Introduction to
Continuous Improvement
in Healthcare
Why Lean?
Why Lean in Healthcare?
Lean Philosophy
Seven Wastes
Reliable Methods as Countermeasures
1
Our Mission Is Simple: to help companies become
more productive and competitive through Continuous
Improvement education and implementation.
• Hands-on consulting/training in
Continuous Improvement
• Award winning Training Products
• Lean practitioners with a passion for
Gemba-based learning
• Promoting a
culture of improvement
• Not-for-Profit Organization
www.gbmp.org
617-287-7737
“I would recommend
participation to all healthcare
department heads and quality
improvement practitioners.
GBMP did a great job applying
the material to healthcare,
"going to the gemba" after
learning lean concepts and
tools in order to apply
knowledge learned in the
classroom.”
- Christine McMullan, Director of
Continuous Quality Improvement,
Stony Brook University Hospital
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Prize
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Prize
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Partnership
Introductions
• Pat Wardwell, GBMP
• Chief Operating Officer
• 25+ years Operations and
Improvement Roles
• Lean Gold Certified
• Shingo Prize Recipient
• Shingo Prize Examiner
• AME Excellence Award Council
and Assessor
3
Why Lean in Healthcare?
“While technologies and treatments have made enormous strides during my
career, nuts-and-bolts hospital operations haven't.” – Dr. Patricia Gabow.
Errors
Work-Arounds
Cost
Reporting
Requirements
Payment Systems
Waste
Staff Frustration
Silos
Waiting
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4
Desire to Improve Quality, Cost, Delivery and Safety of Care
Lean in Healthcare
Affinity Healthcare – A Healthcare Remedy
5
What Is “Traditional”?
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What Is “Traditional Operating
Methods”?






Customer requirements
not known
Batch processing
Pacing to “maximize”
resources
Processes/Equipment
keep running despite
defects
Lack of standardization
Questionable quality

Operator’s work out
of control
 Operators not
working together
 Limited
communication
between operators
and management.
 Management
occasionally present
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What Is “Traditional
Healthcare”?






Patient requirements
poorly communicated
Batch processing
Unnecessary
procedures and tests
Lack of standardization
Long wait times
expected
Questionable quality

