Lean Yellow Belt Training

Lean Yellow Belt Training
VA Pittsburgh Healthcare System Veterans Engineering Resource Center (VERC) & Office of Systems Redesign (OSR) Last Updated: June 2012

Introductions Who are you? Why are you here?
What do you want to learn?

Overview of Training Objectives
Learn Process Improvement Understand Lean principles Use strong problem solving methodology VA-TAMMCS Participate in hands on learning activities

Insanity: doing the same thing over and over again and expecting different results.
We are here to change the way you think!

Process Improvement Throughout Time
Measured Work Taylor, Gilbreaths, etc… Toyota Production System Total Quality Management Plan Do Check Act (Deming) Six Sigma Lean

Systems The term ‘System ‘ is frequently used in professional conversation What does it mean ? What system characteristics are important to understand from a process improvement view?

Systems System: A collection of elements that function together to achieve a desired goal Key issue: functions as a ‘Whole’ Systems thinking : The attempt to understand and describe the system as a whole by analyzing not just the individual components , but by understanding the complex structure of interrelationships among the components Systems thinking is often counter-intuitive

Process Orientation Systems Thinking – understanding the interconnections and pathways that define the system Process Orientation – system resources and activities are organized around processes rather than functional tasks Connections are complex in functionally oriented operations making systems thinking difficult if not impossible Process orientation facilitates systems thinking by placing emphasis on connections (handoffs and flow)

What is Lean? LEAN: Eliminates waste to create more value with less work. Proven program derived mostly from the Toyota Production System (TPS) used to improve work processes. Allow us to improve our organizational culture. Enable teams to define problems and create solutions.

Lean Improvement Model
Goals: Define the problem Evaluate current processes related to the project focus areas Utilize Lean tools and methodologies to identify operational barriers and process failure modes Apply Lean tools to improve systems Implement control strategies to insure long term sustainability of process improvements and spread adoption Team/AIM MAP Measure Recommended Narrative: Change Sustain

What is Lean? “Lean provides a way to specify value, line up value creating actions in the best sequence, conduct these activities without interruption whenever someone requests them, and perform them more and more effectively.” -from Lean Thinking, by James Womack and Daniel Jones (1996) Toyota Production System – aimed at smoothing flow and eliminating waste.

Lean Concepts Value Identify and eliminate waste
Value is determined by the “end customer” – the patient Identify and eliminate waste Anything that does not add value from the patient’s perspective Value flows without interruption Identify ideal patient experience – streamline process and eliminate waste to achieve Allow customer to “pull” value from process Available when they want it – one piece flow Continuous pursuit of perfection Reliable and sustainable systems design (Must know who the customer is…)

What is Waste? The basis for Lean thinking is systematically eliminating or minimizing waste in a process or system Waste is defined as any resource expenditure that Does Not ADD VALUE Value is an activity or expenditure of resource directly contributing to patient care

Eliminating Waste Start Step 1 WASTE WASTE Step 2 Finish Total Cycle Time Start Step 1 Step 2 Finish Total Cycle Time Lean is a systems redesign methodology that shortens the time between start and finish of any given process by eliminating sources of waste.

VA Systems Redesign System Redesign provides a team approach for VA staff to plan, redesign, map, measure and integrate processes and systems to deliver real-time improvements in VA Health care systems. System Redesign expands on the concepts established in Advance Clinic Access to broaden the scope to include all clinical and administrative processes.

Systems Redesign: Goals
Empower the workforce to make improvements Improve Access To Healthcare Improve Work Processes Eliminate Waste Focus improvement on customer needs Evaluate centralization vs. decentralization of functions

VA - TAMMCS Following a systematic process greatly increases
the chances for successful implementation of systems redesign. Team based approach. To that end, VHA offers VA-TAMMCS, as a SOLID framework for success. 17

VA-TAMMCS Vision Analysis Team Aim Map Measure Change Sustain / Spread
Role of leadership at the outset of process improvement and identifying the project's mission. Analysis The analysis portion of the framework covers establishing priorities to identify the most important areas on which to focus improvement efforts and in evaluating performance. Team Teams work best when they have clear sponsorship, consist of front-line staff, are passionate around improvement, possess a facilitator, and are unified around a common aim or goal. Aim An aim is an explicit statement summarizing what the team hopes to achieve during the project. Map Mapping serves to identify a process clearly by clarifying the start, end, and key decision points. Measure Measurement is important in order to know if changes teams make are really an improvement and fulfill our obligation to manage by fact not feel. Change All improvement requires making changes, but not all changes result in improvement. Sustain / Spread Improvements that can be sustained will continue to provide value to veterans and employees who serve them.

