Members Talk
May 10, 2011
Lean – is it generically applicable?
Lean in different industries
Lean in Healthcare in the U.S.
Create a picture of your perfect “factory”
Excerpt from US New and World Report
What Medicine Can Learn From Business (U.S. News & World Report, June 17, 2008)
“…During the visit, a team led by Virginia Mason's chief of medicine met with a Toyota guru, a
sensei who had absorbed the Toyota approach into his very marrow. Examining a layout of
the hospital, the sensei learned that there were waiting rooms scattered across the campus.
"Who waits there?" the sensei asked.
"Patients," said the chief of medicine.
"What are they waiting for?"
"The doctor."
The sensei was told there might be a hundred or so such waiting rooms and that patients wait
about 45 minutes on average.
"You have a hundred waiting areas where patients wait an average of 45 minutes for a
doctor?" He paused and let the question hang in the air. "Aren't you ashamed?“ “
Create a picture of your perfect factory
Why?
How do patients make Lean in
Healthcare different?
Lean in Healthcare
Types of Customer Waste…
Defects
Re-sticks, redraws, med errors
Overproduction
Blood draws done early to accommodate lab
Inventory
Pts waiting for bed assignments
Lab samples batched
Dictation waiting for transcription
Movement
Looking for pts
Missing meds
Missing charts or equipment
Excessive Processing
Multiple bed moves
Retesting
Transportation
Excessive transporting pts for tests
Waiting
Inpts waiting in ED
Pts waiting for discharge
MDs waiting for test results
Under-utilization
Nurses transporting patients to X-ray
Lean in other
industries…
Financial Services
Research from the Corporate Executive Board finds that financial firms leveraging Lean techniques achieve
20 percent to 40 percent cost reduction in 12 to 18 months. Equally remarkable are specific anecdotal
results:
One of the world’s largest financial institutions headquartered in the U.S., increased credit card activation by
10 percent in one year, achieving $2 million in additional revenue through increased card utilization. A
prominent national bank reduced its wholesale lockbox (payment processing) unit cost by 58
percent while reducing associate handling time by 48 percent and errors by more than 75 percent in
only eight months.
By implementing the right Lean tools and practices at each level of the organization, they create a continuous
improvement mindset throughout the culture. For example, senior leadership may leverage a “value-stream vision
session event” as a methodology to support the continuous improvement goal of communicating, translating and
deploying a new retail mortgage strategy. Middle managers may rely on Kaizen, Business Reviews, and “War”
Rooms to drive weekly and monthly execution to operating commitments. And first level managers and
employees may use MDI (Managing for Daily Improvement) tools, Performance Boards, and Point Kaizens for
daily continuous improvement of existing processes.
Ultimately, most executives who have experienced the transformative power of Lean note how it provides a
disciplined, repeatable way to engage every employee to see their business from a customer’s
perspective, identify areas for improvement and make changes rapidly. They say the true power of Lean isn’t just
in the quick, dramatic results, but in its ability to create a sustaining, continuous improvement mindset throughout
an organization.
Examples
• Cell manufacturing of CT scanners
• Kanbans, Visual Instruction in factories
• Factory lines synchronized to demand
• Lean processing of payroll and benefits
• Lean “complaints” processes
• Early warning of equipment prior to break-down
• Call centres using control charts to drive proactive
action rather than wasted time later
BUT…
How do patients make Lean in Healthcare
different?
Lean in the US
Healthcare System
Miami Children’s
http://www.youtube.com/watch?v=be1HsYhr82c&feature=youtube_gdata_player
Virginia Mason Production System
How VMPS Works
Virginia Mason's vision is to be the Quality Leader in health care. This vision requires adopting a paradigm shift
from expecting errors and defects, to believing that the perfect patient experience is possible. Key to
accomplishing this is understanding that staff who do the work know what the problems are and have the best
solutions. VMPS strategies range from small-scale ideas tested and implemented immediately to long-range
planning that redesigns new spaces and processes.
