Transcript Slide 1

Creating a Culture of
Continuous Improvement
Richard J Zarbo, MD
1 Lean- 1
Ohio
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Pathology & Laboratory Medicine, Henry Ford Health System, Detroit
Lean is not a program; It is not a quick fix;
it is not a responsibility that can be delegated.
Rather, Lean is a cultural transformation that
changes how an organization works…
It requires new habits, new skills and often a
new attitude throughout the organization.”
-John
Toussaint, MD
Ohio Lean- 2
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Organizational Culture
Toyota Production System
Stability of Manufacturing Processes
tools
Human
Development
Philosophy
1. Customer first
2. People are the most valuable resource
3. Kaizen (continuous improvement)
4. Shop floor focus
Philosophy
….An Integrated System
Ohio Lean- 3
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Toyota’s culture built on pillars of continuous
process improvement,
founded in respect for people,
sets an expectation and facilitates
empowered workers
to contribute to the ever-improving enterprise.
Ohio Lean- 4
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
What is Empowerment
and How Do You
Sustain It?
Ohio Lean- 5
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Empowerment
Definition
“Employee empowerment is a strategy and philosophy that enables
employees to make decisions about their jobs.
Employee empowerment helps employees own their work
and take responsibility for their results.
Employee empowerment helps employees serve customers at the level
of the organization where the customer interface exists.”
Ohio Lean- 6
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Empowerment Can’t Be Willed
“An empowered workforce is something that
is highly desirable in an improvement
culture. Unfortunately, just because we
want it, it doesn't make it so.”
“Leaders of the organization must create the
conditions for empowerment.”
Ohio Lean- 7
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Empowerment rarely succeeds
Why?
• Management comes up short
–
–
–
–
–
–
–
Culture, philosophy
Managers discomfort with new leadership style
Leadership and team training
Leadership and team structure
Incentives for behavior change
Incentives for engagement
Sustaining mechanisms
Ohio Lean- 8
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Culture
Culture is a desirable but secondary
outcome to changing structure and
process
that enables and expects employees
to work differently
Ohio Lean- 9
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
How
Philosophy
Management principles
Reporting relationships
People structures
Sustaining tactics
Ohio Lean- 10
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
As leader,
I don’t have all the answers
“Doing your best is not good enough.
You have to know what to do.
Then do your best.”
-W. E. Deming
Ohio Lean- 11
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Mindset for
Continual Improvement
“We know from the changes that have already
been brought about that far greater changes are
to come, and that therefore
we are not performing a single operation
as well as it ought to be performed ”
- Henry Ford
Ohio Lean- 12
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Never Pass a Defect
‘The Mantra’
“Quality is doing it right when no one is looking."
-Henry Ford
Ohio Lean- 13
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Blameless
“Don’t find fault, find a remedy;
anybody can complain.”
-Henry Ford
“On the internet, nobody knows you’re a dog.”
Ohio Lean- 14
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Expose Defects
The Visual Workplace
“Even a mistake may turn out to
be the one thing necessary to a
worthwhile achievement.”
-Henry Ford
Ohio Lean- 15
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
The Power of Integrated Teams
Aligned Path of Work Flow
“Systems do not produce quality,
people do.”
-anonymous
Ohio Lean- 16
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Waste, Rework, & Inefficiency
"It is not possible to repeat too
often that waste is not something
which comes after the fact”
-Henry Ford
“My theory of waste goes back of
the thing itself into the labour of
producing it”
-Henry Ford
Ohio Lean- 17
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
EXPECTATION
OF
MANAGERS
Ohio Lean- 18
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Deming Culture
Deming’s Redefinition of Management
“In companies that have embraced Deming’s vision,
management’s job is to ‘work on the system’
to achieve continual product and process improvement.
The Deming-style manager mustensure a system’s consistency and reliability, by bringing
level of variation in its operations within predictable limits, then by

identifying opportunities for improvement, by
enlisting the participation of every employee, and by
giving subordinates the practical benefit of his experience
and the help they need to chart improvement strategies.”
(A. Gabor)
Ohio Lean- 19
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Managers Weekly Checklist
"You get what you inspect not what you expect”
1.
Deviations/Non-conformances outliers and trends
2.
Temp humidity checks -completeness of documentation,
root cause and corrective actions
3.
5S activity documentation
4.
Posted job aides and all visuals reviewed and updated
5.
New or revised procedures reviewed with staff and staff
competencies verified
6.
New problems of risk (mis-ID, safety) and resolutions discussed
7.
DM Board metrics review leading to interventions and process
improvements
8.
