Introduction to Lean Leadership Institute Leadership Institute & & Performance Excellence Performance Excellence
Jan 15, 2015
Introduction to Lean
Leadership InstituteLeadership Institute&&
Performance ExcellencePerformance Excellence
AgendaAugust 16, 2013
• Welcome, Objectives, Expectations• Lean Background/ History• Kaizen Overview• Lean in Healthcare• Dot Simulation 1 Exercise
• Value & Waste Overview• Kaizen Process• Lean Tools: Circle of Work / Spaghetti Charts• Lean Tools: TAKT Time• Lean Tools: Push vs. Pull• Lean Tools; 5S and visual controls• Kaizen: Observing the Current Process• Dot Simulation 2 Exercise
• Lean Tools: Set up Reduction• Developing the future state• Kanban and Single Point• Dot Simulation 3 Exercise • Creating a new Standard Work• Error Proofing• Dot Simulation 4 Exercise
• Dot Exercise Debrief• Summary and Wrap up
Session Objectives• Provide an Introduction to Lean• Identify Lean Principles• Define Value, Non-Value Added work
and Waste• Identify Lean applications in
healthcare• Apply the Lean tools within the
Healthcare environment• Provide a description and
understanding of Kaizen events
Kaizen Definition
Thoughtful Acts of Continuous Thoughtful Acts of Continuous ImprovementImprovement
To take apart and make new
To think about so as to help others
Eliminate WasteEliminate Waste
Solve ProblemsSolve Problems
If the first fix doesn’t work, try againIf the first fix doesn’t work, try again
Lean is …..• A set of operation concepts• A set of tools used in a variety of
industries – including service & healthcare to improve business processes
• A philosophy that helps drive efficiency and speed through employee empowerment and change at the grass root level
Benefits of LeanLean attacks waste in any process or value stream
•Higher customer satisfaction•Reduced cycles•Better delivery•More capacity•Better quality and safety•Improved productivity
History of Lean
• Lean Manufacturing began as the Toyota Production System (TPS)
• Lean came to the US in late 1980’s• Healthcare Providers (Early Adopters)
in the US began to embrace Lean Enterprise concepts about a decade ago
• Insurance Companies and Insurance Providers demanding that Healthcare Providers embrace Lean Concepts
Kaizen
House of Kaizen
Kaizen Training
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Do MORE with LESS
Waste Productivity
Staffing Productivity
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Standards
Enforce Inspect
.
Stabilize
IdentifyWaste
Improve
Problem Solve
Standardize
• Process requires ongoing inspection and enforcement to ensure “Standardized Work” is being followed
• Process does not improve automatically
- Following standards will only maintain, not improve, the process.- Improvement focuses on the entire process.
Why does Lean apply to healthcare?
• Tools easy to learn / teach• Learn by doing• Easier to apply at frontline where work
is really happening vs. other methodologies
• Improvement occurs with the first application
Lean Opportunities in Healthcare
Emergency Reducing Wait Times
Surgery OR Throughput
Radiology MRI/CT Throughput
Admission Bed Turnover
Understand flow of materials, information and people through the hospital, then identify tasks or activities (operations) that improve or
hinder flow
1. Understand who the customer is 2. Solve the customers problem completely3. Understand the value you provide4. Manage by observation facts...do not make
decisions based on reports5. Involve people closest to the problem…team-
based environment6. Drive to root cause7. Try storm, take action now!!8. Standardize – Discipline9. Sustain through customer focused cycle time &
process metrics
Lean Principles
Break-out
Simulation
The Dot SimulationDemonstrating Basic Lean
PrinciplesBackground InformationYou are workers in the Outpatient Radiology department of a hospital. Using colored dots on a sheet of paper, we will simulate the major steps in processing a patient through a radiological exam.
Red Dots = ReceptionGreen Dots = RegistrationOrange Dots = Patient PreparationBlue Dots = Exam Yellow Dots = Check films
We will run four round of the simulation. At each stage, you will have opportunities to improve the process, using some of the Lean principles we’ve studies.
As you participate in the simulation, think about other hospital processes where these principles might help you reduce waste and improve efficiency; admitting a patient to a nursing unit, coding, documenting a patient’s chart, etc.
Intro to Overall Simulation
Care Process Templates
Dots:
Reception
Registration
Patient Prep
Exam
Check Films
Red Green Orange Blue Yellow Red Green Orange Blue Yellow
Completed Care
Patient Care process
Roles and ResponsibilitiesMaterials manager•Record the time on the batch when the process is started. Move the batch to Reception (Red Operator). Only send one batch at a time to the Reception•Stock Room Management: Give out dots when the process workers come to you. You may only give out one sheet of dots at a time and only when the process worker has a signed requisition form from a VP.