VM uses several continuous improvement activities, such as Rapid Process Improvement Workshops (RPIWs)
and kaizen events focused on incremental changes, as well as 3P workshops intended to completely redesign a
process. VM has held 850 continuous improvement activities involving staff, patients and guests.
Benefits of VMPS
•Patients spend more value-added time with providers, and VMPS helps providers deliver the best
possible care.
•Patients benefit from greater safety, less delay in seeing physicians for care and more timely
results and treatments.
•VM staff benefit by having less rework and greater opportunities to care for patients - one of the
primary reasons many choose health care as a profession.
•The reduction of waste in administrative processes that support patient care but take valuable
resources ultimately benefits customers. As a nonprofit organziation, savings are reinvested to
support VM's mission to improve patient health and well-being.
Virginia Mason Continued
VMPS Success Stories
We have had many successes with VMPS. Below are a few examples of how VMPS has improved the quality of patient care.
PSA System Improves Patient Safety
Virginia Mason used VMPS to develop a Patient Safety Alert (PSA) system requiring all staff who encounter a situation likely to harm a patient to
make an immediate report and cease any activity that could cause further harm. If the safety of a patient is indeed at risk, an investigation is
immediately launched to correct the problem. From the program's inception in 2002 through 2009, 14,604 PSAs were reported. Most reports are
processed within 24 hours — a significant improvement from when reports took three to 18 months to resolve. Patient safety at VM has increased
and professional liability claims have dropped.
One-Stop Care for Patients with Cancer
Using VMPS, the Floyd & Delores Jones Cancer Institute at Virginia Mason was redesigned with a laboratory and pharmacy inside, elimininating the
need for patients to travel throughout the hospital for chemotherapy. Now, all cancer services are brought directly to the patient in his or her private
treatment room. For one patient, this reduced the length of a chemotherapy visit from 10 hours to two and saved about 500 feet of walking at each
visit.
Getting Back to Nursing
In most hospitals, nurses spend about 35 percent of their time in direct patient care. With VMPS, VM nursing teams increased it to 90 percent. They
used RPIWs to evaluate their work and make improvements. Instead of caring for patients throughout a unit, nurses work as a team with a patientcare technician in "cells" (groups of rooms located near each other). The cell model allows nurses to monitor patients and quickly attend to needs.
Also, the most commonly used supplies for each unit were moved to patient rooms so nurses reduced walking back and forth to get supplies. Steps
walked per day fell from 10,000 to roughly 1,200.
Hyperbaric Center Increases Patient Capacity
When the VM Center for Hyperbaric Medicine could no longer accommodate all the patients needing treatment, many assumed the solution was a
new building to house larger chambers. Instead, VM used VMPS tools to design and build a new hyperbaric center in existing hospital space, which
saved $2 million in construction costs and increased capacity from two to three patients at a time to as many as 20.
Express Treatment in the Emergency Department
Emergency departments (ED) are a major entry point for hospitals and can be a bottleneck. ED patient care is typically more expensive and
involves longer wait times. Using VMPS, the ED team at VM learned to predict appropriate staffing levels for times of greatest demand. A "team
sort" process using standard clinical assessment tools to quickly identify and sort patients' care needs was implemented. Those requiring minimal
services receive express treatment and are discharged without going to patient-care beds. This creates capacity for patients who require more
extensive services. This work helped VM decrease the number of hours the ED was closed and unable to receive new patients by more than 90
percent over the past two years. In 2011, VM will move its ED into more efficient space and the team sort process will allow the team to care for
more patients.
Faster Revenue Cycle
VMPS principles are used in all areas of the organization, not just in clinical settings. The Finance Department began using VMPS to address
outstanding revenue (revenue owed to the organization that had not been paid in a timely manner). The team improved Days Revenue Outstanding
(DRO) in the clinic from 52.3 in 2003 to 29.4 in 2009 and in the hospital from 66.5 in 2003 to 42.6 in 2009. Cash deposits improved from $471
million in 2003 to $794 million in 2009.
