1 Camille Camille Rozon Rozon , , MHA, CHE, PMP, IAMP MHA, CHE, PMP, IAMP - - D D 20 October 2010 20 October 2010 LEAN LEAN ing ing Healthcare... Healthcare... the evolution of quality concepts the evolution of quality concepts (and where all those buzzwords come (and where all those buzzwords come from) from)
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Camille Camille RozonRozon, , MHA, CHE, PMP, IAMPMHA, CHE, PMP, IAMP--DD
20 October 201020 October 2010
LEANLEANinging Healthcare... Healthcare... the evolution of quality concepts the evolution of quality concepts (and where all those buzzwords come (and where all those buzzwords come from) from)
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What we are here to talk aboutWhat we are here to talk about
• The history of quality, from inspection to Continuous Quality Improvement, and its modern branded interpretations such as Six-Sigma, LEAN and beyond.
• The difference between quality tools and quality culture
“Quality has to be caused, not controlled.”Philip Crosby
Walter Shewhart -1920s•• First sketch of a modern control chartFirst sketch of a modern control chart
“Assignable causes of variation may be found and eliminated.”
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W. Edwards Deming W. Edwards Deming –– 1950s 1950s
14 Key Principles of Management14 Key Principles of Management
Leadership for change
Transformation is everybody's job
Improve constantly and forever
"The worker is not the problem. The problem is at the top! Management!"
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1st major International 1st major International Quality Control ConferenceQuality Control Conference
•• ““Total quality controlTotal quality control includes not only includes not only workers but all level workers but all level of managementof management”” Cause and Cause and
Effect Diagram Effect Diagram
Kaoru Ishikawa - 1969
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• Key ConceptsDecentralizationWorkers are assets &
knowledge workerCompanies are nothing w/o
customersSubstance over style
Peter Drucker Peter Drucker -- 19501950--1970s1970s“Management is doing things right; leadership is doing the right things.”
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Toyota Way 1948 Toyota Way 1948 -- 1975 1975 The The Toyota WayToyota Way is is management management commitment to commitment to continuously invest in its continuously invest in its people and promote a people and promote a culture of continuous culture of continuous improvement.improvement.
The The Toyota Production Toyota Production SystemSystem, also known as , also known as LEANLEAN, is the most , is the most systematic and highly systematic and highly developed example of developed example of what the principles can what the principles can accomplish.accomplish.
““The highest form of LEAN cannot The highest form of LEAN cannot be achieved unless the be achieved unless the CULTURECULTURE is there to support it.is there to support it.””
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LEAN Principles LEAN Principles
•• LEAN is not an event it is a lifestyle!LEAN is not an event it is a lifestyle!
1.1.Long term Long term -- even at the expense of short term gaineven at the expense of short term gain
2.2.Continuous improvement Continuous improvement -- includes the 8 wastesincludes the 8 wastes
3.3.Use Use ““PULLPULL”” systems systems -- downstream signals need for moredownstream signals need for more
4.4.LevellingLevelling
5.5.Stop & fix the problems so you get it right the first timeStop & fix the problems so you get it right the first time6.6.Standardize wherever possibleStandardize wherever possible
7.7.Use visual controls Use visual controls -- includes 5Sincludes 5S10
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LEAN PrinciplesLEAN Principles8.8. Use reliable tested technologyUse reliable tested technology
