Transcript Slide 1

PRINCIPLES OF LEAN
Lean Awareness Workshop
Outline
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Introduction and Welcome
Background to Lean
Lean Principles
Flow Exercise
Value-stream Mapping
Waste Spotters Exercise
Lean Toolbox
Rapid Improvement Events (RIEs)
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The Six Challenges
Re-engineered care processes
Effective use of information technology
Knowledge and skills management
Development of effective teams
Co-ordination of care across pathways
Making change possible
Institute of Medicine
Crossing the Quality Chasm: A new Health System for
the 21st Century Corrigan JM 2001
Timeliness
Safety
Effectiveness
Patient
-centeredness
Dimensions
of Quality
Efficiency
Equity
Where Does Lean Originate?
• Developed by Toyota as the Toyota Production
System (TPS) over the last 50 years
• Study of TPS led to academics defining the
approach as “Lean”
• The application of Lean is not new – principles
have been used in many industries.
• In the last ten years, increasing application of the
Lean approach in healthcare
Lean Strategy for TPS...
•Requires a focus on whole systems and processes
•Relentless focus on delivering services/products
which meet the needs of the customer, or in healthcare,
the patient
•The application of the PDSA (Plan, Do, Study, Act)
rapid change cycle
Lean Principles
Jones & Womack, Lean Thinking-Revised, 2000
Map the
total
customer/
provider
value
stream
Establish
value in
the eyes
of your
customer
Make
value
flow
with no
interruptions
Search for
perfection
with no
waste
Pull what
you want
when you
want it
Why is Lean Relevant?
• “Lean thinking is not a manufacturing tactic or a
cost reduction programme, but a management
strategy that is applicable to all organisations
because it has to do with improving processes. All
organisations – including healthcare organisations
– are composed of a series of processes, or sets of
actions, intended to create value for those who use
or depend on them (customer/patients)”
• IHI: Going Lean in Health Care, 2005
Lean in Healthcare
•Virginia Mason – USA
•Theadacare - USA
•Bolton NHS - England
•Gwent NHS – Wales
•NHS Tayside, NHS Lothian - Scotland
The Nun and the Bureaucrat
A book and DVD outlining how 2 hospitals used Lean
principles to transform their systems
• “The fact is that a patient is not a car, and never will be. So.
If that were the problem we were trying to solve, we’d be
stopped.
• However, the Toyota system is set up to identify customer
needs in very clear ways and to meet those needs in
explicit, efficient, rapid supplier-building methods.
• They’re quite superior in the world of work, so if you said
there was no work in healthcare then we’ve got a gap. But
as long as you confess that work’s there, then I’ve got a
solution.”
• G. Kenneth Turnbull, Ph.D.,
• Executive Vice President of Alcoa Business Systems
Economies of Flow
Mass/Volume Thinking
Economies to Scale
Lean thinking
Economies of Flow
•Big is good/cheap – fast production
rates
•Right size is good – rate-based
production
•Focus on operation – doing the job (s)
•Focus on process – gluing jobs
together
•Specialists have skills – centralised in
few people
•Everyone has skills – and expected to
use them
•Information – need to know?
•Information – visual
•Performance is about tradeoffs –
example: better quality costs money
•Performance is about root cause –
example: better quality is cheaper
•Manage by variety – by batching
together similar items
•Manage variety – by skills to rapidly
change from item to item
Sources of variation in a
clinical system
Process
Staff
unclear
motivation
skills
illness
shifts
Patients
age
motivation
disease
guidelines
race education
differ
sex
complications
anaesthetics
holiday
training
GP
transcription
Machines/rooms
not the same
suppliers
transport
applications
Resource
Information
80% is under
our control
Resulting in..
Systemic issues
Poor
Scheduling
of
appointment
s and
resources
Absence of
process
ownership
and control
Overly
complex
pathways
built in waits
and delays
Unquantified
capacity and
demand
Few defined
processes
and no
standard
working
Healthcare processes are all
about flow.
“Toyota revolutionised our expectations of production;
Federal Express revolutionised our expectations of
service. Processes that once took days or hours to
complete are now measured in minutes or seconds.