Primary Care Achieves Positive Net Margins
Primary care has long been a money-losing area of health care and often a good year means breaking even. Primary care teams in VM's eight
locations used VMPS to realign their work and improve the patient experience. Teams analyzed how supplies and providers "flowed" through the
day. By making key changes, such as doing non-direct patient care (reviewing lab results, calling the pharmacy) in between patient visits and
setting up each exam room identically with needed supplies, providers were able to see more patients in shorter work days with better quality care.
Doctors, who previously stayed until 8 or 9 p.m. doing paperwork, now leave by 6 p.m. The turnaround time for lab results also improved from 25
days for normal results to two days or fewer. Today, these clinics consistently achieve positive net margins and see more patients without sacrificing
time spent with each patient.
Process capability
Sometimes 99% is just not good enough
Sigma
Patient
Personal
Items
Coding
Processing
Scheduling Time
DPMO
% Yield
3
3,660 Patients
With Misplaced
Personal Items
Every Day
770 Coding Errors
Every Day Require
Correction
257 Calls Each Day
Exceed The Two
Minute On-Hold
Time
66,800
93.32000%
4
340 Patients With
Misplaced
Personal Items
Every Day
72 Coding Errors
Every Day
Require
Correction
24 Calls Each Day
Exceed The Two
Minute On-Hold
Time
6,210
99.3490%
5
12 Patients With
Misplaced
Personal Items
Every Day
13 Coding Errors
Every Week
Require Correction
5 Calls Each Week
Exceed The Two
Minute On-Hold
Time
230
99.97700%
6
6 Patients With
Misplaced
Personal Items
Every Month
During The Year,
Only 10 Coding
Errors Require
Correction
During The Year, 3
Calls Exceed The
Two Minute On-Hold
Time
3.4
99.99966%
Most Useful Tools for healthcare (in my
opinion)
•Value Stream Mapping…Patient at the Centre
•5 S culture
•Spaghetti Diagram
•Single Piece Flow versus Batching
•Visual Management
Examples
• Increase capacity utilization of CT scanners
• Pharmacy workflow
• Lab workflow
• ED results signaling
• Pre-Op assessment
• Lean theatres late start and time between cases
• Asset tagging
• New hospital design
Pharmacy Project
source: isixsigma website
Pharmacy Example – 5S, VSM
Pharmacy Area
IV Area
Lean OR process improvement - OR
Turn Around Time
Turn around Time flows
Eliminated Waste
•Reduced total time to get
patient ready in OR 21%
•Reduced clinician travel
distance to get patient ready in
OR by 54%
•Reduced EVS time to clean OR
by 50%
Team
•10 hospital team members
Lean OR process improvement – Case
cart pick
Before
Eliminated Waste
•Reduced technologist travel
distance by 70%
•Reduced cycle time by 46%
•Improved productivity by 119%
After
Team
•9 hospital team members
Lean ED
Example: ED Value Stream Map
Triage
Express
Care
EKG, Draw
Blood, UA,
Order X-Ray,
administer Pain
med
Front
Desk
X-Ray –
In ED
Registration
If rooms full
may reg pt
while
waiting.
2- RNs
1 Tech
Fax written
report/ED
access via
PACS
Portable
CT
Team Area
ED
Waiting
Room
CT Fax
written
report
MR
ED MD
calls
before
schedulin
g
Lab
Treatment
Patient
Flow
MD
People Flow
(RN, MD,
etc.)
E-Information
flow
Other Flow
(blood, etc.)
Phone Call
Patient Wait
Time
Call critical
values
Tube/blood
Registration
For
collection- if
have White
Dot
Discharged
(home or
elsewhere)
Call
Report
RT
Nursing
Unit
Order Entry,
Call, wait,
page
Respiratory
Therapy
Blood
Gases
Reg-Hospital
PsychConsult
Thank you.