“Tools” Used In Systems Redesign
Basic Tools: Lean Smooth flow Eliminate waste Rapid cycle change PDSA Small tests of change Staff engagement Theory of constraints Efficiency Throughput Advanced Clinical Access Advanced Tools: Six sigma Reliability Queuing theory Matching supply and demand Human factors engineering Error proofing Simulations Modeling complex solutions

VA-TAMMCS Framework Value Stream Mapping A3 Worksheet

Basic Lean Exercise

Defining the Problem What are you trying to fix?
How do you know you need to fix it? Who are the best candidates to fix it?

Theory of Constraints Definitions
Flow: The rate at which patients or item related to patient care (paperwork, materials, and information) are able to progress through the patient treatment processes. Constraint: Any process step that limits the overall patient treatment flow Missing or incomplete information Materials or supplies Limited staffing capacity Constraints are also referred to as ‘bottlenecks’.

Theory of Constraints (TOC) Developed by Eli Goldratt to describe the impact of process constraints on flow through a system or process Process and system throughput cannot be increased unless the throughput is increased at the bottleneck within the system.

Theory Of Constraints 5 Steps To Focus Improvement at a Constraint
Identify the constraint Physical Constraints Policy Constraints Decide how to exploit the constraint How will the constraint be eliminated or managed? Subordinate everything else in the process to the constraint Adjust the rest of the system to enable the constraint to operate effectively Elevate the constraint Invest time, energy, and money to eliminate the constraint Go back to Step 1, but beware of inertia. Source: H. William Dettmer, Goldratt’s Theory of Constraints: A Systems Approach to Continuous Improvement, ASQC Quality Press, 1997, p. 11.

Voice of the Customer Voice of the customer (VOC)
A term used to describe the in-depth process of capturing a customer's expectations, preferences and aversions. VOC is: Market research technique that produces a detailed set of customer wants and needs, organized into a hierarchical structure, and then prioritized in terms of relative importance and satisfaction with current alternatives. Determine what the customer thinks of your product or service

Value Stream Map A Value Stream Map is used to visually represent the current state of the process. The Value Stream Map includes information about processing steps, processing times, wait times and # of items within the process. Information and material flow may be added to provide a complete snapshot of the process. Recommended Narrative: 28

Value Stream Symbols 6 Process Pull System Flow Box Data Box
Information Flow Physical Flow Physician/ Service Chief Electronic Information Flow Hospital 6 Queue/ Inventory Information/Computer System

Value Stream Map Steps to creating a Value Stream Map:
Flow Chart the Process at a very high level (5-7 processing steps) Add Suppliers and Customers Collect/Add information about process times, wait times and queues. Recommended Narrative: 30

Value Stream Map ?? Physician ?? Physician Cancer Diagnosis Work-up
and Surgery Chemo- Therapy/ Radiation Therapy Screening Surveillance Recommended Narrative: 31

Key Value Stream Metrics: Time
Process time (PT) The time that is actually takes to perform the work, if the work can be performed uninterrupted. a.k.a ‘Touch Time’ (physical process) & ‘Think Time’ (analytical process) Cycle Time (CT) The total elapsed time from entry into a processing step until exit from that step and/or ready to go to the next processing step. a.k.a – cycle time, turnaround time Total Cycle Time: The total time that it takes to go from entry to exit within a system

Cycle Time vs. Process Time
Patient Entry into Process step Patient Exit out of Process step Cycle Time = Process Time + Wait Time (all blue) (all red)

Key Metric: Reliability
% Complete and Accurate (%CA) % of the time that the downstream customer can perform the processing step without having to: Correct information or materials Add information or materials Clarify information

