Lean Principles For Healthcare Improving the 8 Main Flows for Value Dr. Stephen R. Mayfield Chief Optimization Officer

What do These Have in Common?

Content Today What’s YOUR Value Add? What is “Lean” and why Should I Care? Two Applied Examples Hands on: Make Toast; NASCAR, Simulation SIPOC Current State Future State Doing It!

KUDOS and THANKS to GAHFM ! GAHFM/ASHE Purpose Statement: Dedicated to Optimizing the Health Care Facilities

Surviving to Thriving: Assume that your organization gets a new CEO. During their first week, you have a chance encounter in the elevator. They introduce themselves and ask: “What do you do around here to provide value? What’s your Response? What’s your “Elevator Speech?’

Elevator Speech on How I add Value:

Key Attributes of A Sustainable Future : Improved Outcomes Reduced Costs Improved Margin per patient episode Improved Satisfaction or Experience All of which depend upon: An optimized physical environment All of which require Hospital Engineers!

In designing Processes and Systems Remove the Wastes or Obstacles (Lean) Eliminate the Defects (Six Sigma) Consider Human Performance characteristics Develop Optimal Solutions Hospital Engineers can Lead the Way !

Eight health care flows that improve operations and safety http://www.hfmmagazine.com/display/HFM-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HFM/Magazine/2015/May/hfm-architecture-health-care-flows Flow of Staff Flow of Patients Flow of families and care partners Flow of information Flow of medications Flow of supplies Flow of equipment Flow of output

Lean Methods & Applications Lean and Value Stream https://www.youtube.com/watch?v=7bZ6yepEgzk

Innovate (v. tr.): application of creative energy to implement change; a departure from past practices. From Webster’s SRM 12/2/2011

Restocking of Specialty Carts Reduce Process Cycle Time by 50% Ben Snead RN, RRT, MBA

Executive Summary The project tackles important issues related to stocking 100 code carts. DMAIC was used to identify waste and cut the total cycle time by 50% Non-value added motion accounted for $433,555 in direct and opportunity costs A new process allows for improved efficiencies, reduced costs, and elimination of non-value added steps.

Specialty Carts 85 Code Blue Carts 15 Pediatric Broselow Code Carts 8 Broselow Bags 4 CAPD Carts 4 Neonatal Code Carts 4 ENT Carts 1 On-Q Pain Cart

Problem Statement The current process for restocking code carts includes taking code carts to the pharmacy twice in the process. Once to remove the drug tray from the used cart and then returning the cart to the pharmacy to replace the drug tray in the restocked cart. The cart is then taken back to central service to be stored until it is ready to be used. Time is wasted moving carts to and from the pharmacy. There is no added value for making the trips and takes staff away from the area where they can be repurposed for other duties.

Problem Cont. Secondary effect occurs when staff are traveling to the pharmacy: Staff not available to deliver supplies and clean equipment. Downstream delays occur as nurses and clinical staff leave the floor to obtain supplies. Delay in patient care Late delivery of supplies (goal <30min) Interruption in the supply chain Pharmacist has to stop what they are doing to actually change out the tray and lock the cart.

WORKING ON PROCESS

The Process Map Legend: Delay in the process Decision Process flow Identified Muda W

Process Flow Code Cart Restocking

Process Flow with Muda Necessary Steps

Mapping

Walking the Process Gemba

Total Cycle Time After Total Cycle Time Before

Total Cycle Time 1st Check 2nd Check Travel Time TCT Before 27.18 19.5 40.4 87.08 After 28.4 19.53 47.93

Summary and Results The project tackles important issues related to stocking 100 code carts. DMAIC was used to identify waste and cut the total cycle time by 50% Non-value added motion accounted for $433,555 in direct and opportunity costs A new process allows for improved efficiencies, reduced costs, and elimination of non-value added steps.

Streamlining the Screening Mammography Reporting Process DMAIC Kenan Hodges Richard Rhodes

Problem Statement Currently, patients must wait from 2 hours to several days in order to receive the results of their screening mammogram studies. The current process utilizes a flow that has several questionable steps which could be streamlined or eliminated in order to speed up the process. If additional imaging is necessary, radiologists and patients will be able to act accordingly.