Ongoing and planned process improvements reviewed
9.
Inventory and kanban check
Ohio Lean- 20
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
STRUCTURE
THAT SUPPORTS
PEOPLE
Ohio Lean- 21
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
QUALITY SYSTEM STRUCTURE
ORGANIZATION CHART
For Worker Driven Continuous Improvement
How is change authorized and made?
Find Your Role
Group Leader
Team
Leader
Team
Leader
Group Leader
Team
Leader
Group Leader
Team
Leader
Team
Leader
Shared members
Workcell 1
Workcell 2
Silo 1
Workcell 3
Workcell 4
Silo 2
Workcell 5
Work
Product
Silo 3
Customer-Supplier Interaction
Ohio Lean- 22
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
EXPECTATION
OF
WORKERS
Ohio Lean- 23
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Redefine the Expectation of
“Work”
Never Accept, Make
or Pass a Defect
“It’s the work, not the man that manages.”
-Henry Ford
24 Lean- 24
Ohio
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
“Most doctors prescribe pills, I prescribe empowerment”
–Jay Parkinson, MD
The Engaged Worker
Transform approach to work
– Not just showing up for work, but arriving to do the
work better
Empowered workers who see their daily
work in the context ofContinually learning
Constantly communicating
Making effective process improvements
Designed and tested by scientific method
Empowered Personnel, Correcting One’s Own Errors,
Accountable For Solving Problems in Teams & Creating Standard Work
Ohio Lean- 25
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Why empower the worker?
Executive Leader
“There
Ultimate Solutions
Depend on the
View
of the
Problems
are no big problems, there are just a lot of little problems.” -Henry Ford
Supervisor/Manager
Line Worker
Ohio Lean- 26
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Workers Deal with Waste
Everyday
• Anything that adds cost to the product
without adding Value
• Non-Value added task that will go unpaid
by patients and payers
• We only get paid for the work one time,
then often poorly at best
Ohio Lean- 27
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Reality Testing
• Juran Institute estimates that
30% of direct healthcare outlays
are due to poor process quality
Midwest Business Group on Health, Juran Institute, & Severyn Group, Inc (2003)
Ohio Lean- 28
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Type of Waste
Definition
Examples in Healthcare
1.Transportation
Unnecessary movement of
products/material/documents
from one place to another
Moving documents/specimens/supplies from room to room
Moving equipment for testing to and fro for treatment
2. Inventory
Excessive stock than needs
handling or stock outs when
needed
Over stocking office supplies/reagents/medication
on units due to standing orders, or stock outs due to expiry dates
/back orders
3. Motion
Unnecessary movement of
people/patients/staff from one
service to another
Staff walking to printers/fax machines
To get inventory that’s kept far away
Patient services/departments far away from each other or different
buildings
4. Waiting
Idle time created when
information, equipment or
material is unavailable
Missing information on Documentation/Prescriptions/Lab
Requisitions/ Physician Note etc
Delays- Bed assignment, ER/Clinic admission, Test result
Patient backup due to equipment downtime or failure
5. Overproduction
Producing more than what is
required for next step
Printing/emailing/faxing the same document multiple times
Duplicate charting by different staff
Preparation exceeding schedules for the day/shift
6. Over-processing
Performing repeated (rework)
or redundant work that does
not add value to the customer
Ordering more diagnostic tests than the diagnosis warrants, Rechecking or Retesting just to be sure. Duplication of paper trails,
excessive charting
7. Defective
product or service
(process mistakes)
Any activity that does not
conform to customers
expectation/specification
Wrong patient demographic labels attached to incorrect specimen
containers- mismatches
Specimen collected in incorrect containers/tubes
Ohio Lean- 29
Incorrect billing/ No billing
Ohio Lean- 29
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
VARIATION
Understanding
&
Minimizing
Ohio Lean- 30
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
What is My Role in Lean?
• Yearly Lean education
• Identify defects on a daily basis
• Brainstorm and get involved to eliminate
defective processes
• Work in teams with your leadership to
propose and test solutions
• Take pride in your work knowing your idea
was recognized and acknowledged
Ohio Lean- 31
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
What is a defect?
Poor quality of service or product that makes you:
• Stop your work
= WASTE
• Reject it
= REWORK
• Return it to sender
• Delay your work to fix it yourself
• Not pleased, could be better
Error
= hurts someone
Ohio Lean- 32
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
“My theory of waste goes
back of the thing itself into
the labour of producing it”
Power of People Seeing
-Henry Ford
POSTANALYTIC
Defect Comparison 2006 to 2007
Amended
Reports
8
13
2
ANALYTIC
97%
66
Immuno Sp.
