (diagnosis) pt is being treated for, what meds/ therapy & for how long Have a VAS nurse available as a float to assist where needed prn… VAS Web; link to radiologist, a.) to be a list for them of pts needing assessment of PICC placement, b.) to let them send result to VAS alert of needed adjustments or if PICC OK to use VAS room for PICC placement; Modeled after current out patient program, which has proven to be both efficient & cost effective. (a.) pts would be scheduled, (b.) they would come to a clean, aseptic environment (vs. less than pristine room & bed…= decreased infection rate). (c.) line is placed, checked, adjusted if needed all in one time frame/ visit. (d.) when pr returns to floor line is ready for use. (e.) PICC nurse would still work floors, especially ICUs for pts unable to be scheduled in “VAS PICC Clinic” Get rid of d/c pending Have one dedicated to dc pending person & another for pending work On VAS website let MD know PICC is done Have the VAS website order = physician order Just take the laptop & go (not enough laptops – people individually resistant to change) Have someone from central dispatching call the floor clerk to ensure order is in place Have a lesser skilled person go ahead and scout out these things before the skilled PICC nurse arrives VAS website to have MD attest to order in chart VAS website info (absolute & relative contraindications) Bedside side should be always be assessed & not auto-referred to Angio unless pts name is recognized Scout person Have the frequent flyer patients looked at first to get them off the list Angio won’t place line if INR > 2 Look into what cut-off is for INR CDC guidelines on infection Have a lesser skilled person go ahead Have floor nurses be aware & coordinate pts’ appointments PICC nurses work on 1 floor at a time Schedule pts and have pts come to you Central scheduling online so people can see where pt is going (perhaps with CPOE) – 6A especially gone to PT/OT RN, MD, clerk on floor give pt a handout on PICC line placement and have pt or guardian initial paper Scout person Was the patient informed to start? (In ICU it’s inferred) Maybe have 2 nd VAS website PICC nurse info page to get consent in advance Sometimes physician can get consent VAS to have access to look at digitized cxr, like a monitor in our office so we can access cxr to visualize malpositioned lines to decide appropriate adjustment Minimize ping-pong effect Navion study magnet guided light tract – there’s a flip side that sometimes it needs to be adjusted What % is re- adjusted? Have ready supply carts / trays (model = Anesthesiology trays are all the same) Schedule pts to come into the PICC nurse so pt is all ready to go at that time. Model from outpatient. But someone needs to have the prepared material, order, consent, labs, etc.

49. Establish need for PICC Physician P/T: 15 min W/T: 30 min FTQ: 100% Results posted to VAS website PICC Future State Map TOTAL PROCESS VAS onlyw/ IR P/T: 165-170 min 260-275 min W/T: 7-10 hr 8.5-11.5 hr FTQ: 88% 86% Write / place PICC order Check order & schedule. Confirm on VAS website Physician P/T: 5 min W/T: 10 min FTQ: 100% Asst. Personnel P/T: 45 min W/T: 1-4 hr FTQ: 98% Assess / place PICC line. Complete documenta tion VAS Nurse P/T: 60 min W/T: 15 min FTQ: 100% Order chest x-ray (fax order, copy made by CXR) VAS Nurse P/T: 5 min W/T: 5 min FTQ: 100% Contact floor clerk to schedule X-ray clerk P/T: 5 min W/T: -- FTQ: 100% Transport patient to CXR Pt transport P/T: 10-15 min W/T: 5 min FTQ: 100% X-Ray digitally completed X-ray tech P/T: 10 min W/T: --- FTQ: 100% Page PICC to adjust as necessary 1700 Rad P/T: 10 min W/T: 30 min FTQ: 90% Check website 3 times daily Lead tech P/T: 5 min W/T: -- FTQ: 100% Contact floor clerk to schedule into designated slots IR clerk P/T: 10-15 min W/T: -- FTQ: 100% Clerk completes check-off list IR clerk P/T: -- W/T: -- FTQ: 100% Talk with floor nurse re: patient status IR Nurse P/T: 10 min W/T: 30 min FTQ: 90% Transport patient to IR Pt transport P/T: 10-15 min W/T: 5 min FTQ: 100% Assess / place PICC line. Complete documenta tion IR PA / fellow P/T: 60 min W/T: 10 min FTQ: 98% For PICCs requiring adjustment VAS notified VAS RN notified AssessmentPatient education General PICC consent, incl. Fluoro Narrow criteria at onset RL / RT Standard orders E-signature Error- proofing order Pre-program fax # VAST education for access Phys Assistant Dedicated Lead-lined PICC room Increase current room utilization hours OR / Procedure checklist W/T: 60 min W/T: 45 min W/T: 5-10 min W/T: 2 hr W/T: 10 min W/T: 30 min W/T: 5 min W/T: 15 min W/T: 30 min

