Lean What Is It, and How Does It Work

Lean – What Is It, and How Does It Work?

Dean Bliss

Iowa Health System

WCBF 9th Annual Lean Six Sigma

And Business Improvement in Healthcare Summit

A little about me…

Where did Lean come from?

Key Publications

� 1990: The Machine that Changed the World – The Story of Lean Production

� 1996: Lean Thinking� 1998: Learning to See� 1999: Decoding the DNA of the Toyota Production System

(Harvard Business Review article)� 2004: The Toyota Way� 2005: Lean Solutions� 2006: The Lean Healthcare Pocket Guide� 2006: A Lean Guide for Transforming Healthcare� 2007: Lean for Dummies� 2008: Toyota Culture� 2009: Lean Hospitals

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.”

� “Lean thinking also provides a way to make work more satisfying by providing immediate feedback on efforts to convert muda (waste) into value.”

- quotes from Lean Thinking, by James Womackand Daniel Jones (1996)

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Womack’s 5 Principles of Lean Thinking

� Specify value from the customer’s perspective

� Identify the value stream for each product and remove the waste

� Make value flow without interruptions from beginning to end

� Let the customer pull value from our processes

� Pursue perfection – continuous improvement

Do this every day in all our activities

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Does this sound familiar?

� Call the clinic, 3 voice prompts, on hold, leave message� Clerk calls back and sets a date for next week� Arrive for visit, check in, sit in waiting room� Called into exam room, wait for doctor� Doctor sees you, says she’s been waiting for you� Diagnoses a URI, and BP is worse� Doctor prints antibiotic prescription, goes to staff room to get it.

You are allergic to that drug� Doctor says to return in a week for the BP� At check out you ask the cost – clerk says they’ll bill you� No appointments available next week� Pharmacist says insurance prefers a different drug

Is there a problem here?

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Using Womack’s 5 Principles In the Clinic Visit

� Specify value from the customer’s perspective� A quick, effective clinic visit

� Identify the value stream� Request, appointment, arrival, seeing doctor, checkout

� Make value flow� Staff and patient moving continuously from check-in to exit

� No waiting room, no staff waiting

� Errors surface immediately

� Let the customer pull value from our processes� Pull the appointment or med refill when you want it

� Pursue perfection – continuous improvement� Every day, every clerk, every doctor, every nurse thinks about

how to redesign work to improve value to the customer

Keys to Success

� Those who do the work should be those who develop the new process

� Involve all affected stakeholders

� Don’t settle for the “easy” stuff

� Have resources available

� Do what we say we are going to do

� Make changes now

But what kinds of things are we looking for?

7 Forms of Waste

7 Forms of Waste

Time spent waiting on items required to complete task(i.e., Information, Material, Supplies, etc.)

1. Waiting

7 Forms of Waste

Any motion that does not add value to the product or service

2. Excess Motion

7 Forms of Waste

Transporting information or Material by mail, cart,conveyor or foot travel

3. Moving Items

7 Forms of Waste

Time spent repairing or reworking material or information

4. Fixing Defects

7 Forms of Waste

Producing more information or product than theultimate customer requires

5. Over Production

7 Forms of Waste

Material or Information that is waiting for processing

6. Inventory

7 Forms of Waste

7. Over Processing

Effort and time spent processing information or material that is not adding value

APPROVED

APPROVEDAPPROVEDAPPROVEDAPPRO

VEDAPPROVEDAPPROVEDAPPROVED

Lean Tools

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Lean Tools

� Value Stream Analysis- Process map w/ data

� Standard Work- best way to complete a task

� 5S- organize and manage a workplace

� A3- structured problem solving tool

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Lean Tools

� Error Proofing- limits operations to desired effect

� Visual Controls- guide action of the group

� Kanban- visual inventory management

� Spaghetti Charts- distance traveled

� Root Cause Analysis- 5 why’s and fishbone

� Andon Signal- stop the line/fix the problem

� Defines value from the customer’s perspective

� All of the actions and tasks, both value added and non-value added, required to bring an item (an idea, information, product or service) from its inception through delivery.

