THE LEAN ENTERPRISE

DR. RAGINI N. MOHANTY

What Is Lean?
Japanese : Kai school, Zen wisdom Elimination of waste Toyota Production System (TPS) Philosophy Produce only what is needed, when it is needed, with no waste ensure swift, even flow through the process of system, through continuous improvement The least wasteful way to provide better, safer healthcare to patients with no delays Providing exactly what the patient needs, safely, when needed, in precisely the right quantity and without waste Making common sense common practice Methodology Determination of value added in the process Tools Five Ss, kaizen event, standardized work, etc.

Types of Waste (Muda)

Overproduction

Underutilized human talent

Waiting Transportation Inventory Motion Overprocessing Defects

Types of waste in H/c Orgn

Overproduction printing reports, labels, meals Underutilized human talent Waiting time service provider idle time customer waiting time Transportation Patient movement and travel across hospital Equipment movement Inventory Holding or purchasing raw materials, work-in-process and finished goods not needed immediately, includes capital investment Wasted inventory: supplies, pharmaceuticals Motion: actions of providers or operators that do not add value to the product/service Repeated visits to service provider to get information or supplies Over-processing Documentation and record keeping Defects requiring rework or scrap off Misfiling documents Serious errors resulting in morbidity or mortality E.g. Medication or Surgical errors

KAIZEN
JAPANESE continual improvement Goal: To change the process so that people cannot go back to the old way of doing business. Focus is on the entire value stream with specific improvement technique focused on a particular process Employee-led suggestions for improvement made and implemented quickly Existing team used and provided with tools to deliver on the metrics and goals with better problem solving capabilities as a group. No or minimum investment. Creates a foundation and motivation to drive continuous improvement in the process. Business leaders like it, can see tangible change quickly.

 Useful for implementation of larger scale improvement & driving smaller local change quickly. Results are achieved in 5 days & change is typically visible. Examples include in pre registration, admitting area, medical records, processing patients, financial services, or a clinical area. Assumptions: Everything can be improved Many small incremental changes will result in a better system Even it isn't broken, it can be improved The elements addressed in a kaizen are: Wastes Flow Non essentials Process Improvements

STEPS FOR KAIZEN

1. what is value from the customers perspective?

2. Understand your process 3. Smooth the flow 4. Shift from Push to Pull - ER triaging 5. Continue to attack waste seek perfection

Process map of the value stream - measures process in terms of time, work in process, etc. and identifies the source of waste Information processing and transformational processing steps included Value adding steps customer willing to pay? Non-value-adding Necessary Unnecessary Non-value-added activity waiting time, patient will not pay to wait non-value-adding necessary activity is employee payroll no value addition to customer, but employees have to be paid. Examine and determine whether any such activities can be eliminated Eliminate non-value-adding unnecessary activities

Value stream mapping

% value added =

x 100 Value-added time Total time in system

Non-Value-Added Activity?
Multiple areas for medication storage 1 Organizational Opportunity

Interruptions?
1. 2. 3. Phone Window Door

Tech work area separated

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Value Stream Mapping

Nurses time sp

Process map
Pictorial representation of a process Assists with identifying and planning improvements Useful basic flowcharting symbols
start Delay

Activity/task/step

Decision point

End Final output

Tools
Takt time Throughput time Five Ss Spaghetti diagram Kaizen blitz or event Jidoka Andon Standardized work Kanban Single minute exchange of die (SMED) Flow Pull Heijunka Poka-Yoke

TAKT TIME
German word meaning rhythm or beat The speed with which customers must be served to satisfy demand for the service Takt time = Available work time/Day Customer Demand/Day Throughput time : the time for an item to complete the entire process, includes waiting time, transport time as well as actual processing time. E.g. OPD patient movement Cycle time is the actual time taken to accomplish a task in a system System cycle time is the longest task-cycle time in the system the rate at which the customers or products exit the system, the drip time. In Lean Cycle time = Takt time
If cycle time is greater than Takt time, demand will not be satisfied and pts will have to wait If cycle time is less than Takt time, resources will be underutilized in a service environment and inventory will be generated in a manufacturing environment.