52. Orthopaedics MedSport Current State Map

53. Orthopaedics Taubman Current State Map

54. Orthopaedics Future State Map

55. MQS Training Development Goal: Build training for wide application of lean thinking to projects and daily problem solving in UMHS Levels: –General awareness: orientation, new manager, senior manager –Just In Time: Team member –Coach training through graded responsibility, tool training Long Term Goal: –Managers understand their job is to optimize the value stream map of their product line –Employees understand their job is to identify immediately when something goes wrong and help solve the root cause

56. Issues for Discussion How do we… create a blame-free, responsible culture - to learn from every error, every day? get all to use the same tools for QI? coordinate improvement efforts? move beyond “projects” to “every day”? choose where to start? Are patients are interested? What is the leader’s role in a Lean Organization?

57. Issue: blame free culture Where there is an error, there is the opportunity to learn and improve. –Learn from every error, every day –How to create a blame-free, responsible enterprise? –The 5 why’s, not the 5 who’s –“The goal is prevention”. Jim Bajian, VA Chief of Patient Safety –Respect the workers: thanks for what you’ve done

58. Issue: one improvement model How do you encourage wide acceptance of one philosophy and set of tools for quality and process improvement to allow synergy across projects? –Cross-silo or cross-department improvement –Value Stream Map for improved efficiency also can be used to improve patient safety –Med Education projects in clinical areas –“Clinical research – clinical flow” interface A Learning Approach, not just a process improvement model 4P Model (Jeff Liker) –Problem solving –People and partners –Process –Philosophy

59. Issue: coordinate improvement How best to coordinate across your groups with Process Improvement expertise and resources? For example, UMHS has: –CQIP (Hospital’s QI program) –Program and Operations Analysis –Chief of Staff office/Safety/Risk Management –Faculty Group Practice –Ambulatory Care –Departmental expertise –Health Services Research faculty

60. Issue: beyond “projects” to every day “Value stream improvement is management’s responsibility”. (Rother & Shook) How can you facilitate “value stream management” as the way that managers view their role? Value Stream Map high level product lines “Projects” merge into daily management Require current and future state value stream maps for all capital, IT, space requests –Park Nicollet: no request for resources without proof of working at tact time, leveling, and other TPS metrics Embed facilitators in units (1-3% of workforce?)

61. Issue: where to start? Do we start at top (leaders), at middle (middle management), or at bottom (front line workers)? –Wherever you start, the problem will be at another level. –Plan on all levels Do you change culture first or do projects first? –“Easier to act your way to a new way of thinking than to think your way to a new way of acting” (John Shook) –“Culture = education, training, rewards” (Jeff Liker) –Culture arises from management reacting to actions/behaviors –Are learners or risk-takers rewarded, encouraged, tolerated, or discouraged? –Are silo-protectors rewarded, encouraged, tolerated, or discouraged?

62. Issue: are patients ready? Will the public flock to high reliability health care as they have to high reliability auto manufacturers? (like JD Power) Can we guarantee that no one loses his/her job as we improve? –“Transforming waste into value” v. “Eliminating waste” High market demand – expert staff shortage –“No job loss” commitment essential to Lean Who would create a Future State Value Stream Map with their job eliminated? Requires management of personnel issues first

63. Lean Transformation “Management has to understand that its role is to see the overall flow, develop a vision of an improved, lean flow for the future and lead its implementation. You can’t delegate it. You can ask the front line to work on eliminating waste but only management has the perspective to see the total flow as it cuts across departmental and functional boundaries”. Learning to See. Rother and Shook Leader as - Problem Solver- Teacher - Servant - Mentor- Coach