Process Workers (1 person per color)•Apply colored dots on the paper as indicated by the customer when a batch is received•Deliver it to the next station. Send only one batch at a time.•Get additional dots from stock as needed. Only one sheet of dots per visit to the stock room is allowed. You must obtain a signed requisition form from a VP to get a new sheet of dots.•Any defective batches returned to your station take first priority. They must be fixed and sent back through the process
Roles and ResponsibilitiesPatient / Inspector•Receives batches from Yellow Operator and inspects for meeting quality requirements. If the batch passes, records the time that a completed batch passed through inspection, places them in the completed bin, and tell the patient it’s ok to leave. (Write the completion time on the unit, fold the unit in half and place it in a location indicating that it has been finished). If the batch does not pass, take it back to the work station responsible for the problem. Keep a record of batches that were sent back to be fixed and batches that were accepted using the inspection sheet.Recorder•On the flipchart, track the Inspection Sheet data and the Process metrics for each of the rounds
Simulation Round 1• Run for 5 minutes• Colors must be applied in sequence – first Red, then
Green, Orange, Blue, and Yellow• No process changes allowed during the round – we
want to understand and baseline the current process• If the process workers run out of dots, they must
complete a Materials Requisition Form and get it signed by a VP before requesting more dots from the Materials Manager
• When Reception (the Red Operator) finishes a batch, he / she must ask the Materials Manager for a new batch
Have Fun!!
Report Out
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SHIFT MINDSET
CURRENTTHINKING
REQUIRED
THINKING
WASTE NOT DEFINEDREACT TO LARGE EXAMPLESREACTIVE IMPROVEMENT
WASTE IS "TANGIBLE”IDENTIFY MANY SMALL OPPORTUNITIES -LEADS TO LARGE OVERALL CHANGECONTINUOUS IMPROVEMENT
WASTETYPES
OFWASTE
Correction
Processing
Motion
Waiting
Inventory
Transportation
Over- Production
Value and WasteValue
•An activity that the customer is willing to pay for•An activity that physically alters the existing state •Who are your customers•What is “Value” for YOUR customer
Waste (Muda)•An excessive or unwanted step, resource, motion, etc.•8 types of Muda
– Defects - Waiting– Overproduction - Transportation– Motion - Over processing– Resources (Inventory) - Under utilization
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Some examples NVA Activities:
WalkingWaiting on test results
Transporting parts
Generating useless reports
THE GOAL IS TO ELIMINATE THE THE GOAL IS TO ELIMINATE THE NON-VALUE ADDED ACTIVITIES.NON-VALUE ADDED ACTIVITIES.
Unnecessary motion
Unnecessary stock on hand
To determine if a process step or activity is VA, NVE or NVA….
Ask:If we stop doing _____task, would our end customer (patient) care?
If “YES”, then it is Value Added (VA)
If we stop doing ____task, would our internal customers or key stakeholders (Physicians, nurses, administration, regulatory agencies, etc.) care?If “YES”, then it is Non Value Added Essential
(NVE)
If the answer to both of these question is “No”, then it is Muda (Waste / NVA)
Kaizen Event Phases
PLAN
• Business Case Metrics
• Scope • Executive
Sponsor• Event
Owner• Team
Leader
PREP
• Observe Work / Flow
• Lean Tools• Team
Members• Support
Functions• Process
Metrics• Finalize
Business Case Metrics
• Approvals
EVENT
• Business Case• Training• Current State• Future State• Test /
Implement• Action Plan• Communicatio
n Plan• Metrics
FOLLOW-UP
• 30/60/90 Day Plan
• Daily Mgmt• Gemba
Walks• Measure
Impact
I II III IV
Kaizen Process • Selecting Projects• Setting Goals• The Team Leader and Team• Support and Infrastructure• The Kaizen Blitz Steps
– Set the scene (Document current reality)– Observe the current process (ID waste and
countermeasures)– Develop the future state process – Implement the new process (Make & Verify
changes)– Report and analyze (Measure results, Create
new standard work)• Potential Roadblocks
Scale for rating each criteria
0 if there is no impact 1 for low correlation 3 for medium correlation 9 for a high correlation
Kaizen Process • Selecting Projects• Setting Goals• The Team Leader and Team• Support and Infrastructure• The Kaizen Blitz Steps
– Set the scene (Document current reality)– Observe the current process (ID waste and
countermeasures)– Develop the future state process – Implement the new process (Make & Verify
changes)– Report and analyze (Measure results, Create
new standard work)• Potential Roadblocks
Pre-Event Preparation1.Describe the opportunity
A. Stakeholder analysisB. Define scopeC. Planning
2.Team selection and training3. Have your targets set4. Select Team leader5.Set event objectives tied to your
company’s goals6. Complete Kaizen Event Charter
Lean Six Sigma Project Charter
Title: Reduce Scrapped Cookies in NW Region BB/GB: B. Thornton
Business Gap
Defects & Metrics
Problem Statement
Team: B. Thornton (BB), A Yamoto (Process Owner), W. Houston (SME), P. Smith (SME), G. Hines (SME), L. David (SME)
