Transcript Document

World-Class Performance
Lean in
Healthcare
Operations
“A Lean Guy Goes to
the Hospital”
Presented Aug 4, 2006
Mark Graban, LFM ‘99
Senior Consultant, ValuMetrix® Services
Ortho-Clinical Diagnostics, Inc.
Agenda
• The Crisis of Waste in Healthcare
• Lean Thinking Principles in Healthcare
• Benefits for:
– Patients
– Employees
– Hospitals
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Mark’s Spaghetti Chart
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Who Do I Work For?
• ValuMetrix Services (Ortho-Clinical Diagnostics)
– Started in 2001 running Lean and Six Sigma pilots in labs
– Launched as a fee-for-service consulting business in 2003
• Not “internal consultants”
– 100% dedicated to healthcare projects
• Hospitals, Laboratory Companies
• U.S., Canada, Europe, China
– Application of the J&J “Process Excellence” Model
– Project-based approach, lean coaching, “train the trainer”
• Goal is to help build a lean enterprise, not to do “kaizen events”
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In the News Almost Daily…
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Hospitals Are Dangerous…
CDC 1998:
90,000 killed
and 2,000,000
injured from
hospital-caused
drug errors &
infections
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Preventable Errors Abound…
“… 3 to 5% of
specimens taken
each year are
defective… blood
that isn’t drawn
correctly… mix-up
with another
patient’s sample”
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Preventable Errors Abound…
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Preventable Errors Abound…
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Mass Production or Healthcare?
• Large batches
• Sub-optimizing one
resource
• Automation is the
answer
• Lack of employee input
• Lack of standard
processes
• One-person / Onemachine
• Not communicating
metrics
• Quality through
inspection
• Lack of leadership
• Constant fire fighting
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Non-Lean, Current Thinking
1. Specify value in the eyes of the
provider (or the payer)
2. Identify your department and
sub-optimize it
3. Make patients wait for the
convenience of the system
4. Ignore some employees and
devalue others
5. Continuously fight the same
fires in the pursuit of surviving
the day
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Applications of Lean in Healthcare
• Laboratories
– Reducing Turn Around Times and Errors
• Emergency Departments
– Reducing diversions, improving flow
• Outpatient Cancer Treatment
– Reducing patient delays, increasing capacity
• Operating Rooms
– Reducing changeover times, increasing utilization
• Pharmacies
– Reducing errors, improving response
• Food Service
– Reducing wasted food, improving quality
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Why LEAN Works in Healthcare
• LEAN is not a list of tools that applies only to
factories
• LEAN is a philosophy of management that
applies to any system
• LEAN rallies people around goals we can all
agree on:
– Patients and Employees
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Not About Cutting Heads
• Shortages of skilled employees
– 51% of hospital med techs greater than 45 years of age,
vacancy rate at 11%
– Shortfall of 265,000 nurses expected by 2010
• Do more…
– With the same
– Eventually, with less
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Not Only About Cutting Costs
• Hospitals are using lean as a
Business Strategy
– Improving quality
– Improving service
– Improving employee satisfaction
– Growth strategies
– “Un-outsourcing” testing work
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Principles of LEAN Thinking
1. Specify value in the eyes of
the customer.
–
–
The customer must be willing to pay
for the activity
–
The activity must change the form, fit
or function of the product
–
The activity must be done right the
first time
Who are the “customers?”
Source: LEAN Thinking, Womack and Jones 1996
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Principles of LEAN Thinking
1. Specify value in the eyes of
the customer.
2. Identify the value stream
and eliminate waste.
13% of hospital costs are due to controllable waste.
Source: Zuckerman, Hadley, and Iezzoni, 1994
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Typical Organization is Silo-ed
Treatment Center
Treatment Clinic Check-In
Pharmacy
Laboratory Testing
Phlebotomy
Physician Clinic
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Value Stream – Anatomic Pathology
Patient & MD
I
Transcriptionist
I
Pathologist
I
Specimen
Collection
I
Send to
Grossing
I
Grossing
Embed
& Cut
Processing
I
I
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Slide
Making
Staining
I
I
Was this an “ER Problem?”
• “…empty beds are available in the hospital, but
there aren’t enough nurses to staff them.”
• This is a Value Stream problem!
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Types of Waste – Lab Examples
• Defects
• Label on the wrong tube
• Overproduction
• Drawing all blood at 4 AM
• Transportation
• Long walks, multiple handoffs
• Waiting Time
• Tube waiting on centrifuge to fill
• Inventory
• 50 weeks of supply
• Motion
• Tech walking 80 ft to the printer
• Processing
• Time/Date stamps added, not used
• Human Potential
• Administration not listening to Med
Techs or RN’s ideas for improvement
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Are We Tolerating Waste?
• Healthcare = Workarounds
– Professor Steven Spear
• “Decoding the DNA of the Toyota Production System” (HBR)
• “Fixing Healthcare Today From the Inside” (HBR)
• Case Example:
– 10-20% of MD orders are missing EVERY DAY
• Call and get the order – done?
• Tomorrow, we’ll do the same
• Problems need to be seen as opportunities
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Laboratory Layouts Drive Waste
Layout is driven by
departments
Benches interfere with
straight-line walking,
encourage batches
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Clinical Laboratory Product Flow
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Clinical Laboratory Timeline
Total CT = 5.44 hours
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Layouts Drive Waste of Motion
Pharmacist Walk Pattern
Med Tech Walk Pattern
Miles per Day!
