Housestaff Lean Academy Module 1: Lean Principles for Physicians Robert Martin, PsyD Performance Excellence UCLA Health

Where does this module fit into the curriculum? Module Description 1 Lean for Physicians (Important Concepts) 2 Focusing Improvement Projects/Efforts (Methods Overview) 3 Managing the Improvement Process (PDCA/A3) 4 Understanding the Current State (Process Mapping) 5 Identifying Waste in the Current State (5S, Waste, Standard Work) 6 Analyzing the Current State I (Organizing & Using Data) 7 Analyzing the Current State II (Organizing & Using Data) 8 Identifying Improvements & Actions (A3 Simulation) 9 Working as a Team (Frontline Empowerment & Engagement) 10 Understanding & Leading Change 11 Supporting Infrastructure (ADM, Huddles, A3/A4 Methodology)

Module 1 Agenda… Physician Process vs. Lean Process Lean Origins Important Concepts Post Questions Physician Process vs. Lean Process Origins Important Concepts Post Questions

Lean should be a familiar process for Physicians… Scenario – a patient arrives with a problem (clinic, ED, etc.). What is the Physician’s process? Physician Process Conduct Health & Physical Develop Initial Diagnosis Order Tests Analyze & Understand Data Develop Treatment Plan Try, Measure, Adjust It Lean Process Understand Scope (Charter) Develop Problem Statement Conduct Observations & Collect Data Develop Improvement Plan Notes Neither process jumps to solutions Both processes involve the patient Both processes use data Both processes use the Scientific Method QI & Lean call “The Scientific Method” PDCA (Plan-Do-Check Adjust/Act) Physician Process vs. Lean Process Lean Origins Important Concepts Post Questions

Lean is a modern term, but the origins are not… Jidoka (1902) Sakichi Toyoda invents device to detect broken threads in looms autonomously Just-in-Time (1937) Kiichiro Toyoda establishes Toyota, has the idea for JIT delivery of parts Takt Time German aircraft industry pioneers use takt time for synchronizing movement of aircraft Mitsubishi brings idea back to Japan where Toyota embraces it Venetian Arsenal 1 Warship/day Standardized Parts Use of canals to flow galleys to workers through assembly phases Deming Prize Japanese Union of Scientists and Engineers creates Deming Prize for statistical quality and PDCA American Meat Packers Conveyor belts to steadily remove carcasses past workers after meat removal Toyota > GM (2007) Toyota becomes the world’s largest automaker UCLA Operating System Established by Amir Rubin 1902- Present 1930s 1500s 1780s 1880s 1890s 1940s 1960s 1980s - 2009 1908-1926 Training Within Industry US Dept. of War introduces Job Instruction, Methods, Relations to teach millions of workers in war industries. Later introduced to Japan after the war Lean Research Toyota Production System (1982, Yasuhiro Monden) The Machine that Changed the World (1990, Womack, Jones, Roo) Lean Thinking (1996, Womak, Jones) Learning to See (1998, Rother and Shook) DNA of the Toyota Production System (1999, Spear and Bowen) The Toyota Way (2003, Liker) Shingo Research Award – Lean Hospitals (2009, Mark Graban) Scientific Management – Frederick Taylor Scientific study of tasks Employee development and training Managers use principles to plan work and workers perform tasks French Army Ordinance Concept of interchangeable parts for muskets (pre-cursor to high-volume flow production Henry Ford 1908 Model T modular car with truly interchangeable parts “there are no files in my factory” 1913 Flow Production Moving assembly line with processing feeder lines 1926 Mass Production with product variety 2009 Mark Graban Shingo Research Award Lean Hospitals Venetian Arsenal - http://en.wikipedia.org/wiki/Image:View_of_the_entrance_to_the_Arsenal_by_Canaletto%2C_1732.jpg Frederick Taylor - http://upload.wikimedia.org/wikipedia/commons/thumb/9/90/Frederick_Winslow_Taylor_crop.jpg/401px-Frederick_Winslow_Taylor_crop.jpg Frederick Taylor – was a laborer and machinist at midvale steel, focused on human component of efficiency (machines worked harder than humans Lilian introduced psychology to management studies, and Frank developed time/motion studies Ford – integrated people, machines, tooling, producs, and supply chain into a continuous flow Kiichiro Toyoda – took Toyoda loom works into auto manufacturing 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 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. 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. Physician Process vs. Lean Process Lean Origins Important Concepts Post Questions