Stain
9
89%
62%
2
61
Histo Slides
151
72
Grossing
PRE-ANALYTIC
Stations in the process
Recuts
Top 4 defects
Lab made
42%
99
2006
31%
50
Accessioning
123
2007
62%
85
Rehab
17
1
Spec.Receiving
24
0
20
96%
40
60
80
100
120
140
160
Totals
Ohio Lean- 33
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
EXPOSE
DEFECTS
VISUAL WORKPLACE
BLAMELESS CULTURE
Ohio Lean- 34
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Visual Workplace “No Problem is a Problem”
7 Wastes
5 Why’s
4 Work Rules
Process
Leader
Wednesday’s
Words
of
Quality
Capture Daily Defects
1. Wrong patient identification
2. Ran out of gloves- size medium
3. Not enough specimen collected for lab test
Daily Resolution of Defects
Rapid (Defects corrected on the spot)
A3 (PDCA analysis and customer-supplier involvement)
Communication & Education
All shifts
(New policy, standard work, hours, competency, quality tool)
35 Lean- 35
Ohio
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
SYSTEMATIC
PROCESS to
FIX DEFECTS
Ohio Lean- 36
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
The Process of Process Improvement
HENRY FORD PRODUCTION SYSTEM
Identify Defect
Share the Gain Learnings
Daily Resolution
policy, procedure, document control
Standard Work,
Connections, Pathways
Rapid Fix
Ongoing
PDCA
Resolution
PDCA-A3
Resolution
Team Leader
Facilitation
Customer-Supplier
Communication
at level of work
Ohio Lean- 37
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
SYSTEMATIC
WORK RULES
FROM TPS
Ohio Lean- 38
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Standardization is the Cure
-Observe & Reinforce-
Systematic Work Rules
Variation is the Enemy of Quality
1.
2.
3.
4.
Activities
Connections
Pathways
Method of Improvement
Spear S, Bowen HK: Decoding the DNA of the Toyota Production System.
Harvard Business Review, 1999.
“Today’s standardization, instead of being a barricade
against improvement, is the necessary foundation on which
tomorrow’s improvement will be based.”
– Henry Ford
Ohio Lean- 39
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
WORKER
KAIZEN
SOLUTIONS
Ohio Lean- 40
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
TATs < 45'
TATs < 60'
95
93
90
85
84
79
84
80
Tu
be
qu
e
Un
i
Ro
ck
e
rR
el
o
lid
at
Au
to
va
d
Re
ca
ti o
n
io
n
ck
Ra
e
BNP
B-natriuretic peptide
68
63
60
50
Ba
se
lin
% BNP TATs Meeting Goal
Continual Improvements Toward Goal
Process Change...
Repetitive
PDCA Cycles
Ohio Lean- 41
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Teamwork
You may lead it……
But it’s ALL about them
“The day you become a leader,
It becomes about them.”
-Jack Welch
Now empower them!
Ohio Lean- 42
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
WORK
PRINCIPLES
Ohio Lean- 43
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Work Flow, Pull & Smoothing Opportunities
Structure and management
Horizontal management across work stations, divisions
Defined workcells, team leaders, teams along path of work, partnerships
Workplace physical redesign
U or linear workstations to reduce motion
Inventory relocated to workstations
Work redesign for continuous flow and pull
Sensitization to time waste and in-process defects
Reduction cycle times
Front loading work in the path of workflow
Elimination of loops, forks
Reduction of steps
Maintenance of sequence
Load leveling across shifts and hours
Batch size reduction
Visual workplace to surface defects
Standardized activities, connections, pathways
Kanban system
Production kanbans to promote pull production & communication
Inventory kanbans for JIT, recovery of stock room space
Metrics to monitor and target variation
Daily metrics to monitor performance variation
Whiteboards to identify in-process defects and outliers
Feedback loops to inform defect repair in real-time by empowered teams
Ohio Lean- 44
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
MANAGING
by
METRICS
Ohio Lean- 45
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
“What's measured improves”
“The only things that evolve
by themselves in an
organization are disorder,
friction and
malperformance”
Peter F. Drucker
Ohio Lean- 46
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Daily Management Board
Q
T
I
P
S
Quality
Time
(Delivery)
Inventory or
WIP
Productivity
Safety
Visual Management At-a-Glance
DAILY Gemba Rounds with workers
• Each square has all days of month
• Color each per performance
• RED: METRIC FAILED THRESHOLD
• GREEN: METRIC MET THRESHOLD
Work Group Specific Metrics
Trendlines
• Trend challenging metrics
• Day, week, month, year…
Daily, Weekly, Monthly, Annual Trends
Root Cause Analysis
• BLUE: THRESHOLD
• RED: TIME OF FAILURE
• GREEN: TIME PASSING THRESHOLD
Pareto Charts, RCA etc.
