Transcript Document

Healthcare Operations
Management
An Integrated Approach to
Improving Quality and Efficiency
Chapter 9. The Lean Enterprise
Daniel B. McLaughlin
Julie M. Hays
Chapter 9. The Lean Enterprise
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Definition of Lean
Types of waste
Kaizen
Value stream mapping
Tools
- Takt time, throughput time, five Ss, spaghetti diagrams,
kaizen events, standardized work, jidoka, andon,
kanban, SMED, flow and pull, heijunka, advanced
access
• Lean Sigma
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What Is Lean?
• Elimination of waste
- Toyota Production System (TPS)
• Philosophy
- Produce only what is needed, when it is
needed, with no waste
• Methodology
- Determination of value added in the process
• Tools
- Five Ss, kaizen event, standardized work, etc.
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Types of Waste (Muda)
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Overproduction
Waiting
Transportation
Inventory
Motion
Overprocessing
Defects
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Kaizen Philosophy
• Employee-led continuous improvement
• Five steps
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Specify value
Map and improve the value stream
Flow
Pull
Perfection
• Even if it isn’t broken, it can be improved.
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9-5
Value Stream Mapping
• Process map of the value stream
• Includes information processing and
transformational processing
• Value-added steps: “Would the customer be
willing to pay for this activity?”
• Non-value-added steps
- Necessary
- Unnecessary
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Value Stream Mapping
Nurses’ time spent on
non-patient care
Supplies
Housekeeping
Rooms
not available
Radiology
LOS
Lab
Long wait after
cleared to discharge
Pharmacy
Anesthesiology
Social
Services
Education
late
Slow
turnaround
Rooms
unavailable
Diagram created
with eVSM
software from
GumshoeKI, Inc.,
a Microsoft Visio
add-on.
Stabilize
Porter
Incorrect
patient forms
Patients
Admitting
Triage
0-2 hr
30-90 min
Labor
and
Delivery
1-3 hr
1-3 hr
Post
Partum
1-8 hr
1-60 hr
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Discharge
1-5 hr
20-80 hr
3 hr
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Tools
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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
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9-8
Takt Time
• The speed with which customers
must be served to satisfy demand for the service.
Available work time/day
T akt time
Customerdemand/day
• Cycle time is the time to accomplish a task in the
system.
• System cycle time is equal to the longest task
cycle time in the system—the rate at which
customers or products exit the system, or
“drip time.”
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9-9
Throughput Time
• Time for an item to complete the entire
process, which includes:
- Waiting time
- Transport time
- Actual processing time
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Riverview Clinic
Cycle, Throughput, and Takt Time
Patient check-in
3 minutes
Move to examining room
2 minutes
Wait 15
minutes
Nurse does
preliminary exam
5 minutes
Physician exam
and consultation
20 minutes
Wait 15
minutes
Visit complete
Wait 10
minutes
Diagram created with eVSM software from
GumshoeKI, Inc., a Microsoft Visio add-on.
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Riverview Clinic
Cycle, Throughput, and Takt Time
• Patient check-in cycle time = 3 minutes.
• System cycle time = cycle time for longest task =
physician exam and consultation = 20 minutes.
• Throughput time = 3 + 15 + 2 + 15 + 5 + 10 + 20 =
70 minutes.
• Takt time  8 physicians  5 hours/day
100 patients/d ay
 0.4 physician hours/pati ent
 24 physician minutes/pa tient.
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Riverview Clinic
Value-Added Time
• Valued-added tasks:
- Nurse preliminary exam
- Physician exam and consultation
• Non-value-added steps, necessary:
- Patient check-in
• Value-added time = 5 minutes (nurse preliminary
exam) + 20 minutes (physician exam and
consultation) = 25 minutes.
• Percentage value-added time = 25 minutes/70
minutes = 35 percent.
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Five Ss
• 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.
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Spaghetti Diagram
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Kaizen Blitz or Event
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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
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Plan
Do
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Results of 175 Rapid Process Improvement
Weeks at Virginia Mason Medical Center
Source: Womack, J. P., A. P. Byrne, O. J. Fiume, G. S. Kaplan, and J.Toussaint. 2005. "Going Lean in Healthcare."
Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Online information available at:
http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm.
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Standardized Work
• Written documentation of the way in which
each step in a process should be performed
• Not a rigid system of compliance, but a
means of communicating and codifying
current best practices
• Massachusetts General Hospital care paths
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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.
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Kanban
Empty
Kanban
Empty
Kanban
Full
Kanban
Task 1
Workstation
1
Full
Kanban
Task 2
Workstation
2
Customer
Order
Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.
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Kanban
Signal
patients
Signal
echo
patients
CT
Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.
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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
- Convert internal setup activities to external
activities
- Streamline all setup activities
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Flow and Pull
• Continuous or single piece flow—move items
(jobs, patients, products) through the steps of the
process one at a time without interuptions or
waiting.
• Pull or just-in-time (JIT)—products or services are
not produced until the downstream customer
demands them.
• Heijunka—“make flat and level”; eliminate
variation in volume and variety of “production”
- Level patient demand
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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.
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Advanced Access
Advantages
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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
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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.
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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
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