OU School of Community Medicine
Summer Institute
Innovation, Action and
Quality Improvement
Lean Thinking
Slide 1
Changing our culture with…
Innovation
Introducing something new
Action
Making changes
Quality
Improvement
Meeting customer requirements
Slide 2
Quality Improvement
Initiatives
Major Improvement Initiatives
√
Topic Lean Thinking
[1]
Baldrige
Criteria [2]
Focus
Reducing waste and Performance
improving speed
Excellence Model
Tag
Line
“Accelerate the
velocity of any
process by reducing
waste in all forms.”
Benefits Improve
productivity, add
value to services,
eliminate waste, and
reduce lead times.
Six Sigma [3]
Breakthrough
Improvements
The Joint
Commission [4]
ISO 9000 [5]
Accreditation of
Quality Management
healthcare
System worldwide
organizations in U.S.
“Winning with a
“Six Sigma is about
high-performance,
breakthrough
high integrity,
improvements.”
ethical organization”
“Helping health care “Say what you do
organizations help
and do what you
patients”
say.”
Improve
performance with
outside perspective:
strengths and ways
to improve.
Accredits and
certifies health care
organizations
commitment to
certain performance
standards.
Significant gains in
customer loyalty
and satisfaction and
reduction in costs.
Documented quality
system with policies
and procedures to
assure quality.
References:
1. “Lean Six Sigma” by George and Doing More with Less: Lean Thinking and Patient Safety in Health Care – Joint Commission Resources
2. “Baldrige National Quality Program”, NIST
3. “Implementing Six Sigma” by Snee and Hoerl
4. The Joint Commission website: www.jointcommission.org
5. “ISO 9001:2000 in Brief” by Tricker and Sherring-Lucas
Slide 3
Lean Thinking
The two pillars of Toyota way
Continuous
Improvement
1. Form a long-term
vision meeting
challenges.
2. Improve operations
continually.
3. Go to the source to
find the facts.
Respect
for People
1. Make every effort to
understand each other.
2. Take responsibility and
build mutual trust.
3. Stimulate personal and
professional growth.
4. Maximize individual and
team performance.
Slide 4
Lean Thinking Concepts and Tools
√
 Increasing customer value
√ and costs
 Improving speed √ of processes
 Reducing waste
√
 Focusing on continuous improvement √
 Designing process for mistake proofing
Slide 5
Lean Thinking – The Five Steps…
1. Value – Specify value.
2. Value Stream – Identify the value stream
and eliminate waste.
3. Flow – Ensure work flows smoothly from
one stage to another.
4. Pull – Implement standard work and pull.
5. Perfection – Implement workplace
organization and continue reducing waste.
Slide 6
Lean Thinking - The first two steps:
Value and Value Stream
Step 1 - Value – Specify value.
Who is the customer?
(Typically the final customer of our work..)
“Value” is defined from the
customer’s point of view?
Slide 7
So…what is “value” for a customer?
[Patients? Students? Faculty? Others in our community?]
Value occurs when your work:
 provides service customer wants
 done correctly first time
 customer requests it
The Test: Would the customer complain if you stopped?
Slide 8
Step 2 - Value Stream – Identify value
stream and eliminate waste.
Waste (muda) adds no value for the customer.
Value Stream Mapping shows where we
have value-added and non-value added work.
Non-Value
Added Time
Value Added
Time
Slide 9
Seven Forms of Waste (muda)
[1]
1. Confusion [Confusion-laden activities; looking up things]
2. Motion/Conveyance [Moving products or people]
3. Waiting [Waiting for anyone or anything]
4. Overprocessing [Doing more than is necessary]
5. Unnecessary Inventory [Too many supplies]
6. Defect [Mistake that does not meet customer needs]
7. Overproduction [Doing more work than is necessary]
Think about examples of these forms of waste…
[1] Jimmerson – Value Stream Mapping for Healthcare Made Easy - 2010
Slide 10
Lean Thinking - Waste Observation Checklist
Your Name: __________________________________ Date: _________________
Checklist Item
Conditions Observed
Ideas to Eliminate Waste
Potential
Savings
1. Confusion
Confusion-laden activities
that require clarification
questions; looking for things;
clarifying information and
instructions
2. Motion/Conveyance
Physical movement to
complete a task; moving
products or people
3. Waiting
W aiting for: a procedure,
medication to arrive, an
order from a provider or a
patient
4. Overprocessing
Doing more than is necessary
to complete a piece of work;
copying records from one
system to another
5. Unnecessary
Inventory
Stored supplies that are
obsolete, duplicated or
unnecessary; supplies that
are kept just in case.
6. Defects
Errors, incorrect act or
decision or misunderstanding
7. Overproduction
Doing more work than is
necessary; redundant
paperwork or reporting
information that is useless
Slide 11
Symbols for Value Stream Map
Cycle Time = Time to complete this process step
Position and
Process steps
No. of People = Number of people performing this process step
Cycle Time =
No. of People =
Kaizen
burst
Improvement
Transport = moving a person or a product
Non-Value
Added Time
Value Added
Time
Manual or oral information transfer
Electronic information transfer
Number waiting
Database for electronic information
X
Delay or Wait
Q
Queue/waiting
Slide 12
Current State Value Stream Map for Patient Office Visit
Why is wait
in lobby so
long?