What
When
Why
How
Countermeasures:
Corrective & Preventive Actions
Assign responsibility and
Accountability for completion
Associated PDCA - A3 Projects
Ohio Lean- 47
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Jane Doe
John Smith
May
11 am
# of amended reports
# of result modifications
Ohio Lean- 48
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 49
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Chemistry Core Lab
Ohio Lean- 50
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
So Honey, How’s Your Day Goin?
Intended Direction
Actual
Experience*
*Note: YMMV
(Your actual
mileage may vary)
Ohio Lean- 51
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
RECOGNITION
Ohio Lean- 52
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
“Share the Gain”
Share your improvements at “ Share the Gain” meeting
Monthly discipline, education, pace and recognition
from leadership and peers. Since 2006.
2013
Clinical Pathology 6:30AM & 2:30PM
Share the Gain presentations
2011
Cytology techs describing
their process improvement
Ohio Lean- 53
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Total Process Improvements
Pathology & Laboratory Medicine Service Line
Henry Ford Production System
Lean Year 6
2000
(6 hospitals)
Lean Year 5
Lean Year 7
(4 hospitals)
(4 hospitals)
Key
1000
1794
Lean Year 4
500
1128
1392
1323
1230
828
All Laboratories,
Hospitals
and 30 clinics
536
2009
Henry Ford
Hospital
Laboratories
2010
2011
2012
Ohio Lean- 54
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Tactics That Sustain a New Work Culture
GOAL SETTING
 Hoshin kanri strategic planning and goal setting
 Quality goals identified, prioritized & pushed to level of worker
PEOPLE ROLES & RESPONSIBILITIES
 Identified workstation teams and leaders
 Employees in charge of own jobs, design standardized work
METRICS
 Expect metrics of reliability & consistency in each workstation
COLLABORATION CULTURE
 Promote horizontal cooperation, customer-supplier, team focus
MANDATORY EDUCATION & RE-EDUCATION
 Include competency assessment in CQI for all workers
LEADER FACILITATED MEETINGS
 Expect routine leader & worker meetings, no exceptions
PERSONAL ACCOUNTABILITY FOR PROGRESS
 Visual trackers of daily defects and improvements
 Monthly worker presentations of their improvements
 Performance evaluations leaders & workers, include behaviors
PUBLIC PRESENTATION & RECOGNITION EVENTS
Ohio Lean- 55
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Lean Leader’s Checklist
• Set Lean leadership and management expectation for all leaders
• Set high performance expectation goals and pace of continual change
• Integrate people, process, tools, technology that support the new manner
of work
• Engage and empower your people to solve problems
• Create organizational structure with identified team leaders to allow
continuous change to happen
• Form core teams with strong leader and team members along the path of
workflow
• Breakdown barriers between artificial silos of control so improvements
can occur horizontally
• Foster regular communication within and between workcells within your
control as well as outside your department (customer-supplier relationships)
• Drive reduction in variability by standardizing the work activities,
connections and pathways
Zarbo RJ: Creating and sustaining a Lean culture of continuous process improvement.
Am J Clin Pathol 138:321-326, 2012.
© 2013 Henry Ford Health System, Pathology and
Ohio Lean- 56
Laboratory Medicine
Lean Leader’s Checklist
• Implement visual management, with posted daily metrics of value for each
work unit reflecting opportunities for change or stability of process
• Stabilize processes through a continuous focus on waste reduction
• Move to continuous flow, innovate triggers to ‘pull’ work or patients etc,
• Identify opportunities for front loading and work simplification
• Continually push to reduce time waste
• Leverage PDCA as a way of thinking and the operational engine of continual
improvement
• Create structure and incentives to sustain the new cultural change of work
• Educate to improve the overall quality and efficiency of work for the
system, not for any one unit
• Create opportunities for your direct reports to work effectively together
and manage horizontally for the greater good. Somebody gives, somebody
takes, but everyone wins
• Celebrate your teams’ successes and learnings
• Make this new approach to work fun!
Zarbo RJ: Creating and sustaining a Lean culture of continuous process improvement.
Am J Clin Pathol 138:321-326, 2012.
© 2013 Henry Ford Health System, Pathology and
Ohio Lean- 57
Laboratory Medicine
Ohio Lean- 58
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine