Lean Strategies For Office Practices University of Michigan Medical Administrative Assistants Ann Arbor, Michigan Steve Mandell, MD University of Michigan Medical Director, MLABS September 9, 2008 Noon-1

“The work we do today is designed to deliver us the exact type and rate of defects we get everyday. Our processes are inherently defective.”

“Insanity is doing the same thing over and over again and expecting different results.” Albert Einstein

Telling people to “be more careful” doesn’t work!

Key Observation “No problem can be solved from the same level of consciousness that created it.” Albert Einstein “What got you here won’t get you there.” Marshall Goldsmith

Burning Platform for Change?

Justification Burning Platform Healthcare Environment Pressures Patient Safety / Ownership Reduced Reimbursement / Pay for Quality Work Processes Changing Automation / Barcodes / Computers / Software Growth Orientation Busier Population – Do More With Less Work Smarter Not Harder Business Culture Changing Lean Leaders Lean Hospitals Lean Labs

The Clinic Appointment Call the clinic, 3 voice prompts, on hold, leave message. Clerk calls back and sets a date next week. Arrive for the visit, check in, sit in waiting room. Called into the exam room, wait for doctor. Doctor sees you, saying she’s been waiting for you Diagnoses a URI, and BP is worse. Doctor prints antibiotic prescription, goes to the staffroom to get it. You are allergic to that drug. Doctor says to return in a week for the BP. Medical assistant does an EKG. At check out you ask the cost – clerk says they’ll bill you, No appointment is available next week. Pharmacist says your insurance prefers a different drug. Is there a problem?

Lean Outcomes Why Lean? Customers Improves service level and quality Reduces cost Workplace efficiency 40-50% reduction in cost of poor quality 30-60% reduction in inventory 20-40% reduction of floor space required 30-60% reduction in service turnaround time 20-50% improvement in productivity 20-30% improvement in equipment capacity Helps plan for growth Employees – THE KEY Higher morale; they are empowered to own and control their own processes Eliminates staffing shortages and overwork Incorporates employee safety and ergonomics Work is easier and makes sense!

What is Lean? Principles over 100 years old Named by a graduate student of an engineer. Lean focuses on eliminating waste in processes Lean is NOT about eliminating PEOPLE !!! Focuses on the Customer

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

Lean Perspective This glass is…..

LEAN - Toolkit Standardized Work Standardized Work Standardized Problem Solving Standardized Problem Solving Single Piece Flow Single Piece Flow Value Stream Mapping Value Stream Mapping Kaizen Kaizen Workload Leveling Workload Leveling 5S 5S Visual Factory Visual Factory Kanban Systems Kanban Systems Cellular Design Cellular Design Error Proofing (Poka Yoke) Error Proofing (Poka Yoke) Value from the patient’s perspective Value from the patient’s perspective Pass no defects Pass no defects Commitment to continuous learning / improvement Commitment to continuous learning / improvement Standardization is the road to improvement Standardization is the road to improvement Go see for yourself to understand Go see for yourself to understand Flow where you can Flow where you can Pull where you must Pull where you must You get what you expect and deserve what you tolerate You get what you expect and deserve what you tolerate & Philosophy TOOLSTOOLS P H IL O S O P H Y Quality TOOLSTOOLS P H IL O S O P H Y Quality What you are about to see are tools used to CHANGE PEOPLE by teaching them to identify waste, savings and opportunity.

CURRENT THINKING REQUIRED THINKING FORMS OF WASTE I I C C O O M M W W P P M M Correction Over Production Over Production Motion Material Movement Material Movement Waiting Inventory Processing WASTE Required Lean Thinking

Transfer Data Over processing: Redundant, unnecessary or ineffective processes; work that is giving the customer more than he/she is willing to pay for or doesn’t add value; testing not specifically requested; retesting not needed; requiring information that is not being used Examples: Transferring the same data from one form to another Unnecessary formatting Poor filing system requiring extra effort to locate items Too many required approvals for action to be taken Too many steps to complete a task Reports/memos published that are not understandable

Overproduction: Making more than is necessary or making things faster than downstream processes can handle; working ahead; cutting blank slides ahead of need; making more slides than needed Starting too early in the morning Process starting earlier than it needs to, with preliminary data, driving multiple updates/reworks as “real” data becomes available Reports that are not used or read Too many copies Redundant work performed by different functions Preparing paper copies of documents before final version Oral & written communication that is too wordy

Waiting: Any delay between when one process ends and the next begins. People waiting for machines or information. Information waiting on people or machines Meetings starting late Signature approvals Computer processing (searches, start-ups, etc.) Photocopier and fax machine processing

Transportation: Unnecessary handoffs or transfers. Unnecessary distances material or information travels Process involving multiple handoffs where one person/group could complete Creating temporary locations for items or information Stocking supplies far from their point-of-use Filing papers that will never be used again Organizing unneeded items

DO IT AGAIN!! Rework due to defects: Work done because of errors, mistakes or non-conformity to expectations in the previous process; missing or inaccurate information; patient complaints; work done in error Reworking something due to error or requirement changes Reprinting informal documents to get “perfect look” Starting tasks without knowing the end goal Reworking a presentation / report / memo over and over again Re-training of personnel

Inventory: More information, material, parts or products on hand than the customer needs right now. Purchasing excessive quantity of materials, supplies, equipment Keeping excessive supplies at desk Filed paperwork that is never used Computer files not used Too many meetings

Motion: Unnecessary movements of people, travel, walking, searching; Leaving work area to gather supplies. Extra clicks or keystrokes; reaching or re-sorting Copy machine locate a far distance from user Travel to meetings that you don’t really need to attend or that could be conducted via conference call / net meeting Searching for misplaced items or remotely located items Digging through stacks of paper Dialing phone numbers rather than using speed dial or distribution lists

Employee Initiative Not getting, considering or using ideas of the workforce to improve processes. “The solution to all our problems lies in the collective wisdom of our workforce.”

Misplaced Talent Poor utilization of specialized training, skills or pay grade of personnel; skill set to job task misfits

If there is time….. The Signature Game Part 1 – Baseline Assessment Part 2 – Lean Process