1. 1 A Quick Summary of Lean Thinking Do our work every day in a standard way that we created –Not just the way the work evolved! Be alert to things going wrong –They always do! Fix the problem now –For this patient or co-worker Find and fix the root causes of the problem –So it never happens again! Modified after Spear; Billi Solving problems: –1. Go and See –2. Ask why 5 times –3. Respect people Mr. Cho jbilli@umich.edu www.med.umich.edu/mqs www.lean.org

2. Michigan Quality System & Lean References Books: Womack J, Jones D. Lean Thinking. (An overview) Liker J. The Toyota Way. Liker J, Meier D. The Toyota Way Fieldbook. Shook J. Managing to Learn. (Best book on leadership in a lean organization and A3 use) Dennis P. Getting the Right Things Done. (Strategy deployment or hoshin kanri) Rother M, Shook J. Learning to See. (Value stream mapping) Baker M, Taylor I. Making Hospitals Work (2009 from Lean Enterprise Academy, UK) Sobek D, Smalley A. Understanding A3 Thinking. (Problem solving and A3 use) Marchwinski C, Shook J, eds. Lean Lexicon. Articles: Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med. 2006;1:191. Bush R. Reducing Waste in the US Healthcare System. JAMA 2007;297:871. Spear S. Fixing Health Care from the Inside, Today. HBR. 9/05. Spear S. Learning to Lead at Toyota. HBR 4/04 Spear S. Decoding the DNA of Toyota Production System. HBR 9/99 IHI Whitepaper: “Going Lean in Health Care” www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm Web: Michigan Quality System at UMHS: med.umich.edu/mqsmed.umich.edu/mqs Lean Enterprise Institute: www.lean.org webinars, books, meetings…www.lean.org Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htmwww.med.umich.edu/i/acs/ipe.htm Crossing the Quality Chasm (IOM): newton.nap.edu/catalog/10027.htmlnewton.nap.edu/catalog/10027.html Lean Enterprise Academy (UK): www.leanuk.orgwww.leanuk.org National Health Service (UK): www.networks.nhs.uk/networks.php?pid=211www.networks.nhs.uk/networks.php?pid=211 Wikipedia: en.wikipedia.org/wiki/Lean_manufacturingen.wikipedia.org/wiki/Lean_manufacturing

3. 3 Lean Thinking: Troubleshooting Guide 1.What is the problem? 2.Who owns the problem? 3.What is the plan? 4.What is the current status of the plan? How will it be monitored? 5.What worker training is needed? 6.How does this problem relate to the organization’s most important goals?* 7.What leader development is needed? Adapted from John Shook. Ask questions in order. *As a variation, 6 may be asked second. J Billi

4. 4 We know half the plan is wrong, we don’t know which half. We have to watch it unfold, detect normal from abnormal right now, and fix it. Traditional companies think of a plan - as a prediction of what will happen. Lean companies think of a plan - as an experiment to be conducted - to tell us what we didn’t know about the work –Paraphrase of Steven Spear, Fixing Healthcare… HBR’05 Plans are useless, planning is essential. (Eisenhower)

5. UMHS Chief Engineer System Med Surg Anes Nursing Pharm Med Surg Anes Nursing Pharm Modified from John Shook

6. Problem and PDCA Tools for different levels Key to success: The Mid-management and First Line Supervisory Level FRONT LINES SENIOR MANAGEMENT MIDDLE MANAGEMENT MUST PROVIDE VISION AND INCENTIVE MUST “DO” MUST LEAD THE ACTUAL OPERATIONAL CHANGE Likes the involvement Likes the results Requires tools and support to lead RoleImpact Problem: MUDA PDCA tool: (HK) Strategy deployment PDCA tool: A3 or VSM PDCA tool: Standardized Work Problem: MURA, MURI Problem: MURI, MURA Shook Muri – overburden Mura – uneven workload Muda – waste HK – hoshin kanri (strategy deployment)

7. 7 Lean Thinking is just… …simple and practical, consistently solving real problems in real time, at the source, at all levels. …not jumping to solutions. …fixing the problem now. …hard on the problem, easy on the people. …leader saying, “Follow me. Let’s look at it together”. …leading by being knowledgeable, fact-driven, expert negotiator, strong willed (for organization’s goals) yet flexible; leading by influence and persuasion. …not telling people exactly what to do. …having individual responsibility clear. John Shook

8. 8 How can we create (liberate) “18,000 problem solvers”? Help each worker take initiative to find and fix causes of problems he/she faces daily –This means each of us has two jobs: Do the work Improve the work Managers role: –Support improvement work (time, mentoring) –Align improvements so value flows to the customer Modified from J Shook

9. 9 Lean Thinking as the Scientific Method Applied to Daily Work Scientific Method Observation Hypothesis Intervention Results/reflection Revise hypothesis New intervention… Structured abstract Lean Thinking Go see, ask why, respect PlanP DoD Check/reflectC AdjustA Repeat PDCA cycle… A3 report, Value Stream Map

10. 10 Lean Thinking: Great Medical Care for Daily Work Great Medical Care Collect data personally, systematically, at the bedside (H&P) Impression and plans Tests and treatments Assess results & reflect Revise impression & plan Std write-up, presentation Lean Thinking Go see, ask why, respect people PlanP DoD Check/reflectC AdjustA Value Stream Map, A3 Tackle work problems with the rigor and systematic thinking we use for patient problems. Help every worker become an expert clinician doing an H & P on the problems they face.

11. Title: What we are talking about. Background Current Situation Goal Analysis Recommendations Plan Follow - up Of all our problems, why are we talking about this one? The “ugly story”… Historical/organizational/business context… Where do we stand? Trend chart, current state value stream map, current gap… What is the specific change you want to accomplish now? -What are the root causes of the problem? Fishbone, 5 Whys, Pareto -What requirements, constraints and alternatives need to be considered? What are your proposed countermeasures, strategies, alternatives? Include options (some needing no resources) What, Who, When? What activities will be required for implementation and who will be responsible for what and when? How we will know if the actions have the impact needed? What remaining issues can be anticipated? When/how will we follow up? Modified -Verble/Shook Date: Owner: An A3 Template

12. Just-in-TimeBuilt-in-Quality QUANTITY QUALITY MQS Error Proof Surface Problems Stop and Respond to Abnormalities Solve Problems at Root Cause Pacing by Demand Continuous Flow Pull Systems Work Force - Skilled, Capable, Flexible - Engaged, Motivated - Design Work, Solve Problems Technology and Equipment - Reliable, Tested - Serve People and Processes - Preventive Maintenance -TPM Materials - Materials Readiness - Supplier involvement Make Value Flow By Eliminating Errors and Waste STABILITY MQS Methods (All Mission) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, Park-Nicollet /jmk 04.09..07 Methods - Robust Processes - Organized Workplace (5S) - Visual Control Leveled Workload Continuous Improvement (P-D-C-A) and Learning Standardized Work Customer Defines Value Michigan Quality System Quality – Safety – Efficiency – Appropriateness – Service