Jennifer Wortham, Dr. PH
President, Society of Healthcare Improvement Professionals
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Introduction to the Lean
Management System
Lean and the Toyota Production System
▫ “Lean” is a management philosophy derived mostly from the Toyota Production System (TPS). It is renowned for its focus on reduction of the original Toyota seven wastes to improve overall customer value.
▫ The Toyota Production System is a comprehensive management system that focuses on continuous improvement and innovation. Key elements include:
Management System that focuses management on achieving strategy by aligning strategic goals with management objectives.
Active Daily Management (focuses on the execution of strategy).
Focused improvements – large cross-functional teams focused on improving a specific process.
Incremental improvements – everyone is doing improvements everyday.
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Why Lean
• Lean is a proven method that enables
organizations to improve service and quality,
reduce waste and free up resources.
• It accomplishes this through engaging
employees in continuous process improvement,
and sustaining gains through a systematic,
standardized approach to “process”
management.
Waste Categories & Healthcare Examples
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Excess Motion Searching for materials, people, information; gathering supplies from multiple carts/closets, walking between workstation.
Waiting Waiting for others to complete tasks before work can begin on the next task; waiting for tests results; physician waiting for access to OR (between cases).
Overprocessing Using more supplies then required to perform the job; gathering more information then required; over utilization in clinical practice (tests, medications).
Inventory Overstocked meds or supplies; supplies not available when/where needed; expired supplies.
Unused creativity Variation in practices, confusion/lack of clarity,
Idle staff, staff not performing at their level of capability
Overproduction Auto-copies of reports; multiple forms w/ same information, left-over food at meetings
Rework Unclear orders; correcting mistakes/errors; redoing work; medication errors; incorrect billing
Transportation Moving patients, supplies, equipment from one location to another.
Causes of Waste
• No method to prevent/catch errors
• Ineffective design/layout of
facilities
• Fragmented, poorly designed
processes
• Equipment failures
• Unorganized workspace
• No standards, non-compliance
with standards
• Poor communication
• No visibility to performance
• Lack of integrated systems & poor
system functionality
• Unbalanced workloads
• Lack of flexible workforce
• Inadequate training (no training)
• Batch systems
• Push vs. Pull
• Overburden or unreasonable
demand
• Redundancy in process
• Lack of information
• Poor layout
• Just in case
• Regulatory constraints
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Improvement Opportunities & Countermeasures
6
Eliminate excess motion, confusion and searching?
Reduce over-processing, & eliminate redundant and unnecessary steps?
Reduce / remove physical barriers to flow?
Ensure you have the supplies you need, when/where they are needed?
Perform more consistently?
Eliminate downtime due to equipment failures?
Eliminate mistakes?
The 5S System
Process Smoothing/Flow Design
Equipment, Office/Cube Layout
Kanban System
Standard Work
Overall Equipment Effectiveness
Visual Workplace/Error Proofing
Match resources to demand? Load Leveling
Reduce Wait-
times
Improve
Throughput
Improve
Quality
Enhance
Service
Making Improvements
• Lean improvements are managed through small tests of change using a Plan-Do-See-Act cycle.
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Do
See Act
Plan
1. What’s the problem, how
you know it’s a problem,
what causes it, what action
will address the cause?
2. Perform/test the action
that you think addresses the
causes
3. What was the result of the
test? Was an improvement
made?
4. If improvement made,
make the tested action the
standard. If not, what was
learned, what else needs to
be tried?
Lean Pathway for Large Improvement Projects
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Identify The Value Stream Process Mapping
Gap Analysis
Elimination of Waste Set Up Reduction, 5 – S, Takt
Improve Value Stream Flow Kaikaku , Visual Management
Improve Stream Quality TQM, Poka Yoke
Pull System Kanban,. JIT, P.O.U.