Problem Statement The following problems currently exist in the breast cancer screening process: Lack of a consistent process flow Staff not following best practices Lack of physician level support for the process Insufficiently utilized resources Poor communication

Critical To Quality CTQ’s for Mammography Results Availability 1) Reduced reporting delays, (completion of study to report available). 2) Improved number of reported studies within a set timeframe. 3) Improved staff utilization. 4) Increased patient satisfaction

SIPOC for Mammo Results Reporting Suppliers Inputs Process Outputs Customers Patients Physicians Service Line Corporate Facilities Manpower Resources Equipment Orders for Procedures Business Process Patient Satisfaction Timely delivery Increased quality Dashboards Report Results Patients Physicians Service Lines Departments Staff Executives Exam completed Report dictated Report transcribed Report signed off Results available

Process Flows

Process Map Current State Basic Flow Chart – Prior State

Pre-Implementation Proportion Graph Historical data: 2015 577 exams in < 24 hours TAT = 1.12 days

Process Map Post Improvement Basic Flow Chart – Post Improvement

Post Improvement Proportion Graph Post Implementation Data: 2016 939 exams in < 24 hours TAT = .69 days

Effect of results As we began this second phase in trying to improve breast center results reporting within 24 hours, we looked at the process flow in greater detail and determined that sometimes human resistance can be a significant factor in achieving optimal results. The staff and the radiologists were adamant in their efforts to forestall change in their area and it took no small amount of statistical and industrial engineering effort to show them how inefficient their process was. Even after this work was performed, the simple fact that the radiologists felt a staff member might lose their job if the process was changed continued to hamper our efforts. Only when we were able to re-purpose this staff member, were we able to eliminate the roadblocks to change and proceed with the improvements. The results have been impressive and we currently have achieved a rate of 94% in reporting exams within 24 hours with a mean TAT of .69 days or 16.7 hours. In our Design Phase, we had hypothesized that by reducing the TAT by 50%, we would be able to realize a significant increase in volume and revenue, possibly by as much as 25%. In an analysis of the latest volume statistics, we have seen a 14% increase in volume over the same time period from last year. Based on current revenue, this would equate to $517,000 annualized. With the new process in place, we would expect the volume to continue to increase as radiologists and staff become more familiar and more comfortable with the new process. We will monitor the volume over the next several months to see if this bears out.

4 Lean Process Steps Step 1 Step 4 Step 2 Step 3 Lean Enterprise Current State Mapping Identifying Waste Creating the Future State Continuous Improvement Step 1 Step 4 Step 2 Step 3

Process Definition Process Inputs Outputs Suppliers Customers A process is a set of conditions or set of causes that work together to produce a given result. It includes inputs, outputs, transformations, and feedback. A process is any work that meets the four criteria: it is recurrent; it affects some aspect of organizational capability; it can be accomplished differently so as to make contribution to customer and/or profit; it involves coordination. Suppliers Inputs Process Outputs Customers SIPOC or COPIS Model

A method to assist in developing the flow on a process map is SIPOC. SIPOC (COPIS) A method to assist in developing the flow on a process map is SIPOC. Suppliers: Who supplies the inputs to do the job? Inputs: What are the products/services that your suppliers give you? Process/Sequence: What are the steps to convert the inputs to outputs? Outputs (products or services): What products or services are produced? Customers: Who receives your products and services? What do they need? What are their requirements? 39

SIPOC Interventional Scheduling Suppliers Inputs Process Outputs Customers Requirements Physician Patient Radiologist Pathology/Lab Nursing/ I.P. Registration Convenient Accurate Results Timely On Demand Clear expectations Timely Results Results Previous Exam Good History Convenient Schedule H&P Accurate Scheduling Completed record Demographic info Payer info ICD 9 Physicians Orders Patient Information Schedule Information Capacity Staffing See Below Completed Procedure Specimen Obtained Results in System Receive call from Physician for Interventional test Approve Test Contact ordering Physician, Schedule test Patient enters our “system” (“Orders, Labs, H&P) Administer and complete test

SIPOC Example: Peri-Operative Prophylactic Antibiotic Administration CTQ CRITICAL TO QUALITY SUPPLIER INPUT PROCESS OUTPUT CUSTOMER Patient Physician Pharmacy Nursing Pre-operative antibiotic medication order Provision of the antibiotic Administering the ordered pre-operative antibiotic medication Appropriate pre-operative antibiotic medication is ordered Pre-operative antibiotic medication is provided via PYXIS or picked up Pre-operative antibiotic medication is administered in the correct timeframe Selecting the correct antibiotic Administering the antibiotic at the correct time Reducing the risk of post-operative infections High-Level Process Map