Lean is based on a few important concepts… Value Waste Scientific Method (PDCA) Empowered Staff True North Alignment Lean is more than a collection of tools…. It is about creating a culture based on a few important concepts. There are more- but these are sufficient for now! Physician Process vs. Lean Process Origins Important Concepts Post Questions

Lean is based on a few important concepts… Value Waste Scientific Method (PDCA) Empowered Staff True North Alignment What is Value? What patients are willing to pay for Value must be discerned Lean systems produce what the patient values What do Patients Value? “Timely” Nursing & Physician Time Information to participate in choice A safe and effective Treatment Plan to become healthy, alleviate their pain and suffering, or restore function To be listened to; Trust and Privacy Physician Process vs. Lean Process Origins Important Concepts Post Questions

Lean is based on a few important concepts… Value Waste Scientific Method (PDCA) Empowered Staff True North Alignment Activity (Individual or self-organized) Spend a few minutes to discern what your patients value Group Discussion Physician Process vs. Lean Process Origins Important Concepts Post Questions

Lean is based on a few important concepts… Value Waste Scientific Method (PDCA) Empowered Staff True North Alignment Waste is: the opposite of what patients value… Waste hides in complex systems, and healthcare is complex! Waste must be understood so that it can be discovered and highlighted as abnormal Focus on minimizing or eliminating waste: Waiting for appointments, to be seen, etc Waiting for physician’s orders to be written Late/Missing callback for test results Clinicians who don’t listen, lack of trust, lack of privacy, etc. Administrative errors Clinical Errors Unnecessary documentation protocols & approvals Physician Process vs. Lean Process Origins Important Concepts Post Questions

Lean is based on a few important concepts… Value Waste Scientific Method (PDCA) Empowered Staff True North Alignment Activity (Individual or self-organized) Spend a few minutes to discern What your patients do NOT value (i.e. waste) Wasteful activities that inhibit your value production Group Discussion Physician Process vs. Lean Process Origins Important Concepts Post Questions

Lean is based on a few important concepts… Value Waste Scientific Method (PDCA) Empowered Staff True North Alignment The Scientific Method (PDCA) … Was discussed earlier! Is taught to staff so that they can Use data to solve problems Support value-added activities Minimize or eliminate waste Continuously improve Also known as Plan-Do-Check-Adjust/Act (We are going to have a whole class on this) Physician Process vs. Lean Process Origins Important Concepts Post Questions

Lean is based on a few important concepts… Value Waste Scientific Method (PDCA) Empowered Staff True North Alignment What does Empowered Staff mean? Why is it important? The best ideas from the smartest physicians often result in: Passive or Active resistance from staff Staff who feel disempowered and disengaged No change Staff must feel that they “Own” changes which will support value-added activities and minimize/eliminate waste They are experts in their areas and have great ideas on how to improve Leaders (Administration & Physician) must engage, empower, and align staff (We are going to have a whole class on this also!) Physician Process vs. Lean Process Origins Important Concepts Post Questions

Lean is based on a few important concepts… Value Waste Scientific Method (PDCA) Empowered Staff True North Alignment What would happen if all staff was trained in PDCA, engaged and empowered without alignment to the organization’s goals? Some improvement certainly! Likely much silo’d improvement which might sub optimize the system (i.e Schegistration might make their job easier and everyone else’s more difficult!) Improvement can occur at all levels, but always in consideration of linked-activities in the organization What is True North Alignment? A vision or ideal from Leadership that can “rally” the case for change (should be aligned or supports the hospital or SoM vision) “Minimally sufficient” strategies and initiatives (3 to 5, not 25 to 75) to focus staff effort The most ideal strategies include participation from all layers of management and staff (i.e. catchball) to ensure that they are realistic Physician Process vs. Lean Process Origins Important Concepts Post Questions

Post Questions & Next Module Preview… Module Description 1 Lean for Physicians (Important Concepts) 2 Focusing Improvement Projects/Efforts (Methods Overview) 3 Managing the Improvement Process (PDCA/A3) 4 Understanding the Current State (Process Mapping) 5 Identifying Waste in the Current State (5S, Waste, Standard Work) 6 Analyzing the Current State I (Organizing & Using Data) 7 Analyzing the Current State II (Organizing & Using Data) 8 Identifying Improvements & Actions (A3 Simulation) 9 Working as a Team (Frontline Empowerment & Engagement) 10 Understanding & Leading Change 11 Supporting Infrastructure (ADM, Huddles, A3/A4 Methodology) Physician Process vs. Lean Process Origins Important Concepts Post Questions