Continuous Improvement
Tra
inin
g &
Aw
are
ne
ss
Define the Problem
Analyze the Root Cause
Improve the Environment
Implement Error
Proofing
Control &
Standardize
Tra
inin
g &
Aw
are
ne
ss
Measure the Problem & Make it Visible
Improve the Process
Em
plo
yee E
ng
ag
em
en
t,
Tra
inin
g a
nd
Aw
are
ness
Eliminate Unnecessary Steps
5 S, Cell Design, Point of Service
Issue Analysis/Five Why’s
GEMBA / Data Collection/ Process Mapping
Problem and Issue Identification
Active Daily Management System (ADM) Strategic Goals / Focus Area
Sustain through ADM
Lean Six
Sigma
Process
Improvement
Methodology
Lean
Management
Practice
Continuous Flow
Work-loads
are balanced Redundant
work is eliminated
Just in Time
Right Service Right Time
Right Amount
Right Place
True North
Patient Focused
Built-in-Quality
Errors are prevented
We never pass along defects
The Lean Health Care Model
Lean Management System
Workplace Organization – 5S
Culture: Respectful - Responsive - Responsible
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Measure What
Matters
Focused
goals, data driven
decisions and regular
review of performance
Make It Visual
Display /
review performance
metrics
Standardize Work
Identify and spread best
practices
Continuous Improvement
Engage the front-line through huddles, posting
performance to standards & rounding
Lean Management
System
Sy
ste
ma
tic
Ma
na
ge
me
nt
Ac
tive
Da
ily M
an
ag
em
en
t
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Advantages of the
Lean Management System
• Establish clear quarterly goals for improvement, and
align unit-level work group activities with our supporting
commitment goals and priorities.
• Better communication of goals and expectations
• Help us achieve greater transparency
• Involving employees will promote teamwork
• Helps identify and solve problems instead of working
around them
• Provides a mechanism to measure on-going progress
How Lean Works
• Aligns and integrates work (add value, decrease activity)
• Articulates consistent expectations for the organizations
leaders
• Improves organizational results
• Builds stronger leaders
• Engages everyone in problem solving
• Greater transparency and faster response
• Removes waste and adds value for the customer
Objective Management Plan
Each department should have an objective management plan in place for their each of their areas of responsibility. The purpose of the objective management plan is to: • Provide an overview of the departments longer-term goals • Provide a summary of the departments current (monthly,
and YTD) goals and performance against those goals • Include plans to achieve the goals, including the specific
tasks and associated deliverables • Include analytics and drivers behind each gap in
performance • List issues and possible goals for the following quarter • Identify required resources, if any, to achieve goals • Include anticipated impediments and plans to remove
them
Monthly Management Operating Review & Objective Reporting Tool
Management performance reviews
should be conducted on a regular
basis:
• Directors meet with VP to
establish focus goals and report
on progress towards objectives
every month
• Directors meet with managers to
review progress with active daily
management objectives every
week
Director: VP:
Goal Actual Trend
Due % Com Status
Month / Year
Measure / Description Notes / Action Plan
Service Recovery
Visual Boards
Process flows / metrics
Objective
Act
ive
Dai
ly
Man
age
me
nt Daily Huddles (All shifts)
Peer Rounds
Purposeful Rounding
Evaluations Completed Timely
Employee Recognition
Turn-around times
Effi
cie
ncy
&
Re
sou
rce
Ste
war
dsh
ip
He
alin
g
Envi
ron
me
nt
Co
urt
esy
&
Car
ing
Par
tne
rsh
ipC
linic
al
Exce
llen
ce
HCAHPS
Budget
Department:
A3
's in
Pro
gre
ss
Core Measures
Next Steps
Ke
y In
itia
tive
s
Introducing Leader Standard Work
• Leader Standard Work is a critical
step in ensuring that our Lean
Culture prospers. But, Leader
Standard Work is dependent on a
few things. In what follows, I’ll
cover a few of those items and
provide an example of Leader
Standard Work.
Why Implement Leader Standard Work
• Leader standard work is a set of practices and key activities that bring
greater focus to process performance, helps identify opportunities for
improvement, and enables us to sustain improvement gains.
• Leader Standard work requires a change from traditional management
thinking.
▫ In a conventional world, experienced managers and supervisors
have learned how to patch up and work around problems, to get the
job done.
▫ In the Lean way of thinking, we identify problems, and then ask,
‘Why?’ The focus is on improvement, looking for clues, to
understand and improve.
▫ Visual charts reflect how processes are performing. Keeping these
charts current “leads to identifying problems as they occur, like
preserving evidence at the scene of the crime, where the process
stumbled or was out of “standard”.