Value Stream Map ?? Physician ?? Physician Cancer Diagnosis Work-up
and Surgery Chemo- Therapy/ Radiation Therapy Screening Surveillance Recommended Narrative: Scheduled %CA = % of patients that specific treatment(s) were documented within the step Occurred Results Documented 35

Value Stream Map Primary Care Physician ?? Physician Cancer Diagnosis
Work-up and Surgery Chemo- Therapy/ Radiation Therapy Screening Colonoscopy Surveillance Colonoscopy PT=2 hrs Recommended Narrative: PT=4 hrs PT= 4 hrs PT=8 days WT=52 days PT=2 hrs WT=10 hrs WT=10 hrs WT= 44 hrs WT=4 hrs %CA=60% %CA=90% %CA=20% %CA=50% %CA=80% 5 days 27 days 81 days 90 days .5 days 2 days .3 days 60 days .5 days Wait Time Between Steps 36

Value Stream Map Primary Care Physician ?? Physician Cancer Diagnosis
Work-up and Surgery Chemo- Therapy/ Radiation Therapy Screening Colonoscopy Surveillance Colonoscopy PT=2 hrs Recommended Narrative: PT=4 hrs PT= 4 hrs PT=8 days WT=52 days PT=2 hrs WT=10 hrs WT=10 hrs WT= 44 hrs WT=4 hrs %CA=60% %CA=90% %CA=20% %CA=50% %CA=80% 5 days 27 days 81 days 90 days .5 days 2 days .3 days 60 days .5 days Cycle Time through each step 37

Value Stream Map Primary Care Physician ?? Physician Screening
Colonoscopy Cancer Diagnosis Work-up and Surgery Chemo- Therapy/ Radiation Therapy Surveillance Colonoscopy PT=2 hrs Recommended Narrative: PT=4 hrs PT= 4 hrs PT=8 days WT=52 days PT=2 hrs WT=10 hrs WT=10 hrs WT= 44 hrs WT=4 hrs %CA=60% %CA=90% %CA=20% %CA=50% %CA=80% 5 days 27 days 81 days 90 days .5 days 2 days .25 days 60 days .5 days Total Cycle Time = 266 days 38

Create a Value Stream Map and then ID the constraints
ACTIVITY Create a Value Stream Map and then ID the constraints

ACTIVITY

Successful Teams Need Senior Support, Front Line and staff empowered to implement change Need Coach and Team Leader Need Team Facilitator Define roles and rules Have a schedule and plan Meet frequently

Developing a Team Charter
Project Charter States the scope, objectives and participants Defines the team membership Provides a preliminary description of roles and responsibilities Identifies the main stakeholders Serves as a reference for team members and leadership It is a working document…

AIM = S.M.A.R.T. Goals Specific Measurable (time, $, units, or %)
Achievable Realistic Timely Example: The number of routine work orders greater than 30 days in the AC shop at UD will be no more than 50 by September 1, 2009.

ACTIVITY Review Team Charter Team Problem Statement AIM(s)

Plan for Achieving Results:
Facility Name: Date Chartered: Service Line / Department: Submitted By: Project Title: Project Start Date: Project End Date: Team Member Name: Phone Title Position within Team Project Owner Project Facilitator SR Point of Contact Member Problem Statement: (Problem & Plan) Describe the problem, opportunity, or objective in concise, measurable terms. Include a summary of the problem and impact (a.k.a. PAIN). Problem: Linkage to Strategic Priorities: Goal/Aim Statement: (SMART – Specific, Measurable, Attainable, Relevant, Timely) Describe the team’s improvement objective (What is the team GOAL) Begin with the words “reduce, increase, eliminate, control” AIM #1: Measure: What will you be measuring? Where will the data come from? (ie. Data Warehouse, VISTA, CPRS, Observations, etc.) How will you collect the data? (Manual collection, Automated Data Warehouse report, etc) What is your current baseline data? Project Scope: Where does the process under investigation start? Where does this process stop? What is inside of the project scope? What is outside of the project scope? Deliverables: What end result(s) do you expect to achieve from this project? How will you know that any changes have resulted in improvements? Plan for Achieving Results:

Process Flow Map A flow map is a graphical representation of a process. It represents the entire process from start to finish. Mapping a process out helps you clarify your understanding of the process, and helps you think about where the process can be improved. The team then identifies value added and non-value added tasks.