SIPOC Worksheet Suppliers Inputs Process Outputs Customers      

Why Map your Process? “Just as you should know the anatomy of a body before performing surgery, you should know the detailed steps of your process before improving it” - G. Nelson Process Maps/Flow Charts help a team step back and take an objective look at their processes and expose the places were defects, confusion and variation contribute to inadequate care Defines and documents the process Serves as a check and balance Helps keep the team focused Used to identify scope, benefits, opportunities, data needs, etc. Replaces pages of words with a single picture Identifies provider-customer relationships Helps the team to respect the amount of work being done Opens the team’s eyes to the amount of variation in the methods we use

Flowcharts A flowchart is a graphical representation of a process. The first step in many process improvement projects is to create a flowchart. Go out and WALK the process – see it for yourself. Ideally, start at the end of the process and work backwards. Identify what is being done that is not necessary (waste or non-value-added) Identify what is not being done that should be done

How to Create a Flow Chart Basic Flowchart Symbols Process Beginning and End Activity/Process Step Decision Point Waits and Delays Process Flow Direction Connector (to another page, for example)

Process Map Example Start Task One Task Two Task Three Task Four Scrap Meet Spec? Meet Spec? Yes Task Four No Yes No Rework Delay Ship Inventory

How do you make Yours?

With A Partner: Create the SIPOC for making toast as shown in video Create a process map of making toast as shown in video. Use ‘start’ and ‘stop’. Show any decisions. After completion, write the process step number in the bottom right hand corner of each step. Be prepared to discuss and share how many steps, decisions, etc. you have.

Improvement Suggestions

We must first SEE the Opportunities The Business Model Requires Better Performance To Improve the Performance….. We must first SEE the Opportunities

4 Lean Process Steps Step 1 Step 4 Step 2 Step 3 Lean Enterprise Current State Mapping Identifying Waste Creating the Future State Continuous Improvement Step 1 Step 4 Step 2 Step 3

What is waste? Now that you have value stream mapped the process, you can identify waste

Muda : Waste A Japanese term for anything that is wasteful and doesn't add value. Waste reduction is an effective way to increase profitability. A process adds value by producing goods or providing a service. A process consumes resources. Waste occurs when more resources are consumed than are necessary to produce the goods or provide the service.

Definition of Waste Anything that doesn’t add value to the process - Anything that doesn’t help create conformance to your customer’s specifications - Anything your customer would be unwilling to pay you to do

Value-Added and Non-Value-Added Time Value-Add (VA) - any operation or activity the customer values (and would be willing to pay for) Who are your customers? What do they really want? Non-Value-Add (NVA) - any operation or activity that consumes time and/or resources but does not add value to the service provided or product sold to the customer Necessary – regulatory requirements, etc. Unnecessary – everything else Value-Added These are the tasks or activities that are valuable from our external customer or patient’s point of view. Patient cares and would pay us for this activity if they knew we were doing it Some change is being made to the service or end-product This is the first and only time we are doing it (Fixes, rework, replacements do not add value) Non-Value Added - Unnecessary The “rude awakening” aspects of a process Delays, Inspections, Transport, etc. Non-Value Added - Necessary May allow the work to be done more quickly, effectively, with greater accuracy, etc. For example, a patient doesn’t care if we purchase a high-speed, advanced computer system. They won’t pay extra for us to purchase the computer but it will enhance our overall care to that patient. Another example is performing a step to satisfy legal, regulatory or mandated practices

Identification and Elimination of Muda CAN ANYONE TELL ME IF THERE IS ANY WASTE IN THIS PROCESS? YES, YOU WILL FIND WASTE IN EVERY PROCESS .

Those activities between the value-added steps that typically account for 70-95% of steps, process time, and nonmaterial costs equal waste

Lean Methods Support Improvement by Attacking Waste – “Downtime” Lead time can only be minimized by the elimination of the Eight Types of Waste Defects/Rework (correcting mistakes) Overproduction (producing more than is needed) Waiting (delays caused by shortages, approvals, downtime) Non-Utilized talent (unused, or under-utilized capabilities) Transportation (moving material/product from one place to another) Inventory (material/product waiting to be processed) Motion (excess movement and/or poor ergonomics) Extra Processing (adding more value than the customer is willing to pay for) Source: “When Going Lean, Waste is the Enemy”; Kastango, 2009

Eight Wastes of Healthcare Defects Overproduction Eight Wastes of Healthcare 1. Defects Work that contains errors, rework, or mistakes or that lacks something necessary Medication errors Wrong patient – wrong procedure Patient falls Chemical spills What are possible causes?