64. Thoughts and Feedback?

65. Additional Materials Some Lean terms References Liker’s 14 Principles of the Toyota Way UMHS Model Line Project selection process and steps Value Stream Mapping information Waste categories Full report on one model line project (PICC)

66. Lean Terms Jidoka – designed not to pass on a defect; really “machines working for people” Poka-yoke – error proofing – forcing functions of built-in quality, designed not to build a defect JIT – Just In Time, for pull systems Andon Cord – to correct the error and its root cause in real time; if needed, to “stop the line” Andon Board – tracks “down time” by cause Kaizen – continuous improvement, or “burst” Sensei – teacher or master Muda – waste Muri – waste of stress, leads to Karoshi (death from overwork) Heijunka – leveling the workload Kanban – signal for pulling work

67. References UMHS Lean Website: www.med.umich.edu/i/mqswww.med.umich.edu/i/mqs Liker J. The Toyota Way. Womack J and Jones D. Lean Thinking. Rother M and Shook J. Learning to See. Marchwinski C and Shook J, eds. Lean Lexicon. Spear S. Fixing Health Care from the Inside, Today. Harvard Business Review. Sept 2005 Spear S. Learning to Lead at Toyota. Harvard Business Review. May 2004 Spear S, et al. Decoding the DNA of the Toyota Production System. Harvard Business Review. Sept 1999

68. 14 Principles of the Toyota Way Can Work in Healthcare 14 Principles in 4 Major Categories Philosophy Process People Problem solving Source: Liker: The Toyota Way

69. Principles of the Toyota Way Philosophy –Base management decisions on long term philosophy, even at the expense of short term goals Generate value for the customer, society, and economy Source: Liker: The Toyota Way

70. Principles of the Toyota Way Process –Create continuous flow to surface problems –Use pull to avoid overproduction –Level the workload (heijunka) –Build the culture of stopping to fix problems, quality right the first time Machines serving people (jidoka) Signals for stopped flow (andon) Source: Liker: The Toyota Way

71. Principles of the Toyota Way Process, continued –Make standard work If an improvement works, make it the new std –Use visual controls so no problems are hidden –Use only reliable, thoroughly tested technology that serves your people and processes Source: Liker: The Toyota Way

72. Principles of the Toyota Way People –Grow leaders that understand the work, live the philosophy, and teach it to others –Develop exceptional people and teams who follow the philosophy –Respect extended network and challenge suppliers to improve Source: Liker: The Toyota Way

73. Principles of the Toyota Way Problem solving –Go and see (the workplace - gemba) Solve problems by going to the source to personally observe and verify data –Make decisions slowly, by consensus; implement rapidly Discuss with all affected people (nemawashi) –Become a learning organization through relentless reflection (hansei) and continuous improvement (kaizen) Source: Liker: The Toyota Way

74. Model Line Project Selection Process Criteria: Institutional priority/visibility Potential for creating an exemplar Opportunity to expand upstream, downstream, sideways Opportunity for improvement – gaps –access/waits/bottlenecks, financial, satisfaction, errors Process dependence Existence of a “clinical champion” A defined process, with a start and stop, and an owner. It has SIPOC –Suppliers, Inputs, Process, Outputs, and Customers

75. Model Line Project Selection Process Selection: Selection of Areas: –Prioritization Committee (hospital COO, CFO, CON, COS; FGP Exec Med Dir) Project leads: Determine scope, participants and timing Decision panel: All the leaders who need to approve the Future State Value Stream Map

76. Model Line Project Flow Select area: institution leaders (CEOs, COOs) Select project leads: MQS leaders Determine actual project, scope, team members, timing: Project Leads Pre workshop scoping: Project Leads, facilitators Three day workshop model (one of many options) –Day 1: Decision Panel charge, learn Lean & Current State Value Stream Map on their data –Day 2: Future State Value Stream Map, Decision Panel approval –Day 3: Implementation plan, barriers, Decision Panel approval