Available worktime/ physician=5 hrs Number of physicians = 8 Pts expected/day (Demand) = 100

Takt time = 8 phy x 5 hrs/day = 0.4 phy hrs/pt 100 patients/day = 0.4 x 60 = 24 phy min/pt Move to examining room 2 min

Patient check-in 3 minutes

Wait 15 min

Wait 15 min

Nurse does preliminar y exam 5 minutes

Wait 10 min

Physician exam and consultation 20 minutes value added

Visit complete

Throughput time = 3+15+2+15+5+10+20 = 70 min Lean: - reduce throughput

Longest cycle time = 20 minutes % Value added time = 20/70 minutes = 28% Lean : - increase value added time %

Five Ss 5S - Visual order is the foundation of excellence in manufacturing. When it is in its place on the production floor, work gets done efficiently and effectively. When it is not in place, work still gets done but at a level of cost that is hard to justify Benefits Improved safety Reduced waste Improved morale Ownership of workspace Improved productivity Improved quality Improved maintenance Better impression on customers

Five Ss Nippongo words

Seiri (Sort)Separate necessary from unnecessary items, including tools, parts, materials, and paperwork, and remove the unnecessary items. Seiton (Straighten)Arrange the necessary items neatly, providing visual cues to where items should be placed. Seiso (Sweep)Clean the work area. Seiketsu (Standardize)Standardize the first three Ss so that cleanliness is maintained. Shitsuke (Sustain)Ensure that the first four Ss continue to be performed on a regular basis.

5ss pre-Lean
Scrounge Steal Stash Scramble Search

Lean 5S strategy
Sort Set in order Shine Standardize Sustain

Sort Eliminate Waste

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Set In Order - A place for everything

Like meds separated by bins Alphabetized inventory by generic name

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Supplies & Equipment

Supply Bin Color Coding

Color Red Yellow

Meaning IV supplies/needles Urinary supplies

Symbol

Brown GI / Ostomy supplies Blue Orange Green White Respiratory supplies ADL supplies Dressing supplies Miscellaneous
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 and everything in its place

Clear signs posted

Supplies organized and in a central area (point of use storage)

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Shine
Work area cleaned, straightened and organized

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This cart was well-organized but it was still difficult to find some items. Labeled each shelf and bin as to its contents. Saved staff time looking for items.

Turned off the auto print option at the ED monitor station, and now only print when needed. Reduced clutter and saved paper and disposal costs. Also saved staff time and printer wear and tear. Estimated cost savings at $1000+ per year BEFORE AFTER

Medication Location Confusion (Search)

Before, After Color Coding

Before

After

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Color Coding and Two-Bin Kanban

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Spaghetti diagram
A visual representation of the movement or travel of materials, employees or customers. Movement from place to place and backtracking Can help to find and eliminate wasted movement in the system

Guidelines for Spaghetti diagram Note the time, date and process being evaluated, but not the name of the individuals Explain to the team what's being done and ask for a volunteer Trace the actual steps taken Note any stops with sequential numbers and mark the time for each stop Note any awkward elements in the line taken Mark any inherent interruptions in the path - such as gowning up Note why certain trips are made eg getting necessary supplies or signatures Ask questions and seek suggestions from the team - the best ideas often come from those who live the process

Spaghetti Diagram

Non-Value Added Activity

Adding Value
  

Eliminate non-value added activity Reduce movement Double the speed

Add Visual Aid

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Spaghetti Diagrams
Current Condition

Pilot Condition

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Kaizen Blitz or Event

Determine and define the objectives Act Determine the current state of the process Determine the requirements of the process Create a plan for implementation Check Implement the improvements Check the effectiveness of the improvements Document and standardize the improved process Continue the cycle
Plan

Do

Jidoka and Andon

Jidoka is the ability to stop the process in the event of a problem.
Prevents defects from passing from one step in the system to the next Enables swift detection and correction of errors

Andon is a visual or audible signaling device used to indicate there is a problem in the process.