9.9. Grow your leadersGrow your leaders
10.10. Develop exceptional teamsDevelop exceptional teams
11.11. Help your partners and suppliers to improveHelp your partners and suppliers to improve
12.12. Go & See Go & See -- the power of direct observationthe power of direct observation
13.13. Make decision slowly Make decision slowly -- implement quicklyimplement quickly
14.14. Never stop asking Never stop asking ““How can we be better?How can we be better?””
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5 steps in a LEAN improvement event5 steps in a LEAN improvement eventSpecify value Specify value –– from the patientfrom the patient’’s s perspective (what are they willing perspective (what are they willing to pay for)to pay for)
Map the Value Stream Map the Value Stream –– Map all Map all the steps in the processthe steps in the process
Identify waste Identify waste –– using the list of using the list of 8 wastes8 wastes
Eliminate wastes Eliminate wastes –– identify identify strategies (not work arounds)strategies (not work arounds)
Analyze success, adjust and Analyze success, adjust and repeat cyclerepeat cycle
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Value Stream MapValue Stream Map
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5 steps in a LEAN improvement event5 steps in a LEAN improvement eventSpecify value Specify value –– from the patientfrom the patient’’s s perspective (what are they willing perspective (what are they willing to pay for)to pay for)
Map the Value Stream Map the Value Stream –– Map all Map all the steps in the processthe steps in the process
Identify waste Identify waste –– using the list of using the list of 8 wastes8 wastes
Eliminate wastes Eliminate wastes –– identify identify strategies (not work arounds)strategies (not work arounds)
Analyze success, adjust and Analyze success, adjust and repeat cyclerepeat cycle
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What does waste look like?What does waste look like?DDefectsefects
•• Moving patients to testsMoving patients to tests
•• Tests batched, waiting for equipmentTests batched, waiting for equipment
•• Looking for information, equipment, suppliesLooking for information, equipment, supplies
•• ReRe--testing, resending informationtesting, resending information
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How can you tell if there is waste?How can you tell if there is waste?
•• RemeasureRemeasure
•• RemakeRemake
•• ReRe--evaluateevaluate
•• RecallRecall
•• RedoRedo
•• RepeatRepeat
•• RedesignRedesign
•• ReviewReview
ReshipReship
RetypeRetype
RetestRetest
ReissueReissue
RejectReject
ReviseRevise
ReturnReturn
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5 steps in a LEAN improvement event5 steps in a LEAN improvement eventSpecify value Specify value –– from the patientfrom the patient’’s s perspective (what are they willing perspective (what are they willing to pay for)to pay for)
Map the Value Stream Map the Value Stream –– Map all Map all the steps in the processthe steps in the process
Identify waste Identify waste –– using the list of using the list of 8 wastes8 wastes
Eliminate wastes Eliminate wastes –– identify identify strategies (not work arounds)strategies (not work arounds)
Analyze success, adjust and Analyze success, adjust and repeat cyclerepeat cycle
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Waste ManagementWaste Management
Go and see Go and see –– direct observation direct observation -- A3 reportA3 report
Timed observation Timed observation –– 11-- 2 weeks, 3 to 10 observations2 weeks, 3 to 10 observations
Circle of Work Circle of Work –– time for motion, wait, travel, waste (think time for motion, wait, travel, waste (think ““rere””), ), actual workactual work
Spaghetti maps Spaghetti maps –– staff and patient movementstaff and patient movement
5S 5S –– Sort, set in order, shine, standardize, sustainSort, set in order, shine, standardize, sustain
A3 ReportsA3 ReportsGraphic representation of the Graphic representation of the ““problemproblem””Basis for root cause analysisBasis for root cause analysis
The 5 whysThe 5 whysCountermeasures are identifiedCountermeasures are identifiedNew ideal state is then describedNew ideal state is then describedHow to implement the countermeasuresHow to implement the countermeasures
WhatWhatWhoWhoWhenWhenOutcomeOutcome
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A3 Report TemplateA3 Report Template
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Waste ManagementWaste Management
Go and see Go and see –– direct observation direct observation -- A3 reportA3 report
Timed observation Timed observation –– 11-- 2 weeks, 3 to 10 observations2 weeks, 3 to 10 observations
Circle of Work Circle of Work –– time for motion, wait, travel, waste (think time for motion, wait, travel, waste (think ““rere””), ), actual workactual work
Spaghetti maps Spaghetti maps –– staff and patient movementstaff and patient movement
5S 5S –– Sort, set in order, shine, standardize, sustainSort, set in order, shine, standardize, sustain
•• Identify the major Identify the major activities in your activities in your job and track for job and track for 11--2 weeks to 2 weeks to identify areas for identify areas for improvementimprovement
29% of the time is spent waiting to consult with physician
Example: COW for Sonographer in Antenatal Testing Unit
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Waste ManagementWaste Management
