Healthcare CEO Briefing

The “Lean Method”

Approach to Performance
Excellence

May 2, 2007
Tim Ashe, RN, MS, MBA
Principal
Director of Operational Consulting
Fazzi Associates, Inc.
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 Presentation Objectives
• Objective #1: Discuss some of the core
principles of Lean Methodology

• Objective #2: Demonstrate application of

Lean Methods in a Medical Center

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Lean Programs Were Developed from TPS
(Toyota Production System)

“All we are doing is looking at the time line;

from the moment the customer gives us an
order to the point when we collect cash. And
we are reducing that time line by removing the
non-value-added wastes.”
Taiichi Ohno

Order Cash

(Reduce by removing non-value-added wastes)

Simple, very clear focus

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 Lean Methodology
• A Lean Program is a way of thinking

• Lean is a way of doing more with less. Less human

effort, less equipment, less material, less time, and less
space

• Lean Programs strive to provide customers with

exactly what they want, when they want it

• At the heart of Lean Programs are flexible, motivated,

invested team members continuously solving problems

• All waste can and should be eliminated

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 The House of Lean Methods
Goal
Customer Focus
Highest quality, lowest cost, shortest lead time
by continually eliminating muda

Just-in-time Jidoka

Involvement
Flexible, motivated
team members
continually seeking
a better way

Standardization

Stability

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 Lean Toolbox
• Hoshin Planning

• Kaizen

• 6-sigma

• Plan-Do-Study-Act

• Standard Work

• 5S

• Value Stream Mapping

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 Value Stream Mapping

It helps you to see and understand the

flow of material and information as a
product idea makes its way through the
value stream. It helps you see waste.
More importantly, it helps you see the
sources of waste.

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 7 Forms of Waste
1. Transportation of materials or information
between processes or storage
2. Inventory in a system where
facilities materials
inside flow
or outside the
in a steady
company flow from raw
3. Motion includes all unnecessary
materials operations,
to finished product
movement,
directly toandthesteps taken by people
customer
4. Waiting happens when delays occur in
the process
5. Overproduction is when we produce too much,
too early, or in excess of
6. Overprocessing is doing more
customer work than is
demand
necessary to perform an
7. Defects include the creation
operation oroftransaction
items, information,
or services that don’t meet customer
specifications and require scrapping,
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 Kaizen Workshops
Kaizen (KI-zen)
“Kai” to take apart, “Zen” to improve so as to help others

Do It
Start here Document Again
Reality
Celebrate!

Identify Waste

Make This
Plan the Standard
Counter-
measures

Measure
Results
Kaizen
Reality Verify
Check Change
Make
Changes

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Management Sponsorship for the Kaizen
Management shows its commitment to the process of Lean
by
● Preparing
• Allocating the time and resources for training
• Establishing precise Area Profile and Target Sheet
• Providing clear incentives for team’s success
● Executing
• Constantly communicating with the team and
monitoring progress
• Maintaining flexibility as the team learns more
• Removing roadblocks and allocating funds
● Following up
• Staying engaged throughout the process
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 Kaizen Team Selection and Training
● Team Selection
• Involve representative employees from the
department with at least one person from each
functional area
• Maximum 12 people
• Bring in a pair of “Outside Eyes”
• Facilitator(s)
• Team Leader – focused and influential
● Team Training
• Lean principles
• Understanding of the Area Profile and Target
Sheet
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 Kaizen Workshop Agenda
● Understand the current state
● Gemba (go to where the work is)
● Identify waste and areas of opportunity
● Try-storm ideas to address waste
● Break and “go to work”
● Regroup and report back on how things went
● Try-storm new ideas if initial ideas didn’t
work, or if more is learned
● Document Future State Map to enable continuous
improvement

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 Medical Center Bed Management
Project
● Using Lean Methods, design the most
efficient and effective bed management
process for adult services that:
• Improves throughput
• Reduces waste
• Improves real time information and
communication

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 Our Process

● 4 hour weekly “Kaizen” meetings

● 9 meetings – Measure, Measure, Measure
● Try storming our solutions
● Value Stream Mapping—current and future
states
● Presentation of Proposals to Management
Sponsors

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 Current State VSM

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 Future State VSM

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 Provider Recommendations

● Medicine must establish plan to assign

providers and teams; assignment to patients
in ED must take priority.