Eight Wastes of Healthcare Defects Overproduction Eight Wastes of Healthcare 2. Overproduction Producing more than the customer needs right now Working ahead rather than waiting Medication given early to suit staff schedules Just-in-case thinking What are possible causes?

Eight Wastes of Healthcare Defects Overproduction Waiting-Delays Eight Wastes of Healthcare 3. Waiting - Delays Idle time created when material, information, people, or equipment is not ready Waiting for lab results Waiting for a bed assignment Waiting for collection of specimens What are possible causes?

Eight Wastes of Healthcare Defects Overproduction Waiting Non-Utilized Skills Overproduction Transportation Motion Waiting Eight Wastes of Healthcare 4. Non-Utilized Talent Organizations employ their staff for specific skills that they may have. These employees have other skills; it is wasteful not to take advantage of these skills as well. “It is only by capitalizing on employees’ creativity that organizations can eliminate the other seven wastes and continuously improve their performance.”

Eight Wastes of Healthcare Defects Overproduction Waiting Non-Utilized Skills Transportation Eight Wastes of Healthcare 5. Transportation Movement of product that does not add value Moving patients for testing or treatment Centralized storage Moving papers or documents Are all of these avoidable? What are possible causes?

Eight Wastes of Healthcare Defects Overproduction Waiting Non-Utilized Skills Transportation Inventory Eight Wastes of Healthcare 6. Inventory More materials, medications, or goods on hand than needed to serve patients right now Pharmacy stock Office supplies Patients in beds Clinical supplies Specimens awaiting analysis and release of results What are possible causes?

Eight Wastes of Healthcare Defects Overproduction Waiting Non-Utilized Skills Transportation Inventory Motion Eight Wastes of Healthcare 7. Motion Movement of people that does not add value Searching for charts Gathering supplies Searching for patients, equipment, staff, etc. What are possible causes?

Eight Wastes of Healthcare Defects Overproduction Waiting Non-Utilized Skills Transportation Inventory Motion Extra Processing Eight Wastes of Healthcare 8. Extra Processing Effort that adds no value from the patient’s viewpoint Paperwork Unnecessary procedures Retesting Multiple bed moves What are possible causes?

Revisit Wastes Code Carts? Mammography?

Improve Toast With Your Partner, Identify the Wastes and what Improvements you would make.

Getting Started……… Kaizen Toast……. Improved !!

Toast – Before and After Lessons? Take-Aways? Decisions, Delays, Wastes?

Toast Improvements Voice of the Customer (VOC) Have materials ready Adjust settings toaster (toast faster) Eliminate movement Move toaster closer to frig Stagger toasting vs. batch Soften butter Pre-slice butter Better organization Reduce walking Rearrange frig Rearrange cabinet

How Long Would it Take You to Change a Tire?

Map the Nascar https://www.youtube.com/watch?v=nQQbEfr9irE Bring post-it flipchart and markers. Have each table map what you observed.

Requirements: 7 people 2 tire changes 2 tire carriers Jack man Gas man Gas can catch can man 5 lugs Jump wall Run around the car Jump back over the wall Actions Remove lug nuts Remove tires Accept tires Give tires Jack up one side Jack down one side Jack up other side Jack down other side Run around car Put gas can in Hold gas cans Take gas cans out

Any Wastes in NASCAR? Are there any categories of waste? Would you do anything differently? How would you go about doing that? What Decisions are being made? When?

“Deciding on Lunch” Ever been to a restaurant and wondered why it took someone “so long” to order?

Welcome Back ! How many Lunch Decisions?

Process Map -> Value Stream Map

Value Stream Map Peanut Butter & Jelly Plant

Value Stream Map

Play the formula one clip. Discuss

Versions of a Process What It Actually Is ... What You Would Like It To Be ... What You Think It Is ... Future Current Current

Future State Mapping Now you’re going to create a future state map The future state map is a version of a process map that shows how things can, should, or will work in the future The future state map is created by making the current state map flow!