The challenge is to revolutionise our expectations of
healthcare: to design a continuous flow of work for
clinicians and seamless experience of care for patients”
Don Berwick, “Reducing Delays and Waiting Times
Throughout the Healthcare System” IHI 1996
Value-Stream Thinking
• “Stop looking at aggregated activities and
isolated machines…Start looking at all
the specific activities and see how they
interact with each other.”
Womack and Jones
What does it do to our patients?
• When a patient experiences a service it is either
good - and therefore what they expect - or it is bad.
Patients do not experience “averages”
• As consumers in the outside world we have
expectations of good quality and service, if these
expectations are not met then we take our business
elsewhere…
• In health our patients do not readily have that
choice.
Process Map
A process map answers questions, such as…
• What is the waste in the process?
• Where are any blockages to flow?
• How long does each process step take?
• How many handovers are there?
Mapping and analysis of the
Process
Increasing level of detail
Two Elements to Every Job
Value Adding
Valuable Effort
Non-Value Adding
Valueless
Effort
Obvious
Waste
Costs Time
Costs Money
Adds Value
Costs Time
Cost Money
Adds No Value
VALUABLE
WASTE
Types of Waste
• Toyota’s Seven Wastes
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* Transport
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* Inventory (work in progress)
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* Motion
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* Waiting Time
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* Over-processing
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* Over-production
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* Defects
• TIMWOOD
Wastes in a Healthcare Process
Lean waste
Examples in radiology
Defects
Running unnecessary scans; forms not being signed, faxes sent that
are illegible
Overproduction
Undertaking multiple scans
Excess inventory
Extra supplies
Excess processing
The process for ringing porters in the evening is to ring the Help Desk
and then to be routed to the porters; entering duplicate information;
printing paper reports to send in post
Unnecessary motion
Time spent looking for staff; entering duplicate information; looking for
parts and forms; interruptions from other staff
Unnecessary
transportation
Transportation of scan results in post
Waiting
Waiting for referrals/scans; waiting for reports/signatures; waiting for
patients, doctors, porters
Underutilised staff
Helpers in waiting rooms; secretaries waiting for reports to be signed
Lean Thinking – Improving flow and eliminating waste
- Neil Westwood, NHS Institute for Innovation
and Improvement
Standardisation
•This is an important challenge in healthcare
delivery
•It requires agreement from all groups in the
pathway of the best way to do the job
•Requires a clear way in which this is shared
•Needs a clear procedure for agreeing any
process changes
•Performance management to track adherence
Lean Tools
• Value-stream mapping
• PDSA cycles
• Understanding Demand, Capacity and
Variation
• Root Cause Analysis – often called 5 Whys
and How (5W + H)
• 6S/Visual management
• Glenday Sieve
• Rapid Improvement Events (RIEs)
Lean Principles
Jones & Womack, Lean Thinking-Revised, 2000
Map the
total
customer/
provider
value
stream
Establish
value in
the eyes
of your
customer
Make
value
flow with
no
interruptions
Search for
perfection
with no
waste
Pull what
you want
when you
want it
‘Flow’ in health care
Progressive uninterrupted movement of patients,
information and equipment between
departments, staff groups or organisations as
part of their care pathway.
- NHS Modernisation Agency,
2005
Effective flow is a property of
the entire system
Patient Pathway
Micro-system
Micro-system
Micro-system
Micro-system
Teams make day to day, minute by minute decisions in their own
micro-systems without a view of the whole system. Even if they
have optimised their own system it may do nothing for the whole
patient pathway.
Patients need to flow through the healthcare system, however if
underlying processes are inefficient we will not manage patients
effectively.
Effective flow in action – Unscheduled
Care Collaborative 5 Patient Flows
Group 1 Minor Injury &
Illness
Group 2 – Acute
Assessment
Group 5 Out of Hospital Care
Group 3 –
Medical Admissions
Group 4 –
Surgical
Admissions
Advantages of Improving
Patient Flow
• Improved patient outcomes and improved service quality
• Reduced time that patients stay in hospital, improving
patient experience and freeing up inpatient capacity
• Reduced DNAs, improved resource utilisation and
improved overall value for money
• Improved discharge pathways and reduced variation in
length of stay
• Improved appropriateness of care – to make sure that
patients get the right treatment, from the right
professional, in the right place, at the right time
- Planned Care Improvement Programme, Patient Flow in
Planned Care, IST, 2007