Go and see Go and see –– direct observation direct observation -- A3 reportA3 report
Timed observation Timed observation –– 11-- 2 weeks, 3 to 10 observations2 weeks, 3 to 10 observations
Circle of Work Circle of Work –– time for motion, wait, travel, waste (think time for motion, wait, travel, waste (think ““rere””), ), actual workactual work
Spaghetti maps Spaghetti maps –– staff and patient movementstaff and patient movement
5S 5S –– Sort, set in order, shine, standardize, sustainSort, set in order, shine, standardize, sustain
How to create a spaghetti mapHow to create a spaghetti map
Tool that helps identify waste / physical bottlenecksTool that helps identify waste / physical bottlenecks
Show where staff/patients move during processShow where staff/patients move during process
Things to rememberThings to remember
Get as accurate space plan as possibleGet as accurate space plan as possible
Observe then followObserve then follow
Do not lift pencil Do not lift pencil –– continuous flowcontinuous flow
Measure total distanceMeasure total distance
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Waste ManagementWaste Management
Go and see Go and see –– direct observation direct observation -- A3 reportA3 report
Timed observation Timed observation –– 11-- 2 weeks, 3 to 10 observations2 weeks, 3 to 10 observations
Circle of Work Circle of Work –– time for motion, wait, travel, waste (think time for motion, wait, travel, waste (think ““rere””), ), actual workactual work
Spaghetti maps Spaghetti maps –– staff and patient movementstaff and patient movement
5S 5S –– Sort, set in order, shine, standardize, sustainSort, set in order, shine, standardize, sustain
SortSort: separate needed from unneeded: separate needed from unneeded
Set in OrderSet in Order: arrange how remaining items will be : arrange how remaining items will be usedused
ShineShine: Repair / replace all necessary items: Repair / replace all necessary items
StandardizeStandardize: system to maintain order: system to maintain order
SustainSustain: Periodic checks for continued maintenance: Periodic checks for continued maintenance
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Waste ManagementWaste Management
Go and see Go and see –– direct observation direct observation -- A3 reportA3 report
Timed observation Timed observation –– 11-- 2 weeks, 3 to 10 observations2 weeks, 3 to 10 observations
Circle of Work Circle of Work –– time for motion, wait, travel, waste (think time for motion, wait, travel, waste (think ““rere””), ), actual workactual work
Spaghetti maps Spaghetti maps –– staff and patient movementstaff and patient movement
5S 5S –– Sort, set in order, shine, standardize, sustainSort, set in order, shine, standardize, sustain
The workplace is set- up with signs, labels, colour-coded markings, etc. so anyone unfamiliar with the process will know what is going on, understand process, and know what is being done correctly and what is out of place.
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Waste ManagementWaste Management
Go and see Go and see –– direct observation direct observation -- A3 reportA3 report
Timed observation Timed observation –– 11-- 2 weeks, 3 to 10 observations2 weeks, 3 to 10 observations
Circle of Work Circle of Work –– time for motion, wait, travel, waste (think time for motion, wait, travel, waste (think ““rere””), ), actual workactual work
Spaghetti maps Spaghetti maps –– staff and patient movementstaff and patient movement
5S 5S –– Sort, set in order, shine, standardize, sustainSort, set in order, shine, standardize, sustain
and supplies and supplies that are that are frequently and frequently and predictably predictably required for a required for a processprocess
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ISO 9000 ISO 9000 -- 1980s1980s
Off-the-shelf, canned, "just add water" quality solutions cannot generate the level of human commitment within the organization needed to succeed.Peters and Austin - A Passion for Excellence: The Leadership Difference
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Six SigmaSix Sigma19801980
Motorola Corp.Motorola Corp.
Reduce defects to 3.4 / Million Reduce defects to 3.4 / Million
or 99.99966% = to six standard deviations or 99.99966% = to six standard deviations σσ SigmaSigma
Six Sigma’s focus is measurement tools to help identify problems and establish when they are resolved.
Lean is operations tool to help define from a system-wide perspective the most effective way for work to be performed.
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Collaborative Collaborative Model 2003Model 2003
White PapersWhite Papers
LEAN 2005LEAN 2005
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Michael Hammer 1990
• Advanced the concept of Business Process Re- Engineering
“The major challenge for managers is to obliterate non-value added work.”
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“Reengineering Health Care gets to the core of transforming our current system by advocating the widespread use of IT, eliminating inefficient practices, and keeping the system focused on a healthy individual and not on a broken process.”Newt Gingrich, Founder of the Center for Health Transformation, and former Speaker of the U.S. House of Representatives
June 2010June 2010
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AgileAgile Methodology 2001Methodology 2001
Origins in software development Origins in software development
Iterative and incrementalIterative and incremental