Process Flow Map Why map out the process?
Sometimes there are surprises Problem areas Unnecessary steps Rework Group consensus on how the process really works: a meeting of the minds Understand the present before you define the future Decide where data can be collected and investigated

Steps in Creating Flow Map
Map the process “as is” (not what you want it to be) Identify scope of process to flow map Write each step on a Post It note Each color Post It can depict a different Service Line, Department, position, or owner involved in the process Identify Internal and External Customers Internal = other employees, Service Lines, etc… External = patients, vendors, etc…

Steps in Creating Flow Map
Plan to use a different colored post-it for each department doing the task No open-ended tasks (all paths must terminate) Use decision symbol for two choices or yes/no decisions Use brackets with multiple lines if there are more than two choices or paths Use pencil for connectors at first Make copy of each document used in the process and tape to bottom of map Once you are satisfied that it is finished and correct, go over connectors with sharpie Make critical notes on map

Questions to ask when creating Process Flow Map
Maintain process perspective What, where, how, role – not why Does this step work like this all the time? Do some people do things differently than others? Where does the information / material come from? How does the material or information get into the process? Who makes the decision? What happens if the decision is “yes” What happens if the decision is “no” What test or checks are done? What happens if the test or check fails?

Situations to consider when creating Flow Map
Flow of people, information, equipment Inventory or supply problems Unnecessary motion Waiting / delays The right amount of information at any step Work that may not be necessary from the customer’s standpoint Errors

Process Flow Map Symbols
Process: Show a Process or action step. Decision Point: Usually two options (yes/no, pass/fail, etc). Terminators: Shows the start and stop points in a process. Document: Step that produces a document. Storage of Information: Electronic storage of data. Connector: Shows a jump from one point in the process to another.

Example of Process Flow Map: VAPHS Work Order Process

Example of Process Flow Map

Swim Lane Diagrams

Metrics Based Process Map
Type of process map depicting process flow, process durations and staff members and/or departments involved in processing steps. More detailed representation of a sub-process within a Value Stream Map, often used to investigate specific sub-processes

Metrics Based Process Map
Steps to creating a MBPM Review the process under investigation and establish boundaries as outlined in the project charter. Using brainstorming techniques, identify steps in the process as well as personnel/departments involved in the process. Arrange the processing steps in order, align to resources. Validate the process flow either by showing the process map to a non-team member involved in the process, or by physically observing the process.

Out-Patient Registration Processes
Yes Clerk Requests ID and Medical Card Patient Arrives At Registration Desk Registration Clerk Patient Pre-registered? No Patient Assigned To Registrar Wait for Registrar Registrar Enters patient information Registrar Wait for Escort Patient escorted to radiology Escort PT = 1 min WT =12 min %CAC=30% PT = 2 min WT =2 min PT = 5 min WT =13 min %CAC=10% PT = 1 min WT =12 min %CAC=30%

Fishbone: Cause & Effect

Create: - Process Flow Map
ACTIVITY Create: - Process Flow Map

Lean Proven process improvement method that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful Focuses on the continual reduction of non-value added activities Directly improves speed and productivity

8 Sources of Waste The Eight Forms of Waste Defects Overproduction
Waiting Not Utilizing Employees Transportation Inventory Motion Extra Processing

Defects Hospital-acquired illness Wrong-site surgeries
Medication errors Foreign objects remaining in patient after surgery Problem orders Misfiling documents Dealing with service complaints Mistakes resulting from miscommunication Illegible, handwritten information Collection of incorrect patient information

Overproduction Too many meal trays delivered
Asking the patient the same questions multiple times Large supply of forms Extra floor space utilized Unnecessary carbon copying Batch printing patient labels

Waiting Idle machines/people Large waiting rooms
Patients waiting to see physician, nurse, etc. Waiting on the phone to schedule patients Early admissions for procedures later in the day Waiting for internal transport between departments