● Consult services often delay admission

decisions—expectations of timeliness should
be established.

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 Discharges

● Establish Discharge time at 10:00 am. Plan

communication strategy to patients.

● Discharge must be planned prospectively and

when possible, parameter based.

● Discharge orders and instructions completed

or started evening before?

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 Technology

● Bed Board- single source of bed and admission

information throughout the hospital

● Hardware/big screen installations

● Bed Board becomes primary notification system

● Tech committee to investigate proprietary systems

for bed/patient flow tracking and communication in
all departments and units

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 Capacity

● Bed assignments need rightsizing

● Empty specialty beds should be used when

feasible and clinically/age appropriate.

● Medicine needs additional identified units.

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 Work Redesign

● Units:
• Patient Flow Facilitator role (PFF) is a priority.
No patient assignment. Role is to move patients
in and out and track.
• PFF manages bed board/attends bed meetings
• Charge Nurse- clinical staff support and
oversight.
• Patient Unit Secretary- arrives and inputs
accommodation codes
• Bed ready- patient admitted; no calls
• RN-RN report from ED
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 Work Redesign
● ED
• Chart assembled one time using inpatient
binder
• Clinical Resource Nurse role changed to
Patient Flow Facilitator in ED; manages all
admissions, deploys transport and
housekeeping etc.
• Charge Nurse serves as ED clinical support and
oversight
• Technology needs—radios, scanners, etc
• Verbal report to receiving unit

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 Work Redesign

● Hospital-wide CRN is for clinical support

and oversight

● Admitting: manages all points of entry in a

centralized fashion

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 Functions drive Role changes

● Focus is on today plus tomorrow

● Administrator of Patient Flow has

appropriate authority and influence over
SDS / OR scheduling

● Eliminate multiple account/bed manager

positions and centralize

● Determine frequency and time of bed huddle

and participants
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 Proposed Results

● 35% Reduction in time from bed ready to

patient arrival on unit

● Net elimination of 12 FTEs

● Accountability described for bed status and

patient flow triggers

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 References
● Dennis, Pascal. 2002, Lean Production Simplified: A
Plan Language Guide to the World’s Most Powerful
Production System, Productivity Press, Portland.

● Ohno, Taiichi. 1978, Toyota Production System

Beyond Large-Scale Production, Diamond Inc,
Toyko.

● Shingo, Shigeo. 1985, The Sayings of Shigeo Shingo:

Key Strategies for Plant Improvement, Productivity
Press, Portland.

● Tapping, D, Shuker, T. 2003, Value Stream

Management for the Lean Office, Productivity Press,
New York.

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 Questions?

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 Home Health Event Description

Improve Referral to Admission Process and

eliminate non-value-added work

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 Value Stream Mapping
Current State, June 28, 2005

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 Try-Storming
Iterative trials
• Clerical Person addition in hospital setting
• Wireless trial
• Admission planning consolidation after 5 pm
• Eliminate Access database (duplicate to
McKesson)
– Worked with McKesson to get reports (removed
crutch/pacifier)
• Standardize expectations of HCC productivity
per unit
• Referral directly to Clinical Team rather than
to Intake for further processing
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 Value Stream Mapping
Future State, July 12, 2005

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 Target Sheet
KOS Kaizen Workshop Target Sheet

%Increase
Start Target 28-Jun-05 Jul-06 Difference / Decrease
Staffing Benchmark 0.18 0.15 0.18 0.15 0.03 -17%
Volume Per Day/FTE 1.27 2.21 1.27 2.1 0.83 +65%
Volume Per Day 28.9 33 28.9 32 3.1 +11%
Full-time Equivalent Crew 41 37 41 38 3 -7%

Cost Reduction 0 $150K 0 $275K $275K

Quality Improvements 0 2 2 2
Safety Improvements 0 2 0 0
# Poka-yoke Implemented 0 2 1 1

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 Progress toward Targets
● Matching skill set to job duties - Nurses
doing clerical work
● Created New Patient Specialist position

● Technology enhancements
● Add VPN and reduced by 11 laptops
● Simplification of process and elimination
of duplication
• Eliminated Access database
• Maximized McKesson functionality

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 Progress toward Targets

● Decentralized Admission Planning

● Enhanced coding process
● Reduced walking time
● Improved customer satisfaction by
consistency in care
● Savings 2005: $103K
● 2006: Savings $275K

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