Reception
Is the nurse
and physician
communication
effective?
Nurse
Nurse
Is the nurse
and physician
communication
effective?
Physician
Nurse
Checkout
Greet; receive pt.
Call pt. back
Take vitals and
chief complaint
Examine pt.;
define treatment
Give script to pt.;
review treatment
and next appt.
Checkout pt.;
schedule next
appt.
Cycle Time = 2
No. of People = 1
Cycle Time = 1
No. of People = 1
Cycle Time = 5
No. of People = 1
Cycle Time = 12
No. of People = 1
Cycle Time = 3
No. of People = 1
Cycle Time = 4
No. of People = 1
1
1
1
15
min.
5
min.
EMR
25
min.
2 min.
1 min.
2
min.
5 min.
Seven Forms of Waste [Waste adds no value in eyes of the patient]
1. Confusion [activities that require clarification questions; looking for things]
2. Motion/conveyance [Physical movement to complete a task]
3. Waiting [Waiting for a procedure, medication to arrive, order from provider]
4. Overprocessing [doing more than is necessary]
5. Unnecessary Inventory [excess things; stored supplies that are obsolete]
6. Defects [errors, incorrect act or decision or misunderstanding]
7. Overproduction [Doing more work than is necessary; redundant paperwork]
12 min.
3 min.
1
min.
4 min.
Legend
1. All times in minutes
2. Value-Added Time has value in
the eyes of the patient.
[Pt. would pay for it if given option]
3. Non-Value Added Time has no
value in the eyes of the patient.
[Pt. would not pay for it if given the
option]
Non-Value
Added Time
Value Added
Time
45 min.
60%
30 min.
40%
75 min.
100%
James Shirley Management Consultants, Inc. [7/29/10]
Slide 13
Steps to Create a Value Stream Map
1. Give the process a name.
(Such as: Student Enrollment Process)
2. Create a list of the major process stages and
estimate the time to complete each stage.
3. Put process stages and times on Post-It notes.
(Categorize each stage as value added, non-value
added or necessary non-value added.)
4. Identify waste you see in the process.
Slide 14
Steps to Create a Value Stream Map
(continued)
5. Create the current-state value stream map.
(Put Post-It notes of process stages on a poster sheet
using value stream map symbols.)
6. Analyze waste on a separate sheet of poster paper:
a. Identify causes and root causes of waste.
b. List ideas to eliminate waste.
7. Create a future-state value stream map.
(Implement your improvements to reduce waste.)
Slide 15
Step 3 - Flow – Ensure work flows
smoothly between process stages.
Flow  No waiting, interruptions or
delays in the value stream
“Mura”  Uneven workload,
(MOO rah) variation and fluctuation
Slide 16
Flow – Ensure work flows smoothly from one stage to another.
[1]
Wash
Wax
Dry
2 min
2 min
2 min
Wash
Wax
Dry
Interior
Service
2 min
2 min
2 min
4 min
Wash
Wax
Dry
Valet
Service
2 min
2 min
2 min
20 min
80% of cars
Runners – activities
that occur often.
15% of cars
Repeaters – activities
that occur less often.
5% of cars
Strangers – activities
that occur occasionally.
[1] Lean for Practitioners by Mark Eaton (2008)
Slide 17
Visual Work Place to improve flow
Implement the 5S
workplace:
1. Sort – Remove unnecessary items from area.
2. Set in Order – Organize items that remain.
3. Shine – Clean, paint, replace or cover up.
4. Standardize – Use standardized procedures to
maintain benefits.
5. Sustain – Ensure discipline occurs to maintain
the workplace; audit and improve the area.
Slide 18
Creating visual workplace tools…
OU Bedlam Longitudinal Clinic
Slide 19
Concepts of Mistake Proofing
Mistake proofing can be a visual control…
Slide 20
Step 4 – Pull – Customer pulls what is needed.
Pull – Pull only what you need for flow.
Pull people… pull equipment…pull material…
Opposite of Pull is “Push.” Push triggers
movement whether the next stage is ready
or not!!
Slide 21
Pull example of supplies using a
“kanban” (signal or card) system…
Flow of supplies through a multistage kanban system in a hospital [1]
Kanban
Signal
Kanban
Signal
Kanban
Signal
Hospital
Stockroom
Vendor
Point of
Use 1
Department
Stockroom
Material
Movement
Point of
Use 2
Kanban
Signal
[1] “Lean Hospitals – Improving Quality, Patient Safety and Employee Satisfaction by Mark Graban
Slide 22
Step 5 – Perfection - Continue reducing waste.
1. We continually improve our work.
2. Always look to reduce waste.
3. Set up Continuous Improvement “events.”
(Called “Kaizen events” or rapid-cycle events.)
4. Use visual controls.
(White boards, graphs and color codes).
5. Conduct 5S audits.
Slide 23
Lean Thinking – The Five Steps…
1. Value – Specify value.
2. Value Stream – Define value stream and
eliminate waste.
3. Flow – Ensure work flows smoothly from
one stage to another.
4. Pull – Implement standard work and pull.
5. Perfection – Implement workplace
organization and continue reducing waste.
Slide 24
We are changing our culture through…
Innovation
Introducing something new
Action
Making changes
Quality
Improvement
Meeting customer requirements
Slide 25