Not Utilizing Human Potential
Not using people’s mental, creative, and physical abilities Staff not involved in redesigning processes in their workplace Workarounds Nurses and Doctors spending time locating equipment and supplies Staff rework due to system failures

Transportation Poor workplace lay-out for patient services
Carrying files from location to location Moving equipment in and out of procedure or operation room Patient transportation

Inventory and Inspection
Office supplies stored in hallways Charge slips piled up to be dictated Physician orders building up to be entered Unnecessary instruments contained in operating kits Multiple quality control checks Much rework

Motion Leaving patient rooms to get supplies or record
document care provided Large reach/walk distance Documenting in more than one place Nurse checking electronic medication record to see if order entry is completed

Extra Processing Multiple signature requirements Extra copies of forms
Multiple information systems entries Printing hard copy of report when digital is sufficient Multiple steps to get pre-approval for urgent treatments Overstocking inventory

Non-Value Added

Identify Non-Value Added Steps In Flow Map
Identify each step with the following: Red Tag = Non-Value added process Yellow Tag = A required process, but not value added Green Tag = Value added to customer

Activity Evaluate each step in the Flow Map with either a red, yellow, or green dot

“If you keep doing what you are doing, you will keep getting what you’ve gotten.”
As you begin the process of designing the futures state keep in mind…. Unknown author, heard it on WIBC Radio morning show, Indianapolis, Indiana

Designing the Ideal State
Eliminating all waste, barriers, obstacles, variation, and non-value adding necessary, and non-value adding unnecessary process steps in the current state The ideal state is designed in the pursuit of perfection A constant goal Stretch exercise

Example Ideal State Map
LP draws blood from patient Core lab tests blood sample MD determines need for blood draw

Future State Mapping

Designing the Future State
The future state is designed to the best known process – pursuit of perfection Consistently brings value (what the patient needs) to the patient when they need it (pull) Requires elimination or minimizing of as many non-value adding process steps as possible Must be achievable Continuous improvement required

Detailed Process Map – Current State

Process Map: Future State
After the team identified the value adding steps these are the steps they were left with. This is what the team was striving for – the future state in this case was the ideal state. Future State With Elimination of Non-value Adding Steps = 6 Steps 92% of the process steps were identified as non-value adding

Create a Future State Map
Activity Create a Future State Map

Gap Analysis: Future State vs. Current
What is stopping us from reaching the future state? Non-value added process steps The eight forms of waste Bottlenecks/backups Process variations J

Activity A rapid generation of ideas by all group participants. AVOID DISCUSSION! AVOID SOLUTIONS! Remember team dynamic rules Write down as many ideas as possible on the star-shaped post-its of the waste, bottlenecks, obstacles, barriers, variation present in the current state Place “Star Shaped Post-It” on the current state map where they occur

Prioritizing Opportunity
Affinity Diagram A simple process of identifying and grouping like information Powerful tool to use when working as a group The Process Brainstorm ideas (completed earlier) Group like ideas You have already brainstormed the idea

Affinity Diagram Example

Prioritizing Opportunities Multi-voting
Multi-voting is used to prioritize greatest to least Each participant has 10 points Each participant votes on the opportunities with their points Each participant can use all the points on one opportunity or spread it across multiple opportunities Point totals will be added to determine priorities

1) Complete Affinity Diagram 2) Vote
Activity 1) Complete Affinity Diagram 2) Vote

Einstein on Data Collection
“Not everything that counts can be counted, and not everything that can be counted counts." -- Albert Einstein

Sources of Data: IT System Manual Collection
VSSC (VHS Support Service Center) Data Warehouse CPRS (Computerized Patient Record System) VistA etc… Manual Collection

Check Sheet Description It measures frequency by unit of time
A check sheet is a structured, prepared form for collecting and analyzing data. This is a generic tool that can be adapted for a wide variety of purposes. Check Sheet Procedure Decide what event or problem will be observed. Develop operational definitions. Decide when data will be collected and for how long. Design the form. Set it up so that data can be recorded simply by making check marks or Xs or similar symbols and so that data do not have to be recopied for analysis. Test the check sheet for a short trial period to be sure it collects the appropriate data and is easy to use. Each time the targeted event or problem occurs, record data on the check sheet.