� Mapping the process brings common understanding and the ability to see weaknesses that can be corrected/improved

Value Stream Mapping

Value Stream Map - Emergency Room

Wait

Out Patient

RegistrationTaken to ER

Room

Nurse Examines

Patient

Doctor Examines

Patient

Nurse brings Medical Supplies

Doctor Treats Patient

Patient Goes Home

Patient Hospital Records

Attending Nurse

Attending Physician

Material Flow

Information Flow

Go to Waiting

Area

Wait Wait Wait Wait

Insurance Company

Departing Instructions

Wait

Available Room

Patient history Vital Statistics

Patient history Vital Statistics

Treatment Information

Diagnosis & Supply Needs

Treatment Information

Insurance InfoNature of Injury

Patient history

Patient Info

Patient ready for Treatment

Patient history Vital Statistics

Diagnosis & Departing Inst.

Departing Instructions

Lean Tools

Standard Work

Represents the current best, easiestand safest way to do a job.

Lean Tools

Standard Work

Removing Variation and Variability

Using Best Practices Consistently

A3

� A single sheet of paper (A3 size, 11x17) that, for a project, contains the:

� Problem

� Analysis

� Corrective actions

� Action plan

The Five S’s

� Sorting – separating the needed from the not-needed

� Simplifying – a place for everything and everything in its place, clean and ready to use

� Systematic Cleaning – cleaning for inspection

� Standardizing – developing common methods for consistency

� Sustaining – holding the gains and improving

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Lean is a Culture

� Lean is a management style….not a bunch of tools.

� Lean initiatives aren’t successful from the conference room….go to where the work is being done.

� “SEE” the 7 wastes and remove them from your processes.

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What is the Toyota Way?

� A total business philosophy aimed at driving value to the customer and society

� A culture, the “DNA,” “its in our blood.”� A long-term, sustainable learning organization

� The particular culture that evolved over decades at Toyota

� Guiding principles of people, process, and technology

� A spirit of challenge and competitiveness

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The Toyota Way

� Respect: Build mutual trust

� Teamwork: Maximize team performance

� Challenge: A long-term vision to realize dreams through courage and creativity

� Kaizen: Improve relentlessly

� Always go to the source

CONTINUOUS IMPROVEMENT

RESPECT FOR PEOPLE

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The Lean Leader leads:� By setting the vision (more why than how)

� By building systems and processes that cascade responsibility

By influence

� by example

� by being knowledgeable

� by getting into the messy details

� by coaching and teaching� through PDSA learning cycles

� through questioning

Lean Leadership = Mentorship

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Why is the Toyota Way difficult to teach and difficult to Sustain?

Not the natural way to approach problems and make decisions� Going and seeing when we have already been there

� Observation is different than “walking around”

� Seeking alternative solutions when we have a “good enough” solution

� “Good” is the enemy of “great”

� Thinking beyond our own group’s interests in a budget-conscious culture

� Recording and analyzing data, following standardized procedures, updating standards as conditions change

� Data-driven decision-making, rather than intuition

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The Leader’s Challenge

The essence of Leadership can be summed up simply:

“Get everyone in the organization to take initiative to continually improve their jobs”

“Align all jobs (all processes, all work) around providing value for the customer. “

This isn’t magic

� The concepts and practice of process improvement aren’t

� Rocket science, or

� Brain surgery, or

� Quantum physics

� With a little training and practice, anyone can do them

Rawlings video

Healthcare Examples

� Chemotherapy turnaround time improved 37%

� Cash flow improved by $8.1 million

� Lab turnaround time improved 64%

� CT capacity increased 30%

� Nurse walking distanced decreased over a mile a day

So keep in mind…

� The 7 forms of waste

� The Lean tools

� The Lean vision

� “Learning to see”

� Willingness to change

� Continuous improvement

“Do what you can, with what you have, where you are.”

Theodore Roosevelt

“The things that matter most must never be at the mercy of things which matter least.”

Johann Wolfgang von Goethe

How can you do this?

� Your hospital association

� Local Lean companies

� Manufacturing Extension Partnerships (MEP)

� Institute for Healthcare Improvement

� Universities/Community colleges

� Online connections

� Start a group

Online resources

� www.lean.org� Articles, events, information

� www.leanblog.org� Discussion on lean topics

� http://finance.groups.yahoo.com/group/hme/� http://finance.groups.yahoo.com/group/NWLEAN/

� Discussion groups, where questions can be posed and answered

� www.ihi.org� Institute for Healthcare Improvement

� www.ihconline.org� Information, resources, success stories

Questions?

Dean Bliss

Iowa Health System

Cedar Rapids, Iowa

515-979-9413

[email protected]