Key Lean Management System Tools
• Systematic Management
▫ People and strategy alignment
Focus on the “True North Goals”
▫ Objective reporting (dashboards/metrics)
▫ Leader standard work
• “Active Daily Management” for continuous process
improvement
GEMBA (Go see) “Rounding” and coaching in the
moment
Standard work reinforced through a visual workplace
Team Huddles focused on continuous improvement –
PDSA/Lean projects – with visibility to performance
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Rounding
• Rounding
• Provides the manager an
opportunity to see work as it is
performed
• Observe critical to quality
metrics
• Observe and coach
standard work
• Round with a checklist and
tracking tool
• Post results on the huddle
board
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M T W Th F M T W Th F M T W Th F M T W Th F
All Staff 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am
Team Leader
MD of the Day
AN II
Liza Caabay9am 7am 9am 7am 9am 7am 9am 7am
Operations Manager
Erick Ascencio11am 7am 11am 7am 11am 7am 11am 7am
Manager, Non-Invasive
Robert Yang7am 7am 7am
Manager
Lisa Gorski7am
Director
Johanna Bruner7am 7am 7am 7am 7am 7am 7am 7am 7am 7am 7am 7am
Director of Operations
Dr. Mahajan7am 7am 7am 7am
Executive Director
Shannon O'Kelley7am 7am
Medical Directors
Dr. Shivkumar and Dr. Tobis 7am
Pediatric Team
Drs. Alejos, Patel, Aboulhosn,
Levi, Schwarzenberger
7am
Key
AM Huddle
AM Coordination Rounds
CICARE Rounds
Management Rounds
*Quarterly Rounds
RRUMC Cardiovascular Linked Check-ins
Week 1 Week 2 Week 3 Week 4
Month
Visual Management
• Visual Queues – signs, visible standards, and posted instructions.
• Performance board and huddle boards in each unit.
• Performance Board: departmental-level metrics, goals, and tactics
• Huddle (two-way Communication) board: includes measures that are relevant to staff, updated daily with daily stats and trended where indicated. Staff can write on the board or use sticky notes to share their ideas for improvement. Display feedback from patients (i.e., staff recognition, and/or complaints, etc.).
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Service
Financial
Quality
Growth
People
Key
Drivers of Performance
A3’s In Progress &
Completed
Audit of Compliance with
Standard Work
History
Performance Over Time
x x x x
Example:
Daily data
Department/Division Performance Board
Example Departmental Visual Wall
• Department and unit-level goals and performance metrics (include
process/task level metrics)
• Updated daily with daily stats and trended where indicated.
• Improvement opportunities / A3’s
• Displays feedback from patients (i.e., staff recognition, and/or
complaints, etc.).
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Daily Stat On Cycle Time % for Stats
Staff-level Measure
A3’s Improvement Projects
Audit of Compliance with Standard Work
Building a Department /
Division Performance Board Goal & History of
Departments Performance Over Time
Key Drivers of Performance
A3’s Improvements /
Standard Work
Audit of Compliance with
Standard Work
Example
Department/Units History of
Performance Over Time
Key
Drivers of Performance
Tests and
treatments
are
thoroughly
explained
Plan of Care
Not Explained
in Clear
Terms
Standard
Process for
Communicating
Plan of Care
Observation of
Staff
Communicating
Plan of Care
Customer Service
This is the metric you should include in the Staff Huddle Board
Summary
Your Performance Board should:
• Communicate about the things that matter to your department.
• Create transparency – staff need to understand how they are performing
• Instill and reinforce standard work
• Communicate improvements being made – so everyone can support the change effort
Team Communication - Daily Huddles
• Daily Huddles provide an excellent
means for two-way communication
with staff
• Daily huddle message
• Review critical to quality metrics
• Review trended dashboard metrics
• Engage staff in the process of
improvement
• Provide valuable and timely coaching
• Read patient comments and customer
feedback
• Update staff on process or method
changes
Running the Huddle
1. Manager, supervisors, leads and staff gather at the huddle board.
2. Conduct shift updates (staffing situation, special requests/events, patient hand-off’s, etc.)
3. Start by reviewing improvement work in progress. 4. Briefly review your A3’s. If the status indicator is
green move on, if red take a moment to discuss. 5. Prioritize opportunities to determine improvements
that will be implemented and those that will be tabled.
6. Assign resources to new improvement actions. 7. Take a moment to acknowledge a staff person for job
well done.
Examples
• http://www.youtube.com/watch?v=uaQ8GGXCxjM
• Everett Clinic
• http://www.youtube.com/watch?v=dJrORZEiXpo
• Intermountain
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Develop Your Huddle Strategy
Question Your Strategy
Where should the huddle board be located in your department?
How often should you have huddles (list time of day / day of week, etc.)?
Who should participate in the huddle?
Who will lead the huddle?
What are the key objectives of your huddle?
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