Process Observation Worksheet
Process Observation Procedure List the steps from the process map in sequential order. Identify the specific activities, decisions, motion and transport steps Observe the process and collect information on process step durations, wait times, and travel distances. Perform multiple observations in order to determine the range of variation in processing steps and times.

Spaghetti Diagram Helps to visually identify wasteful steps

Spaghetti Diagram: Office Layout and Traffic Flow Acquisitions and Contracting Lean Project Team
Relocated Offices Eliminated 36 Hrs/Yr from AO task by moving printer Eliminated 2 Hrs/Yr from Lead PA task by moving printer Original After 5S

Why Develop Measures of Success?
This answers the following question: How do you know that you made an improvement? It allows for continuous monitoring (Sustaining)

ACTIVITY Determine Measurements:
(Go Back to Project Charter and complete) Measure Project Scope Deliverables

Change Types of Change External (Imposed by outside force or condition) Planned Change Our Topic of Interest Going from a current state or condition to a proposed state or condition Change management requires strategic thinking, planning, decisive implementation and stakeholder consultation

Change At this point in the improvement process your team has:
Defined the current process state Analyzed the current process and determined causes of waste and ineffectiveness Designed a desired future state Now what?

Change Designing an implementation plan
It must be thoughtful and specific The following elements are essential: What Who When Sequence Duration How Resources needed

Change Thoughts on Planning:
“If you don’t know where you are going, any road will get you there” Lewis Carroll “If you don’t know where you are going you will probably end up somewhere else” There is no substitute for a well thought out specific objective

Change Root Cause Analysis Aims improvement at root cause
Avoids addressing symptoms Performed systematically Continuous improvement tool Systems focused The “5 Why’s” not the “5 Who’s”

The Washington Monument is deteriorating
5 Why Example The Washington Monument is deteriorating Why? The use of harsh chemicals on the surface. To clean up after the pigeons. Pigeons eat spiders and there are a lot of spiders here. Spiders eat gnats and there are a lot of gnats here. Gnats are attracted to the display lights at dusk. We never change the timers during different seasons. SOLUTION: Program the lights to come on later.

5 Why Example Multiple needle sticks are occurring with piggyback intravenous medications Why? Staff are recapping the needles. To safely unscrew the needle from the IV tubing so the needle can be placed in the sharps container without getting stuck by the needle. All needles are to be disposed of by placing them in the sharps container. To avoid who ever is handling the trash from being stuck by a needle. SOLUTION: Needleless intravenous medication administration system

Identifying Solutions
ACTIVITY Identifying Solutions Brainstorming technique: Each participant to write down as many SOLUTIONS as possible There are NO bad ideas No gate keeping or filtering Individual activity (No talking, just write)

(Focus on these as much as you can) (Complex/Time Consuming)
Activity: Solution Impact/Effort Grid Quick Wins (Focus on these as much as you can) (LH) EFFORT High IMPACT Major Projects (Complex/Time Consuming) (HH) Thankless Tasks (Time Wasters) (HL) Highest Priority Fill Ins (Quick Fix) (LL) Low Take each solution and place it in the quadrant that best reflects the impact expected and the effort it would require. - Establish priority by using Multi-voting technique if needed.

Integrated Lean Exercise

Change PDSA (Plan, Do, Study, Act) Small scale experimental in nature
Improve your solutions Improve implementation skills Uncover barriers that need to be addressed Elevate organizational receptivity to change Pilots Sometimes used interchangeably with PDSA Generally larger in scope Implemented to demonstrate proof of concept

Change On PDSA’S and Pilots
“proven results speak loudly” “Creating initial success sets the table for long term success” Demonstrating success is a critical element of successful implementation Failure is an educational experience

PDSA Cycle Plan the improvement: Remember: it’s a cycle
Select a process to improve Flow Chart the process Write aims (goals) Develop an action plan to track improvements Remember: it’s a cycle

Does placing sanitizer outside room increase hand-sanitizing?
PDSA Duct Tape to wall outside three rooms Does placing sanitizer outside room increase hand-sanitizing?