Champion: T. Wong
Project Scope/Boundaries:
Process Start: Mix Ingredients Process Stop: Bake CookiesIn Scope: Chocolate Chip Cookies in all NW Bakeries Out of Scope: Packaging
Milestones/Timeline: Scheduled ActualDefine Tollgate Review: June 4, 2007 6-4-07Measure Tollgate Review: July 9, 2007Analyze Tollgate Review: August 13, 2007Improve Tollgate Review: September 10, 2007Control Tollgate Review: September 24, 2007
Customer
Objective Statement
Our bakeries scrap approximately 25% of all cookies baked. Scrapped cookies limit our ability to remain profitable while we are being pressured to reduce prices by our competitors. Scrapped cookies have always been an issue and it has become worse since new ovens were installed. Based on a Pareto Analysis we will focus initially on the NW Region.
External: Grocery Stores, Consumer
Internal: Regional General Manager
Defects: Scrapped CookiesPrimary: Scrap Rate for Cracked Chocolate Chip Cookies (CCCC)Secondary: Returns dues to CCCC’sConsequential: Taste, Chewiness
The scrap rate due to cracked chocolate chip cookies in the NW bakeries was 15% for the past 12 months based on daily scrap reports.
Reduce the scrap rate due to cracks from 15% to 8% by 11/12/07 as measured by the daily scrap report
Financial Impact$204,400 in direct savings based on current production rates
© BMGI. Except as may be expressly authorized by a written license agreement signed by BMGI, no portion may be altered, rewritten, edited, modified or used to create any derivative works.
Problem vs. Goal Statement
The purpose of the Problem Statement is to describe what is Wrong
The Goal Statement defines the Team’s Improvement Objective
Kaizen Process • Selecting Projects• Setting Goals• The Team Leader and Team• Support and Infrastructure• The Kaizen Blitz Steps
– Set the scene (Document current reality)– Observe the current process (ID waste and
countermeasures)– Develop the future state process – Implement the new process (Make & Verify
changes)– Report and analyze (Measure results, Create
new standard work)• Potential Roadblocks
Forming a Kaizen Team
Team member considerations:• Effective problem solvers• Team players• Open minded• Be aware of:
– CAVE
Kaizen TeamsSkeptics vs. Critics (CAVE)Skeptics vs. Critics (CAVE)
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Steps on Team Development
FormingForming This is the development of a multi-functional team with a variation of backgrounds and knowledge
NormingNorming Stage where the group agrees how to operate as a team
StormingStorming Open & honest discussion, also brainstorming
PerformingPerforming Agreement on solutions & taking action
AdjourningAdjourning Closing on the continuous improvement process after 30 days
Document Reality
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Kaizen NewspaperKaizen NewspaperAdd problem when you Add problem when you find themfind them
Responsibility listResponsibility list
Due dates for Due dates for completion completion
Use as a to-do list during eventUse as a to-do list during event
Kaizen Process • Selecting Projects• Setting Goals• The Team Leader and Team• Support and Infrastructure• The Kaizen Blitz Steps
– Set the scene (Document current reality)– Observe the current process (ID waste and
countermeasures)– Develop the future state process – Implement the new process (Make & Verify
changes)– Report and analyze (Measure results, Create
new standard work)• Potential Roadblocks
Go to the Gemba
ManagersMust Not Must Do
Give Up
Flex Muscle
sThrow Fits
Blame the
workers
Blame the
measuresShow boatCover
UpGame the measures
Throw people at problemsStress out
Hide in the
office
Create smoke screens
Grovel Be clueless
Think of at least 7 ways to do better
Kaizen your standard
work
Observe the process
Find the waste
Have a vision
Provide the right tools
Set goals
Communicate direction39
Kaizen Process • Selecting Projects• Setting Goals• The Team Leader and Team• Support and Infrastructure• The Kaizen Blitz Steps
– Set the scene (Document current reality)– Observe the current process (ID waste and
countermeasures)– Develop the future state process – Implement the new process (Make & Verify
changes)– Report and analyze (Measure results, Create
new standard work)• Potential Roadblocks
LEAN EXAMPLESTART
Document RealityVerify how are the processes done todayVerify how are the processes done today– What’s really happeningWhat’s really happening– See it for yourself (Walk the Gemba)See it for yourself (Walk the Gemba)– Target sheets, area profilesTarget sheets, area profiles– 5S Audits, Safety Audit5S Audits, Safety Audit
How does it work todayHow does it work today– Spaghetti Chart, Standard WorksheetSpaghetti Chart, Standard Worksheet– Layouts, DocumentsLayouts, Documents
What happens in this processWhat happens in this process– Photos, Time ObservationsPhotos, Time Observations
Document Reality
Circle of Work – Process Analysis
Circle of Work analysis is crucial1)to establish your baseline for the Lean project and 2)quantify improvements after change have been implemented.