Future State Mapping How do we eliminate the waste we found in the current state map? Here are some strategies and techniques to eliminate and reduce waste for the most ideal future state

Start with the Current State Map

Flow Chart and Sheldon

Five Whys In order to eliminate waste, we have to figure out what’s causing it – we have to find its root cause The root cause is the fundamental cause for a problem, error, or defect in a system The source of waste is not always obvious – we have to look beneath the surface Hence, “root” cause To find the root cause of waste, we simply need to ask “why?”

Five Whys Five Whys (or 5 Whys) refers to the method of continuing to ask why in order to reach a root cause (or causes) of an error or problem (i.e., waste)

Five Whys Example: The National Park Service noticed that the Thomas Jefferson Memorial in Washington, D.C., was deteriorating faster than other monuments. Park services rangers investigated the problem with the five whys technique and came up with the following chain of causes.

Five Whys Why does the memorial deteriorate faster? Because it gets washed more frequently Why is it washed more frequently? Because it receives more bird droppings Why does it receive more bird droppings? Because more birds are attracted to the monument

Five Whys Why are more birds attracted to the monument? Because there are more fat spiders around the monument Why are there more fat spiders around the monument? Because there are tiny insects flying around the monument during evening hours Why more insects? Because the monument illumination attracts more insects

Five Whys Note the list could keep going on and on The birds could be treated as the root cause and the building could have been retreated with a water-resistant substance

Five Whys In this case, the park rangers decided to turn the lighting on one hour later, which resulted in a 90% reduction in bird droppings No “evening” No small insects No spiders No birds No bird droppings No excessive washing

Team Exercise 250 Jumping Jacks… Just kidding Pair with a partner for the next exercise. One person will interview the other person and ask about the case study. Be prepared to share your discussion.

Outpatient Surgery: Flow, 5S & Layout AHA Lean Io DaySurgClip 3.wmv AHA Lean Io DaySurgClip 3.wmv

Actual Case Study 20 story Plaza Hotel, New York, 2001. Soon after opening guests complained about elevator service. Building engineers were asked to enlarge cabs. Architect was brought in to add elevator to outside of building. Finally owner called professor from G.T. to examine the problem. Her first question was “what is the problem?”

Actual Case Study Management replied that “guests are waiting too long for elevators.” Professor asked: “are the guests waiting too long, or do they think they’re waiting to long?” Management: “what’s the difference?” An expert in ergonomics, the Professor tried an experiment. She installed a floor-to-ceiling mirror on the 20th floor next to the elevator and observed behavior. She noticed they became preoccupied with looking at themselves in the mirror and primping hair and clothes. This distraction alleviated ‘perceived’ slow service.

Define the Problem What is or isn’t occurring? Where in the process did it occur? Who does the problem affect? When did it occur and has it occurred before? What’s the magnitude of the problem? What are the key metrics?

Now we’ve identified some root causes of waste Future State Mapping Now we’ve identified some root causes of waste It’s time to attack!

Start with the Current State Map

Line Balance: Simple Example Overproduction causes other wastes 5 min 15 min 10 min 25 min       Constant overburden Must wait for Operation 2 Must wait for Operation 3

Line Balance: Simple Example Promotes One- Piece Flow Avoids Overburden Minimizes Wastes Reduces Variation 15 min 15 min 10 min 15 min         Redistribute Work

Airplane Production Simulation

Airplane Production Simulation Set up A Production line has four work stations Please set up your line as illustrated below Use a piece of tape to hold the sheets in place Materials Visual Work In Process Finished Product Worker 1 Worker 2 Worker 3 Worker 4 Space Work Station 1 Work Station 2 Work Station 3 Work Station 4 Work Space Work Space Work Space

What do These Have in Common?

Summarize Today What’s YOUR Value Add? What is “Lean” and why Should I Care? Two Applied Examples Hands on: Make Toast; NASCAR, Simulation SIPOC Current State Future State Doing It!

Surviving to Thriving: Assume that your organization gets a new CEO. During their first week, you have a chance encounter in the elevator. They introduce themselves and ask: “What do you do around here to provide value? What’s your Response? What’s your “Elevator Speech?’

KUDOS and THANKS to GAHFM ! GAHFM/ASHE Purpose Statement: Dedicated to Optimizing the Health Care Facilities