Does having a place to put things down increase hand-sanitizing?
PDSA Place table outside door with sign (ignore clutter) Does having a place to put things down increase hand-sanitizing?

Do color-coded labels help to differentiate lotion from sanitizer?
PDSA Do color-coded labels help to differentiate lotion from sanitizer?

PDSA Cycle Act on the knowledge:
Adapt (Adjust): Improve the change and continue testing plan (additional PDSA cycles) Adopt: Select changes to implement on a larger scale and develop an implementation plan and plan for sustainability Abandon: Discard this change idea and try a different one

Changes That Result in Improvement
Use of the Rapid Cycle Changes That Result in Improvement A P S D DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change

Rapid Cycle Change Specific Test Cycles Daily DC Planning
Discharge appts. Doc. DC plan Day 1 Inpt. priority x-ray studies

“It’s better to get a little better today than to wait months for perfection”
– Brent Seeley, Seattle 119

PDSA: Plan, Do, Study, Act

ACTIVITY Develop PDSA’s

Implementing Change A critical element for success
Stake holders and process owners must be involved in the entire problem solving process; with special emphasis on development and implementation of solutions Ignoring this will generate failure The best change is what people think they did themselves Lao Tzu

Implementing Change Educate and Communicate Relentlessly
Stake holders and those effected by proposed change Include organizational leaders: Develop sponsorship Create a sense of urgency Uncover leadership personalities and give them special focus They can exert positive or negative influence

Implementing Change Sustaining change requires fundamental shifts in mind set and behavior by the process owners Process owners must believe the change benefits them WIIFM (What’s in it for me) “People cannot be expected to support and care for things they do not own”

5 S SORT Eliminating unnecessary items from the workplace
Team tags everything as follows: Red Tag (Never used), Yellow Tag (Not often), Green Tag (Critical) SET IN ORDER Focuses on efficient and effective storage methods A place for everything and everything in its place SHINE Thoroughly clean the work area STANDARDIZE Concentrate on standardizing best practice in your work area SUSTAIN Make 5S a part of daily activity so it becomes part of culture Continue 5S of all areas within the process

How to get started with 5-S
Select team (appropriate size for the project) Including the “owner” of space, their supervisor, and project team member. Determine Area for 5-S Conduct walkthrough of Area Detail all problems and supplies needed for the 5-S Start a timeline for the 5-S Note: Begin and End 5-S with photo timeline

5-S Examples Before: After:

UD Warehouse Before: After:
5-S Examples UD Warehouse Before: After:

5S Examples: ED Reception Desk
Before After Placed all critical numbers in one location Labeled drawer that stored all commonly used forms

Pittsburgh VA – Equipment Room
BEFORE Benefits Clean equipment = pathogen vector Saves frustration, searching Freed up $20K-worth of unused equipment for use elsewhere AFTER Whiteboard indicates location

Benefits of 5-S Improve safety Decrease down time
Raise employee morale Identify problems more quickly Develop control through visibility

Action Item List Develop a Action Plan that defines who is going to do what, and by when… Monday Week 1 Month 1 Quarter 1 Etc…

Example Action Item List

Create Action Item List
Team Assignment Create Action Item List Issues Action Item Benefit Implement Owner Start Completion Status High / Low Easy / Diff. Date

What is an Error? “We make errors when our actions do not agree with our intentions even though we had the capability for completing the intended action.” - Institute for Healthcare Improvement

Poka-yoke (mistake-proofing)
“Any task that requires human intervention and judgment to prevent mistakes is a mistake waiting to happen.” Removing the possibility of human error Often used in combination with visual controls Examples: Decision support/clinical reminders within the EHR system O2 line fittings

Examples

Introduction to Problem Solving
Hierarchy of Controls Eliminating the Causes of Problems Levels of Control Physically Changing the Workplace Warnings that Problems Exist Building Information into the Workplace Training and Standards