Cancer RN Walk Pattern
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Typical 5S Baseline
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
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
Unorganized Workbenches
Product Flow not Obvious
Time wasted looking for things
Hoarding of supplies



Poor Utilization of Space
General Clutter
Supply Shortages and
“Hidden” Inventories
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5S Improvement Examples
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Principles of LEAN Thinking
1. Specify value in the eyes of
the customer.
2. Identify the value stream and
eliminate waste.
3. Make value flow at the pull of
the customer.
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Reducing Patient Wait Times
• Mass Production Thinking
Utilization
– Keep expensive assets heavily utilized
• Machines
Doctors
– The tradeoff is waiting time
• Cars
Patients
• Lean Thinking
Flow
– Focus on reducing Patient Waiting time
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Outpatient Oncology Patient “Flow”
Value Added
• Blood drawn
• MD consult
• Needle into Port
A
NVA But Required
• Check In / Check Out
• Moving from room to room
B
ARRIVAL TO LATENESS FOR
TREATMENT
TREATMENT
PATIENT
(HOURS)
(HOURS)
A
2.5
0.42
B
3.5
1.08
AVG
3.0
NVA, “Pure Waste”
• Waiting for Check In
• Waiting for MD
• Waiting for Treatment
0.75
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Re-Work Loops Cause Delays
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Batching Prevents Flow
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Batching Hurts Quality
• Lack of “standard work” and opportunity for
“error proofing” – Anatomic Pathology
Batch of slides made, 3
patients, risk of mixup?
2nd histotech labels one
slide at a time
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Batching Hurts Quality
• Lack of “standard work” and opportunity for
“error proofing” – Pharmacy
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Flow and Heijunka
• You can’t have flow without some
amount of “leveling” in the system
• “Leveled Production:
– You won’t be Happy without it”
» From Toyota publication
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Typical Hospital Lab  Not Level
39% of Samples Arrive in Just 3 Hours of the Day
TAT expectations are constant
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Leveling Reduces Peak Costs
Shift
Shift
Shift
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Principles of LEAN Thinking
1. Specify value in the eyes of the
customer.
2. Identify the value stream and
eliminate waste.
3. Make value flow at the pull of
the customer.
4. Involve and Empower employees.
5. Continuously improve in the pursuit of
perfection.
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Pre-Lean Med Tech Quote:
“With all of the automation,
I feel like a robot.”
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The “Thinking Production System”
“Perhaps the greatest strength of the Toyota
Production System is the way it develops people.
This is why the T actually stands for ‘Thinking’
as well as for ‘Toyota.’”
– Teruyuki Minoura, Toyota
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What Mistake-Proofing Means to Healthcare
The Global Goal: Reduce Medical Errors
“Human error is inevitable.
We can never eliminate it.” …..
We can eliminate problems in the system that
make it more likely to happen.”
Source: USA Today
August 24, 2005
Liam Donaldson
WHO World Health Alliance
for Patient safety
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Lean Requires a Cultural Shift
• Traditional Approach:
– “Naming, Shaming, and Blaming”
• Lean Approach:
– Supports open reporting of mistakes
– Root cause problem solving process
– “Anyone can make mistakes”
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Error Proofing Example
• Micrograms or Milligrams?
• A medical mistake waiting to happen
when written by hand
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Error Proofing Example
Confusing
Unambiguous
(Lean)
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MD Resistance to Standard Work
Which is
More effective?
• “… some surgeons make a tiny, mole-sized mark on a
patient instead of a big, bold "X”…. I call them passiveaggressive marks…”
– USA Today, 4/18/06
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Lab Benefits from Lean
•
•
•
•
•
Productivity improvement >30%
Space savings of >450 sq ft
Standardized work practices
Reduction in Errors and Error Potential
Test Turnaround Time (CT) reduced by 50%
Business Confidential, © Ortho-Clinical Diagnostics 2006
Hospitals Avoiding Capital Costs
• From 60,000 sq ft to 40,000 sq ft for new lab
– Cost avoidance of $800,000
• Blood bank in new lab w/o adding 2,500 sq ft
– Cost avoidance of $400,000
• Hospital food service cancels new building
– Cost avoidance of $7,200,000
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Improving Patient Satisfaction
PATIENT SATISFACTION SURVEY SCORES
October
Hospital System ED
December
2005
2005
60%
Overall Rating
96%
62%
Privacy
84%
78%
Wait Time for MD
96%
61%
Likelihood of Recommending
98%
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Reflections on a Year in Healthcare
• Lean is a powerful methodology
• People are people
• Healthcare people have incredible intrinsic
motivation
• Humility and asking questions is better than
being a know-it-all
• Coaching the team to “do lean & be lean” is
the only sustainable route
Business Confidential, © Ortho-Clinical Diagnostics 2006
A Call To Action
• What can you do?
–
–
–
–
–
Talk to hospitals and doctors in your communities
Get involved with hospital boards
Encourage employer health plans to push lean
Consider a career shift into healthcare
Resources:
•
•
•
•
•
“Good News… How Hospitals Heal Themselves” (DVD/PBS)
Hardwiring Excellence (by Quint Studer)
www.ihi.org
(Institute for Healthcare Improvement)
www.prhi.org
(Pittsburgh Regional Healthcare Initiative)
www.leanblog.org
(Mark’s lean blog)
Business Confidential, © Ortho-Clinical Diagnostics 2006
World-Class Performance
Lean in
Healthcare
Operations
Mark Graban, LFM ‘99
Senior Consultant, ValuMetrix® Services
Ortho-Clinical Diagnostics, Inc.
[email protected]
www.valumetrixservices.com
[email protected]
www.leanblog.org