77. Learning to See by Rother and Shook a guide to value stream mapping

78. Using the Value Stream Mapping Tool Understanding how things currently operate. This is the foundation for the future state Value Stream Scope Designing a lean flow through the application of lean principles Current State Drawing Implementation Plan Determine the Value Stream to be improved The goal of mapping! Implementation of Improved Plan Future State Drawing Developing a detailed plan of implementation to support objectives (what, who, when) Standardize for later improvement From John Long

79. Value Stream Mapping Make work visible Understand work flow Measure process performance in terms of cost, service, and quality Redesign process to meet specific business objectives Use Lean tools to achieve the redesigned process

80. Drawing a Value Stream Map to Achieve Future State Goals Is process-time too long? Is wait-time too long? Is lead-time (process plus wait-time) too long? –Can each be reduced? –If so, by how much? –How would you draw your map to meet this time goal? Is overall quality (% complete and accurate) acceptable? Is there too much rework? –Can quality be improved and rework reduced? –If so, by how much? –How would you draw your map to meet this future state goal? Source: John Long, M.D., Lean Concepts, LLC

81. Future State Design Questions What are customer requirements? Where and how will you trigger or sequence work? How will you establish rhythm or milestones to pace the work (pitch)? How will you make work flow smoothly? How will you make work progress, delays, and problems visible? What process improvements are necessary? Source: John Long, M.D., Lean Concepts, LLC

82. Waste in Health Care Impacts Quality, Safety, Efficiency & Appropriateness Quality and Safety Defects in products Appropriateness Design of goods and services which do not meet users’ needs Efficiency Overproduction of goods Inventories of goods awaiting future processing or consumption Unnecessary movement of people Overprocessing Unnecessary transport of goods Waiting (for process equipment to finish or on an upstream activity)

83. Eight Types of Waste in Heath Care Waste Category DefinitionHeath Care Examples CorrectionRework because of defects, low quality, errors. Requisition form incomplete/inaccurate/illegible. Order entry error. OverproductionProducing more, sooner, or faster than required by the next process. Inappropriate production. Unused printed results/reports. Unnecessary labs/visit. MotionUnnecessary staff movement (travel, searching, walking). Walking to and from copier/office/ exam room. Searching for misplaced form/ equipment/chart. Material Movement Unnecessary patient or material movement. Multiple patient/paperwork transfers. Temporary locations for supplies. WaitingPeople, machine, and information idle time. Patient in waiting room. Wait for lab results. InventoryInformation, material, or patient in queue or stock. Patient waiting in exam room. Excess stored supplies. ProcessingRedundant or unnecessary processing.Reentry of patient demographics. Repeat collection of data. UnderutilizationUnderutilized abilities of people.Nurses refilling Rx or making appointments. Doctors doing simple patient education. From Elsa Mersereau

84. TYPES OF WASTE I I C C O O M M W W P P M M CURRENT THINKING WASTE NOT DEFINED REACT TO LARGE EXAMPLES REACTIVE IMPROVEMENT REQUIRED THINKING CONTINUOUS IMPROVEMENT Correction Over Production Over Production Motion Material Movement Material Movement Waiting Inventory Processing WASTE IS "TANGIBLE" IDENTIFY MANY SMALL OPPORTUNITIES LEADS TO LARGE OVERALL CHANGE GM’s Categorization of Waste WASTE Unreasonable -ness Unevenness Source: GMS Training

85. Waste in the Current State: Causes and Countermeasures Type of WasteCause(s)Countermeasure Correction of defects and rework Procedure information incomplete or inaccurate; 20% of scheduled, authorized procedures cancelled or rescheduled Reduce lead-time to eliminate rescheduled or cancelled procedure (no-shows only) InventoryBacklog of schedule, authorized procedures Reduce wait-time. Over- processing Process time too long; scheduling and authorization not coupled One-piece flow Over- production Procedures scheduled weeks or months in advance Reduce lead-time to 3 days or less. WaitingPayer authorization too slow and days after scheduling Reduce process and wait time for pending process; 24 hr. in-patient insurance information From John Long

86. Lean Culture Transformation Management owns the Vision Operators own the Vision Learning & Launch Goals Commitment Lean Training Value Stream Mapping Current state map Future state map Implementation (Kaizen Plan) Objectives Methods Responsibilities Timelines Reviews/checks Lean Workshops Lean team training Workplace organization Flexible operations Standard/balanced work Built-in-quality Pull systems Load leveling Source: John Long, M.D., Lean Concepts, LLC