Staff working out of
control
 Dr., nurse, and staff
not working together
 Limited
communication
between staff and
management
 Management
occasionally present
8
What is Continuous
Improvement?
• An approach to
healthcare which
strives to
maximize value
to the patient by
maximizing the
value of
employees.
JIT
Autonomation
Standardization
Stability
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What is Continuous Improvement?
Connects employees and patients.
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Concept of Value and Waste
• Value Added
– Activities involved with the direct care of the patient
– Activities the customer (Patient or Payer) is willing to
pay for
• Waste (Non-Value Added)
– Activities that do not benefit the patient
– Activities that fall under the 7 forms of waste
– Activities not performed right the first time
• Necessary Non-Value Added (Incidental Work)
– Activities causing no value to be created but which
cannot be eliminated based on current technology or
regulations
11
What is Continuous Improvement?
What is CI in Healthcare?
• The primary focus of lean or CI is in developing people
as problem solvers and participants in process
improvement.
• CI or lean is the creation of value for the customer
through the relentless and iterative elimination of waste
(muda), variation (mura) and strain (muri).
• Value is defined as any action or process for which the
customer would be willing to pay.
• In Healthcare, value is defined as any action or process
that directly contributes to the care of the patient.
“Care that is patient-focused, with less waste and cost and
better medical outcomes” - John Toussaint, On the Mend 12
Lean – The Big Picture
10% Techniques & 90% People
Before strategy there is
Philosophy.
Techniques are the
means, not the ends
Management must
lead.
At the center is Human
Development.
Human Development
Philosophy
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Lean Philosophy
Patient is First . . .
• Patients expect zero errors
• At an affordable price
• With no waiting.
Old Thinking
Errors Expected
Price = Cost + Profit
Maximize for Physician
New Thinking
Zero Defects
Profit = Price - Cost
No Patient Waiting
14
Lean Philosophy
Employees are the most valuable resource.
• People want to make valuable
contributions to the world.
• Dissatisfaction is a normal and
necessary condition for
improvement.
• 95% of objection is cautionary.
• If employees truly understand
value, they will gladly provide it.
• People have limitless capability.
15
Lean Philosophy
Direct Observation
• Direct observation on
regular basis is critical to
understanding.
• Best information for
continuous improvement
comes from direct
observation and
involvement with the people
who do the work.
• Workplace is dynamic.
• Go to Gemba often!
16
Lean Philosophy
Kaizen (continuous improvement) is for
everybody, everyday.
• Kaizen is small changes for the
better that come from the
common sense and experience
of the people who do the work.
• The more employees learn and
use CI the better they become
at problem-solving (tacit
learning.)
• Continuous improvement never
ends.
17
Toast Kaizen
18
Toast Kaizen
Event Metrics
Measure
Current
Lead Time
4.2 min. 2.2 min.
Floor Space
24 sq. ft. 4 sq. ft.
Target
Steps
25
4
Customer Happy?
No
Yes
Job Easier?
No
Yes
19
Lean Summary
• Everybody, everyday!
• Patient focused.
• 10% techniques &
90% people.
• Is taken in small
steps.
• Produces orders of
magnitude benefits.
• Is not consistent with
traditional approach.
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Benefits of Lean
•
•
•
•
•
•
•
•
•
Highest Quality
Lowest Cost
Connects Patient to Staff
Shortest Time
Safer for Patient
Least Strain for Caregiver
Greatest Productivity
Better use of Space
Greatest Margin Flexibility
There are no limits to
improvement!
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Process - Operation Model
Operation
P
r
o
c
e
s
s
Feedback
Reading
Screening
Admissions
Main Reception
Patient A Patient B Patient C
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Process - Operation Model
Admissions
Main
Reception
Screening
Reading
Feedback
Waste
95% of process is waste.
23
Seven Wastes
1. Inventory
2. Transportation
3. Waiting
To get in
4. Motion
To get out
In patient rooms
In stockrooms
Between departments
In hallways
Patients and providers
Information
Supplies
For results
For medication, for food
Searching, walking, backtracking,
reaching, bending, climbing, taking
eyes off of work
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Seven Wastes
5. Processing
6. Defects
7. Over-production
Worst Waste
Patient being asked the
same questions, unsafe
or strain producing,
Unnecessary, irrational
Infections, wrong site
surgeries, medication errors
Excessive tests,
unnecessary treatment
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Reliable Methods
•
•
•
•
•
•
•
•
•
•
Identify
reliable
methods.
5S - Workplace Organization
Problem Solving for CI Teams
Value Stream Mapping
Create a
Continuous Flow
favorable
Standardized Work
environment.
Kanban/ Pull Systems
Visual Control Systems
Set up Reduction
Keep all
Poka-yoke/ Error Proofing
employees
Heijunka/ Level Scheduling
practiced.
26
5S - The First Improvement
S1 – Sort Out
S2 – Set Locations
S3 – Shine
S4 – Standardize
S5 – Sustain
27
5S Video Essay
28
CEDAC
Team Based Problem Solving Technique
29
Value Stream Mapping
Good Process Good Result
30
Continuous Flow (Cells)
• Reorganizing physically
and organizationally for
improved flow.
• All steps used to
complete a prcess are
placed in sequence of
production. No space
between steps.
• No material build-up
between operations.
• One piece flow.
Spaghetti Diagram
Lab Flow
31
Standardized Work
• Best (current) combination of people,
machines and material to complete
process for patient demand.
• Takt Time – time allowed by customer to complete
the process
• Cycle time - time to perform the process, including
machine and manual time
• Work Sequence - order of operations to complete
the process
• Stock on Hand – inventory required to maintain flow
• Key safety and inspection points
32
Kanban
• Kanban eliminates
overproduction.
• Kanban re-integrates
inventory data with
material.
• Number of kanban cards
controls level of
inventory.
• Delays (unavailable
kanban) are highlighted
immediately.
• Kanban is like money,
always try for less
money in system.
33
Visual Control Systems
Letting the Process Speak
Visual
Indicator
Visual
Signal
Visual
Control
Visual
Guarantee
34
Reducing Interruptions and
Improving Patient Safety
• A study involving nine San Francisco Bay Area hospitals focused on
improving accuracy in administering drugs - with particular emphasis
on reducing interruptions that often lead to mistakes - resulted in a
nearly 88 percent drop in errors over 36 months at those hospitals.
35
Set-up Reduction
• Reduce every set-up by
“59/60th’s”
• Separation of external from
internal tasks
• external = process running
internal = process stopped
• Convert internal to external
tasks
• Minimize adjustments
• Improve overall set up
• Focus on waste, not operation
Equipment
Patient
Room
Operating
Room
36
Poka-yoke
• Poka-yoke means to
avoid (yokeru) inadvertent
errors (poka).
• “Preventing the act of
forgetting what you have
forgotten”
-- Shigeo Shingo.
• Respect the intelligence of
staff by taking the
judgment out of repetitive
tasks where errors are
likely to occur.
Defects = 0
Cannot connect to the
wrong tank!
71
Continuous Improvement
Summary
• Develop from Need
• 90% People (Patients
and Employees)
• Focus on Workplace
• Create Kaizen Way
• Incremental use of
reliable methods to
counter 7 wastes
Pull Systems
Standardized Work
Continuous Flow
5S and VSM
38
Key Points
• Three aspects to TPS
• Technical – tools like 5S,
Kanban, Set Up Reduction
• Philosophy (see below)
• Management – new strategy,
policy and organization
• TPS (Lean) Philosophy:
• Patient First
• Employees most important
resource
• Direct observation. (Go see!)
• Kaizen – small changes for
the better, everybody,
everyday
• 7 Wastes
•
•
•
•
•
•
•
Storage
Transportation
Overproduction
Processing
Motion
Defects
Waiting
• Basic hierarchy of
improvement
•
•
•
•
JIT
Autonomation
Standardization
Stability
Create a favorable environment: 90% people,10% methods!
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Thank you!
Questions
40