Key points to remember
•Make sure all key elements of the process are included and a representative, reasonable time period observed
•Ensure the observer is familiar with the process and can identify all activities
•Use observation for single workers, work sampling for multiple workers and overall worker / equipment utilization
Spaghetti Chart
An important aspect of the Circle of Work analysis is to visually depict the flow of work from the perspective of the worker and / or product. The standard sequence of work chart, also know as the “Spaghetti” chart, accomplishes this objective.
Key aspects of the Spaghetti Chart are:
•A diagram that shows the motion of the patient / family / caregiver / supplies throughout the course of care.
•A visual representation of the amount of travel involved for an activity to be completed and the number of locations involved
•A Spaghetti chart will include the total distance traveled (in feet)
•Spaghetti charts are created BEFORE and AFTER improvements are made in order to document success.
Document Reality
Standard Work SheetStandard Work Sheet
(Spaghetti Chart)(Spaghetti Chart)• Operator path in RED• Material path in BLUE• Safety YELLOW• Quality GREEN
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Be consistent with colors and symbolsBe consistent with colors and symbols
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What is TAKT Time?
TAKT is used to “set the pace” of the operation such that it takes place at the rate at which the customer “PULLS” from you.
By determining TAKT, you can adjust your offerings so as to add or reduce capacity.
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Single Piece Flow
Single piece flow is the basis of TAKT time
Single piece flow: Completing the process from start to finish continuously
Batch Process Single Piece Flow
How many do you have? You have only one.
Where are they in the process? You know where it occurred.
What is the root cause? Resolve the root cause immediately.
The next process step is the customer……. …..never send defects!!
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TAKT Time CalculationAvailable Time (seconds) / Period
Total Units of Customer Demand / PeriodTAKTTAKT
Available Time / Period (one shift):
Breaks - 2 @ 15 minutesShift Time ( 8 hrs. )
Total Time Available:
- 30 mins.480 mins.
450 mins.
Units Required / Period (one shift):10,500 Units Sold Monthly
21 Working shifts / month
or 27,000 secs.
500 Required units / shift
TAKT Time:TAKT Time: 27,000 secs / shift500 units / shift
54 secs.
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Line BalancingBy redistributing some of the tasksin Step D to A, B, and C…
…we can easily identify our target for Improvement. If we reduce the cumulativecycle times for all the steps by 12seconds, we can potentially reduce fromfour steps to three.
Takt Time
FlowMovement of patients / products, services and information down the value stream.
Objective is a continuous flow as patient / product, service and information is transformed by continuously adding value.
Flow is created by eliminating queues and stops, and improving process flexibility and reliability.
Pull
End customer pulls product / transaction through the value stream.
Each step pulls the product / transaction when needed from the preceding step.
Only the amount required is taken.
No action is taken until the downstream process initiates it.
Push vs. Pull
A Fundamental Lean PrinciplePush Principle – Admitting or feeder units
say: “We have a patient and need a bed”
Pull Principle – Floor Nurse says:“We have a bed and we need a patient”
We always seek to eliminate waste, establish flow and create a pull system
5S System and Visual Management
Maintain and improve sort, set-in-order, shine, and standardize
SortSort Separate the needed items from the un-needed items which are then removed to a "red-tagged" location
Set InSet InOrderOrder
Arrange remaining items in the way in which they will be used
ShineShineMaintain the work area for the already sorted and set-in-order items
StandardizeStandardizeEnsure sort, set-in-order, and shine are consistently followed across all users
SustainSustain
5S5S
SortWhen in doubt, remove it!• Segregate what is needed and what is not needed, discard what
is not needed.
• Use “Red Tags” to make it easy to reduce clutter.
• Note that “remove” does not mean dispose of. Unneeded items that may have some value are moved to a holding area for disposition.
STEP 1: Clarify what is needed.STEP 2: Dispose of things that are not
needed.STEP 3: With items that are needed,
segregate according to frequency of use.
Set in OrderA place for everything, and everything in its place.
• Clearly mark and arrange everything neatly so what is needed can be easily found.
• With unnecessary clutter removed, the team determines appropriate locations for items that are needed to “add value”.
• After repositioning items and tools, the team applies temporary labels, signboards, and positions.
STEP 1: Decide place for storageSTEP 2: Set up markings (Boundary Lines)
for storage locationsSTEP 3: Mark items to be placed for storageSTEP 4: Use ingenuity to make maintenance
easy
ShineClean to inspect, inspect to detect, and detect to correct.
• Clean up personal and working environment so there are no areas untidy with dirt or other clutter.
• Top to bottom cleaning and inspection.
• By touching and observing equipment as they clean, team members can spot early signs of trouble before they cause break downs, accidents, and defects.
STEP 1: Conduct overall ‘Shining’STEP 2: Maintain cleanlinessSTEP 3: Improvement plans to prevent dirtinessSTEP 4: Efficiency plan for sustained improvement
StandardizeYou can see the perfection !
• Maintain the conditions of Sort, Set-in-Order, and Shine
• Turn proven temporary methods for keeping the work place uncluttered into permanent “VISUAL” methods that make new standards obvious to everyone.
SustainSustain the Gain. Pride of ownership!
• Adhere faithfully to the decisions that have been made.
• Communicate and maintain practical approaches for improved workplace conditions.
• Spread the activities and pride of ownership to all levels and areas of the company.
What is Visual Control?
• The visual control method is based on the 5-S System
• Order is established with visual control• Because it impacts us directly, a visual
control is considered aggressive in its approach to adherence
• Visual controls can be very important as a tool for error proofing and should always be considered in a brainstorming effort
Examples of Visuals
Status Board
Work GroupDisplay Boards
OR in Use
Prep Next Patient
OR Ready
Indicator Lights
Direction of Flow Indicators
Gages showing Normal
Operating Range
Fluid Markings
Process Control Boards
Color Coding of Patients
Standards not followed are not standards.
the lean proverbs
Kaizen Process • Selecting Projects• Setting Goals• The Team Leader and Team• Support and Infrastructure• The Kaizen Blitz Steps
– Set the scene (Document current reality)– Observe the current process (ID waste and
countermeasures)– Develop the future state process – Implement the new process (Make & Verify
changes)– Report and analyze (Measure results, Create
new standard work)• Potential Roadblocks
Waste can multiply itself like rabbits.
the lean proverbs
Identify Waste
• Remember the 8 Wastes– Anything that doesn’t add value to the
customer
• Once identified make sure event scope is correct
– Ok to change, make sure everyone knows
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5 Whys• When problems are found
– Find the root cause by using the 5 whys
Asking why opens the mind to new causes.
the lean proverbs
Countermeasures• Solutions need to be
implemented during the week
• Try it out – action versus analysis
• Creativity before capital
• Continuous strive to reduce waste, no matter how small it is
• Attack items that impact– Process flow– Material flow– Information flow
• Solutions strive for– Takt– Flow– Pull– Lower Inventory
Kaizen• Just do it!
– Action over analysis
• Improving specific piece – The Value Stream– Company goal
• Manage to completion
Spirit of Creativity - A “McGyver” Capability
Symptoms to solve is little to resolve.
the lean proverbs
Section Review• Value• 8 types of Waste• Kaizen Process• Problem Statement• Selecting Team• Process Mapping – Spaghetti Map• Takt Time• Single Piece Flow• Push vs. Pull• 5S• 5 Why’s
Break-out
Simulation
Simulation Round 2• Run for 5 minutes• Colors must be applied in sequence – first
Red, then Green, Orange, Blue, and Yellow• You may redesign the work layout – you
will have 10 minutes to do this. Work layout changes must be approved by a VP. Flipchart your changes to facilitate approval by a VP
• You may not change the job descriptions of any of the process workers
Report Out
Examples of Set-up / Changeover Activities
There are numerous examples of set-up / changeover activity in healthcare, primarily for procedures and treatments:
•Starting / Removing IVs for patients•Transporting patients in and out of rooms•Verifying MD orders•Staff understanding what procedure needs to be done and how to do it•Placing/securing/aligning patients on a table/bed and then removing them•Ensuring supplies and instruments are available and ready before procedure or treatment begins•Equipment readiness•Interviewing patients regarding H&P information
Reducing Set-up TimeSet-ups are categorized in four phases•Preparation•Change / loading or unloading•Adjustment / Alignment•Inspecting and / or securing
Set-up reduction minimizes the amount NVA time devoted to these activities
Set-Up Reduction
As previously indicated, the set-up / changeover would include:
•Any preparation•Tearing down or cleanup of previous job, patient, procedure, etc.•Searching for equipment, supplies, information•Moving/transporting•Testing/calibrating equipment•Performing trial runs•Making further adjustments
Setup
Finish “A”
- - - - - - - “A”
Begin “B”- - - - - - - “B”
Set-up time is the time from the last step of the previous item, service or run to the first step of the next.
Process for Set-up Reduction Analysis
The process for analyzing set-up (or changeover) reduction analysis is as follows:
1.Identify all tasks associated with the set-up or changeover
2.Classify activities as happening while a process
3.Record the time associated with set-up activities
4.Associate all tasks with the four categories previously stated – preparation, changeover (loading/unloading), adjustment/alignment, inspection or securing
5.Brainstorm ideas to eliminate NVA time (i.e., maximize room or equipment utilization) and minimize overall set-up activity
6.Quantify the improvements
7.Develop new standard work (SOPs) for the implemented changes
Set-up / Changeover Improvement Ideas
When examining the categories of set-up / changeover (preparation, changing, adjusting, secure/inspect), there are several common flags or opportunities to look for:
•Alignment / Adjustment time: any type of alignment or adjustment of patients or equipment should automatically be considered a flag for evaluation, since they are typically non-valued added tasks. Analysis of equipment options (e.g. guide pins, blocks, scales) or some 5S type controls for patients could provide viable solutions.
•Securing / Inspection time: regarding equipment, consider available options (e.g. Velcro vs. screw type restraints), while with patients evaluate repeatable or duplicative tasks (tests, vital signs, etc.). Multiple approvals or assessments should also be evaluated.
The goal should be to maximize room and/or equipment utilization.
Kaizen Process • Selecting Projects• Setting Goals• The Team Leader and Team• Support and Infrastructure• The Kaizen Blitz Steps
– Set the scene (Document current reality)– Observe the current process (ID waste and
countermeasures)– Develop the future state process – Implement the new process (Make & Verify
changes)– Report and analyze (Measure results, Create
new standard work)• Potential Roadblocks
Make Changes• Make the changes – NOW!
– Don’t get stuck waiting for a better time– Make the changes then observe them
• Pre-plan for large moves before the event
• Everyone needs to contribute– Don’t dictate, build teamwork
• Make sure you update the newspaper
Verify Changes• Verify with new observations• If it’s not easier, make more changes• Goal is to put new process in place
and verify it– Do this early in event to allow time for
more changes– Make sure a better process is working
at end of event
Kaizen Process • Selecting Projects• Setting Goals• The Team Leader and Team• Support and Infrastructure• The Kaizen Blitz Steps
– Set the scene (Document current reality)– Observe the current process (ID waste and
countermeasures)– Develop the future state process – Implement the new process (Make & Verify
changes)– Report and analyze (Measure results, Create
new standard work)• Potential Roadblocks
Kanban DefinitionA Japanese work that means “signboard”
•In a Lean enterprise, it’s a signal authorizing production or delivery of required materials. The signal is initiated by consumption from an upstream process
•Allows a just-in-time (JIT) environment to be set up but it requires:
– Level Production
– Pull
– Defect Free Products
•A Kanban is a high-level tool that is implemented after solving many problems
Kanbans route information in a pull systemSupermarkets provide material for a pull system
Measure Results• Compare results with baseline data
– Did we make it better?– Was waste removed?
• Did we achieve what we wanted to?
Not all changes are successful.Not all changes are successful.
Don’t worry.Don’t worry.
Learn from what we’ve done!Learn from what we’ve done!
Improvement IdeaDate: __________
Kaizen Title:____________________ Team #: ____________ Completed By: __________________________
Description of Problem: Description of steps taken: Results:
Before Kaizen After Kaizen
Remarks:
The lift truck cords were continually being left on the floor causing delays and damage.
A cord retractor was installed at each rechargestation.
Prevents damage to plugs
Eliminated trip hazard
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Single Point Lesson
Water cooling lines• Mistake proofed fittings• Hoses can only be hooked up one way
– Simple fix, no money spent, just switched fitting from hose to fixture
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Mistake proofed is mistake’s pain missed.
the lean proverbs
Section Review
• Reducing Set up Times• Making Changes• Verifying Changes• Kanban• Measuring data
Break-out
Simulation
Simulation Round 3• Run for 5 minutes• Colors must be applied in sequence –
first Red, then Green, Orange, Blue, and Yellow
• You may not change the job descriptions of any of the process workers
• The Department Director has decided to institute a Kanban system. The VP or facilitator will explain Kanban
• In your group, apply the concepts of Set-Up Reductions
Report Out
Create New Standard
• Put new visual standard work in place– Maintain progress made during event– Training tool– Should be understood by anyone observing the process
• Post all open action item on the Kaizen Newspaper– Make sure all items have a name attached to them– Follow up to make sure they get completed
• Visually display what has happened in the area• New process must be repeatable and sustainable
– Try it out during the week!!!
Celebrate
Standard WorkWhat is “Standard Work”?
•For a given process, it is having every activity done in the same sequence and manner every time with the least possible amount of time in order to meet customer specifications. It is the most effective combination of activities that will minimize non-value-added activities while providing the highest quality of care.
•For the process workers, it is knowing what to do, how to do it, and when to do it every time the process cycle occurs
•For the process non-labor, it is having the right supplies and equipment available when they are needed and in the right quantity (Just-In-Time).
Without standard work, there can be no continuous improvement - it is the basis for Lean
transformation
Standard Work – Healthcare Examples
• Clinical pathways, protocols, practice guidelines for disease state or DRG management
• Standard Operating Procedures(s) for a treatment or case, including patient prep and discharge
• Organizational Policy and Procedures – departmental or hospital wide
While we can see from the above that standard work has existed to some degree in healthcare (but not necessarily successfully), it is not even remotely close to where it needs to be for us to meet the challenges in the years ahead
Standard Work – Critical Components
Implementation of Standard Work involves five steps, all of which incorporate numerous lean tools. The five steps are:
•Evaluate the current situation•Identify areas of opportunity•Modify the existing process•Substantiate and enumerate improvements•Implement the new standard work
Standard Work - Evaluation
Evaluating the current situation of the process will involve the use of several tools discussed thus far:•Observation – time value analysis (TVA). Note times, dates, and any specific circumstances involved with the observation•Spaghetti diagrams•Forms – time observation sheet•Determine current line balance of the process (Takt time of the process applied for each process step).
Standard Work – Identify Opportunities
Examples of the 8 Wastes:Defects: Medication errors, wrong site surgery
Over Production: Preparing IV’s ahead of time
Transportation: Transporting lab specimens, patients
Waiting: Waiting for bed assignments, treatments, discharge orders
Inventory: Lab specimens, supplies
Motion: Searching for charts / supplies
Processing extra: Excessive paperwork, unnecessary tests, using IV over oral meds
Under-utilization: RNs doing non clinical paperwork; CPAs doing basic G/L work, idle equipment
Standard Work – Modify the Process
In this step, Lean tools are employed to change the process and make improvements:•Brainstorming•5S•Visual controls, indicators, signals, guarantees •Line Balancing•Leveling•Quick changeover – setup reduction
Standard Work – Piloting Process
Attempt to conduct a pilot of the process changes first before full implementation in order to demonstrate the feasibility and success of the changes
In a Lean Kaizen event, this is normally the “Trystorming” phase. This occurs quickly in the process, and team participants will in real time make whatever changes are needed based upon feedback from workers in the process.
If a pilot cannot be conducted and full implementation is required for the process, ensure that careful monitoring exists and that changes can be made to the new process if warranted.
Standard Work – Implement New Standard
In order to fully implement new standard work for a process, the following steps need to be taken:
•Training of all personnel affected by the changes must take place through formal verbal communication and written documentation. Install as many visual indicators, signals, or controls as possible to help facilitate understanding and compliance.
•Objective, quantifiable measures (if not done previously in the project or Kaizen) must be created to monitor worker compliance and to determine if improvement is continuing to occur. Monthly or quarterly reports to management should be a norm.
Error - ProofingA technique for eliminating errors
Making it impossible to make mistakes
In Japan: Poka-Yoke. Poka means an inadvertent mistake. Yoke means to prevent
It is good to do it right the first time: it is even better to make it impossible to do
it wrong the first time.