87. Issues for Discussion What is optimal coordination model/location within a health system for: –Ongoing training –Project management Selection, assignment of facilitator/coach, actual day-to-day management and coordination (especially for cross-silo projects) Decentralized? Give them the training and get out of the way –Departmental initiatives –Line Managers Troubleshoot overlapping projects –Two groups working on misdirected lab results –Lean and 6 Sigma for prescription security problem

88. Lean PICC Project Jackie Lapinski Sr. Management Engineer Program & Operations Analysis

89. PICC Line Overview Special intravenous (IV) catheter used when IV therapy or antibiotics are administered for a long period of time Inserted primarily by Vascular Access Services nurses, at the patient’s bedside

90. Why Improve the PICC Line Process? Provide high quality patient care Maximize resource utilization Reduce long lead times Manage growth in volume

91. Purpose Statement Streamline the PICC process end to end in order to provide the highest quality and efficient patient care by providing the right line at the right time within 24 hours of the order (or VAS referral, for IR PICCs).

92. Where’s the Waste? Discrepancies between paper order and referral Pending discharge PICC orders receive priority Discrepancies in patient location Patient preparedness Delays in chest x-ray process Lack of standardized IR scheduling process Lack of standardized consent documentation

93. Project Schedule Scoping session and pre-work –SIPOC –In & out of scope –Identify participants 2-Day Workshop –Confirm current state –Develop future state –Develop implementation plan Reviews with leadership –30, 60, 90 day post-workshop Ongoing monthly updates

94. Current State Map – VAS PICC order written in patient’s chart PICC nurse travels to patient unit Locate chart and confirm order Locate and confirm patient Notify patient of procedure Obtain patient consent Review labs & previous records for contraindicat ions / Assess need for PICC Place PICC Review VAS history. Review Care Web for meds, allergies, dx, care plan, location Order CXR (includes order routing, transport, imaging, Radiologist read, MD request for adjustment ) Complete document ation in Mediserv e and VAS web site. VAS nurse P/T: W/T: FTQ: 100% VAS nurse P/T: 5 min W/T: 1 min FTQ: 100% VAS nurse P/T: 3 min W/T: 2 min FTQ: 80% VAS nurse P/T: 8 min W/T: 0 min FTQ: 90% VAS nurse P/T: 3 min W/T: 1 min FTQ: 85% VAS nurse P/T: 2 min W/T: 0 min FTQ: 93% VAS nurse P/T: 30 min W/T: FTQ: 78% VAS nurse P/T: 5 min W/T: FTQ: 78% VAS nurse P/T: 5 min W/T: FTQ: 100% VAS nurse P/T: 2 min W/T: 1 min FTQ: 98% To IR queue Referral entered into VAS website Results posted to VAS website For patients with hx of IR PICCs For patients with inaccessible veins PICC Nurse unable to insert PICC For PICCs requiring adjustment 14 hour delay if no order 4-14 hr delay if patient not in room 4-18 hr delay if patient has concern 2-12 hr delay if patient won’t consent 12-36 hr delay if change in patient status or hold per service request 5 min – 5 hrs Up to 1 hr delay if at the end of VAS nurse shift, battery dies, etc. Up to 2 hr delay if tube lines full and can’t send order Total process P/T: 63 min W/T: 39-97 hr FTQ: 34%

95. Current State - Brainstorms PICC order written in patient’s chart PICC nurse travels to patient unit Locate chart and confirm order Locate and confirm patient Notify patient of procedure Obtain patient consent Review labs & previous records for contraindicat ions / Assess need for PICC Place PICC Review VAS history. Review Care Web for meds, allergies, dx, care plan, location Order CXR (includes order routing, transport, imaging, Radiologist read, MD request for adjustment ) Complete document ation in Mediserv e and VAS web site. To IR queue Referral entered into VAS website Results posted to VAS website For patients with hx of IR PICCs For patients with inaccessible veins PICC Nurse unable to insert PICC For PICCs requiring adjustment 5 min – 5 hrs To IR queue Dr. order form should include what (diagnosis) pt is being treated for, what meds/ therapy & for how long Have a VAS nurse available as a float to assist where needed prn… VAS Web; link to radiologist, a.) to be a list for them of pts needing assessment of PICC placement, b.) to let them send result to VAS alert of needed adjustments or if PICC OK to use VAS room for PICC placement; VAS to have access to look at digitized cxr, like a monitor in our office so we can access cxr to visualize malpositioned lines to decide appropriate adjustment

96. Future State Map - VAS Establish need for PICC Physician P/T: 15 min W/T: 30 min FTQ: 100% Results posted to VAS website TOTAL PROCESS VAS onlyw/ IR P/T: 165-170 min 260-275 min W/T: 7-10 hr 8.5 – 11.5 hrs FTQ: 88% 86% Write / place PICC order Check order & schedule. Confirm on VAS website Physician P/T: 5 min W/T: 10 min FTQ: 100% Asst. Personnel P/T: 45 min W/T: 1-4 hr FTQ: 98% Assess / place PICC line. Complete documenta tion VAS Nurse P/T: 60 min W/T: 15 min FTQ: 100% Order chest x-ray (fax order, copy made by CXR) VAS Nurse P/T: 5 min W/T: 5 min FTQ: 100% Contact floor clerk to schedule X-ray clerk P/T: 5 min W/T: -- FTQ: 100% Transport patient to CXR Pt transport P/T: 10-15 min W/T: 5 min FTQ: 100% X-Ray digitally completed X-ray tech P/T: 10 min W/T: --- FTQ: 100% Page PICC to adjust as necessary 1700 Rad P/T: 10 min W/T: 30 min FTQ: 90% Check website 3 times daily Lead tech P/T: 5 min W/T: -- FTQ: 100% Contact floor clerk to schedule into designated slots IR clerk P/T: 10-15 min W/T: -- FTQ: 100% Clerk completes check-off list IR clerk P/T: -- W/T: -- FTQ: 100% Talk with floor nurse re: patient status IR Nurse P/T: 10 min W/T: 30 min FTQ: 90% Transport patient to IR Pt transport P/T: 10-15 min W/T: 5 min FTQ: 100% Assess / place PICC line. Complete documenta tion IR PA / fellow P/T: 60 min W/T: 10 min FTQ: 98% For PICCs requiring adjustment VAS notified VAS RN notified AssessmentPatient education General PICC consent, incl. Fluoro Narrow criteria at onset RL / RT Standard orders E-signature Error- proofing order Pre-program fax # VAST education for access Phys Assistant Dedicated Lead-lined PICC room Increase current room utilization hours OR / Procedure checklist W/T: 60 min W/T: 45 min W/T: 5-10 min W/T: 2 hr W/T: 10 min W/T: 30 min W/T: 5 min W/T: 15 min W/T: 30 min

97. Level schedule with designated slots for PICC placement in radiology with no bumping Assistive personnel ensuring completion of written order, labs, scheduling patient prior to PICC nurse traveling to the bedside Potential to use the electronic referral as the legal order (using e-signature) Potential process change to close the loop on PICC adjusts by routing that information through the VAS department, rather than the ordering physician Bold Moves

98. MetricCurrent Estimate From Current State Map Target from Future State Map Actual (post implementation) 60 Days Process Time 75 minutes166165 min Wait Time 24.75 hours39-97 hr7-10 hr Lead Time Avg. 26 hrs (max 290 hrs) 1-98 hr10-13 hrAvg 16.6 hrs FTQ 34% 88% % < 12 hours 43% 85%58% % < 24 hours 61% 100%75% Performance Metrics - VAS

99. Metric Current Estimate From Current State Map Target from Future State Map Actual (post implementation) 60 Days Process Time 120 minutes 4.3 – 4.6 hr Wait Time 62.5 hours 8.5-11.5 hr Lead Time 64.5 hrs (392 hrs max) 64.5 hrs4.5-15 hrAvg 42.6 FTQ 86% % < 12 hrs (of referral from VAS) 23% 85%26% % < 24 hrs (of referral from VAS) 49% 100%52% Performance Metrics - I.R.