A3 Provides step by step direction to problem solving or improving a process Is also effective in addressing continuous improvement opportunities Clear concise one page overview Consolidates large amounts of information in understandable format using visual display Challenges user to use as little verbiage as possible Multi-purpose tool Presenting project proposal or recommendations Sharing and reviewing progress Final report and Storyboard

VA Hospital Date: Author: 1. TEAM/AIM: Define the problem
3. MEASURE: Identify operational barriers and failure modes in the current process 4. CHANGE: Improve systems Create a future state process by applying Lean techniques to eliminate operational barriers and failure modes 2. MAP: Evaluate current state 5. SUSTAIN: Sustainability strategy Create a process control strategy – a strategy for insuring long term sustainability and spread adoption

Fill in the Problem Definition Fill in the Current State Map
VA Hospital Date: Author: 1. TEAM/AIM: Define the problem 3. MEASURE: Identify operational barriers and failure modes in the current process What is the standard or desired level of performance? What is the current level of performance? What is the current performance gap? What is the extent of the impact/pain? Fill in the Problem Definition Add Root Causes for Primary Barriers/Waste Quantify Value, Non-value and Waste in Current State Current State Time /Distance • sec. total time for routine orders • sec. total time for STAT orders • total steps traveled VA: Steps NVAN : Steps NVAU : Steps Current State Value Add Primary Barriers/ Waste 4. CHANGE: Improve systems Create a future state process by applying Lean techniques to eliminate operational barriers and failure modes 2. MAP: Evaluate current state Fill in the Future State Map Describe the current state for your assigned scenario High level mapping of current state Summarize current state with a few brief concise statements if needed Fill in the Current State Map Assign Each Step With a Value Using Value Legend Add Time and Distance Required by Each Step Quantify Value and Non-value in Future State VA: Steps NVAN : Steps NVAU : Steps Future State Value Future State Time/Distance • sec. total time for routine orders • sec. total time for STAT orders • total steps traveled Assign Each Step With a Value Using the Color-Coded Legend We will be breaking you into __ (#) of teams. Each team will be assigned a case scenario which they will use to apply each step of the A 3/TAMMCS over the next 2 days. Move into the teams now. Quantify Impact of Improvements Value Adding (VA) Non-Value Adding Nec. (NVAN) Non-Value Adding Unnec. (NVAU) Value Legend % ↓ process steps % ↓ distance traveled % ↓ required time % ↓ NVAN and NVAU steps 5. SUSTAIN: Sustainability strategy Create a process control strategy – a strategy for insuring long term sustainability and spread adoption Add Time and Distance Required by Each Process Step to the Current State Map as Applicable Give high level summary of sustainability and spread plan

Spread/Diffusion Background
Some innovations spread like wildfire while others with great difficulty iPods vs. Zune (Microsoft version) Hospitalists EMR (Electronic Medical Record) Innovations to improve quality of care Klotz, K

Spread/Diffusion Barriers
Difficult to change old habits Resistance in changing longstanding routines Perceived need to work harder What is the organization’s culture? Klotz, K

Diffusion of Innovation Theory
How innovations spread throughout cultures How, Why, What rate Highly studied Used in product marketing, public health Based on work by Everett Rodgers

Diffusion Curve

Adoption Process

Diffusion Rate Factors
Innovation attributes Relative advantage (Cost/Benefit) Compatibility, Complexity / Simplicity Trialability, Observability Communication The “Early Adopter” Opinion Leader Subjective perceptions influence diffusion

Change Personalities (Dance)

Concluding Remarks “The significant problems we have cannot be solved by the same level of thinking with which we created them.” “Vision without action is merely a dream. Action without vision just passes the time. Vision with action can change the world!” Joel Barker

Remember Keep an open mind
Set S.M.A.R.T goals (specific, measurable, attainable, realistic and timely) Develop a project timeline Commit to an action plan Engage leadership support Involve and educate end-users and staff who do the work Spread the program to other departments Recognition for success Schedule a weekly team meeting

Certification Certification can be obtained in two ways:
Free certification through VA Pay approximately $275 for Purdue University Certification Both Require: Completed A3 Participation in improvement project Passing a certification test

For all your participation and hard work!
We look forward to your results!!!

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Lean Yellow Belt Training

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