A caregiver who believes that something is not right in the care process, she can and must stop the process., and inform the patient safety department, RCA will be done and problem sorted out. Examples: medication errors, problems with equipment and facilities, system issues

Standardized work
A written document of the specific way in which every step in a process should be performed Not a rigid system of compliance A means of communicating and codifying current best practices Provides a baseline form which improvements can be made to the process All relevant stakeholders to be involved, promotes employee buy-in and ownership of the process and responsibility for improvement Variation and waste minimized Can be used on clinical, support and administrative operations of h/c organizations Example: Evidence-based medicine documented treatment protocols, clinical pathways of care
Care path optimal sequencing and timing of interventions by physicians, nurses and other staff for a particular diagnosis or procedure, designed to minimize delays and resource utilization and at the same time maximize quality of care.

KANBAN
JAPANESE TERM meaning signal Controlling mechanism in a pull production system Containers of certain size used to signal the need for more production or service Example : supplies and pharmacy

Kanban

Kanban

Single Minute Exchange of Die

(SMED)
Used to reduce changeover or setup time, which is the time needed between the completion of one procedure and the start of the next procedure Steps Separate internal activities from external activities (OR clean up / CSSD supplies) Convert internal setup activities to external activities (organizing surgical instruments) Streamline all setup activities (finding, organizing instruments, getting supplies, cleaning rooms, obtaining paperwork) Examples: diagnostic imaging areas, surgical suites, hospital rooms

Flow and Pull

Continuous or single piece flowmove items (jobs, patients, products) through the steps of the process one at a time without interuptions or waiting. E.g. efficient patient flow Pull or just-in-time (JIT)products or services are not produced until the downstream customer demands them. Heijunka Japanese term means make flat and level; eliminate variation in volume and variety of production to reduce waste Level patient demand:- more responsive to customers and better use their own resources Advanced access provides good ex of benefits of Heijunka

Advanced Access
Patients are unable to obtain timely primary care appointments. Advanced access scheduling reduces the time between scheduling an appointment for care and the actual appointment. The goal is swift, even patient flow through the system.

Advanced Access
Advantages
Decreases no-show rates Improves patient satisfaction Improves staff satisfaction Increases revenue
Higher patient volumes Increased staff and clinician productivity

Promotes greater continuity of care

Increased quality of care More positive outcomes for patients

Advanced Access
Implementation
Advanced access challenges established practices and beliefs. Balance supply and demand:
Obtain accurate estimates of supply and demand. Reduce or eliminate backlog. Minimize the variety of appointment types. May need to:
Adjust demand profiles. Increase availability of bottleneck resources.

Lean Sigma
Lean and Six Sigma are focused on continuous improvement of the system.
Lean Eliminate waste Achieve flow and pull Six Sigma Eliminate defects Reduce variation in processes

6W

Poka-Yoke
Eliminates opportunities for mistakes Poka inadvertent errors Yokeru to avoid Examples:
Insertion of endotracheal tube:
Poka - error - to put the endotracheal tube into the oesophagus. Yoke - to avoid solution squeeze plastic bulb and put it on the tube end. If it inflates tube is in the respiratory tract, if not an error has occurred and tube is in the oesophagus

Wheelchair falls- solution is wheelchair lock when the person is attempting to sit

Impact Of Lean
Before Lean 29 process steps for refills Delay, Employee frustration Tools applied Value-stream mapping 5S, Point of use storage Impact Reduced process steps to 20 Streamlined work flow Eliminated non-value added time - refill time for 3 units from 1hr. 3 min. to 33 minutes

Excess movement Errors in med retrieval

Spaghetti Diagram 5S

Increased employee satisfaction Reduced potential for errors

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