Poke YokePoke-Yoke (pronounced Po-Ka Yo-kay) – stands for mistake –proofing
Usually the physical alteration of a devise or process so as to guarantee only one way (the right way) to carry out a task.•Electrical sockets – only one way to plug in•Petrol vs. diesel spouts at a gas station – a diesel nozzle will not fit into a petrol gas tank
Medical examples of Poke-Yoke:•Anesthesia gas equipment – port valves only designed for correct gas tubing (e.g. oxygen tubes can only fit on oxygen ports of the anesthesia equipment)
Error-Proofing Techniques
Technique Prevention Detection
Control (Shut Down)
An error is impossible
Defective item can’t move on to the next step
Warning An error is about to be made
An error has been made
Errors may either be prevented or detected
Why Do Errors Occur?• Incorrect or non-existent procedures• Overly complex processes• Excessive variation in the process• Excessive variation in the inputs• Inaccurate measuring system• Human error
Human Error Provoking Conditions
1. Adjustments2. Unclear or no instructions3. Undefined process 4. Many units/mixed units5. Multiple steps6. Infrequent production7. Ineffective or lack of standards8. Multiple handoffs9. Hand processing10. Rapid repetition11. High volume demand or deadline pressures12. Environmental conditions
Robust processes reduce Human Errors!
Three Inspection Methods• Traditional inspection (end of the process) – discovers
defects– Sort “good” from “bad” at the end of the process– Measure “Y” into categories (good/bad)
• Informative inspection (during the process) – reduces defects– Use process data to control/correct the process (e.g.
Statistical Process Control Charts)– Measure “Y” for variables information to control “Y”
• Source inspection (before the process) – eliminates defects– Inspect for error producing conditions in the process.– Measure and control “X’s” to create good “Y’s”
7 Steps to Error Proofing
1. Create a process map and identify the locations at which the defects are found and made
2. Evaluate current procedures for adequacy and determine if they are being followed
3. Identify defect provoking conditions at each process step
4. Identify the root cause(s) (error) of each type of defect and in which process step it occurs (FMEA, 5 Whys, Cause & Effect Diagram)
5. Identify the type of error-proofing device or process required (Brainstorming)
6. Create the device or process and try it
7. Measure for effectiveness
Section Review
• Standard Work• Error Proofing• Poke Yoke• Inspection Methods• Visual Controls
Break-out
Simulation
Simulation Round 4• Run for 5 minutes• Colors must be applied in sequence – first Red, then Green,
Orange, Blue, and Yellow• Great news! The hospital has gained such a reputation for
efficient and patient friendly operation that the department’s volume is expected to increase sharply. Your VP will tell you what volume you will need to handle during this round
• The Department Director recognizes that in order to meet the increased demand without adding staff, the department will have to operate more efficiently. She suggests that you may want to make additional improvements by redesigning the job descriptions. You will have 10 minutes to redesign the jobs, train everyone and rearrange the work layout as needed to accommodate the new roles.
• In your group, apply the concepts of Standard Work and error proofing to your simulated process
Dot Exercise Debrief
• What are the “Lessons Learned”?• Can you Apply these “Lessons
Learned” to your area?
Kaizen not maintained dissipates like smoke.
the lean proverbs
Lean Summary• Linking value stream map, cycle time analysis and
value analysis creates a compelling business case for change
• Making the process visible highlights potential problems and sources of variation
• Evaluate the flow through the operations to determine what hinders the flow
• Use the best tools available to help identify solutions / improvements (e.g., process maps, C&E diagrams, brainstorming, etc.)
• The leveled schedule and process sequencing should allow for the process flow to be paced according to customer demand
• TAKT is used to set the pace of the process step• Use Lean and Six Sigma tools in combination and / or
alone to solve your process problems
WebsitesPerformance Excellence Website (go live 8/20)Free Lean Six Sigma & Kaizen forms / images:
www.bmgi.org http://www.youtube.com/watch?v=wfsRAZUnonI
http://www.youtube.com/watch?v=lwWI-3z1wZ0
Pull system
Total Productive Maintenance
Total Preventive Maintenance
Value stream analysis in healthcare
Push system
Gemba kaizen Continuous Improvement
Kanban and Pull systems
Kanban
Lean kaizen Lean six sigma 5S Lean Visual Controls
Problem solving Value stream analysis 5S visual controls OEE
PEx Website (Online 8/20)
http://inside.uams.edu/performance-excellence
The End
What questions do you have?