4th Annual Advancing
Philanthropy Conference
LEAN: Working Smarter Not
Harder by Chuck Derus, MD
Advocate Good Samaritan
Hospital: Who We Are
• Part of Advocate Healthcare
• 333 bed hospital Downers Grove, IL
• 2,700 associates, 950 affiliated
physicians and 500 volunteers
• Community hospital with level 1
trauma and level 3 NICU
• 46,000 ED visits, 156,000 outpatient
visits and 19,500 admissions
Advocate Good Samaritan
Hospital: Who We Are
Who We Are
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Thompson Reuters Top 100 Hospital
Midas Platinum+ Award
Patient satisfaction ≈ top decile
Associate satisfaction 91st percentile
Physician satisfaction 96th percentile
17% market share growth
106% operating income growth
Problem Solving Versus
Fire Fighting
• The story of the missing supply…
• Hunt, gather and assume the problem
is solved
• What if you…
1. Get what you need to fix now
2. Ask how and why did this occur?
3. Ask how can we prevent this (make a
change) from happening again?
Leaning Objectives
• To learn the 8 wastes
• To learn a systematic, repeatable
approach to problem solving (A3
PDSA)
• To hopefully go back to your offices
and apply this systematic repeatable
approach to a problem in your area
and to improve that process
The Eight Wastes
1
DEFECTS
5
OVERPRODUCING
6
WAITING
7
All patient, staff and material movement
Inspection and rework
2
Queuing, idle time
4 NOT BEST USE
OF TALENT
INVENTORY
All stock and corresponding control systems
Too much and too early
3
TRANSPORTING
MOTION
Reaching, bending, searching ...
8
Not using problem solving skills of people
EXTRA PROCESSING
Unnecessary activities, Over-complicated
Definition:
Defects
A product or service
needing repair to
fulfill customer
requirements
Characteristics:
Medication error
Wrong patient
Wrong procedure
Missing information
blemish
blooper
blot stain
blotch
blunder
bobble
boner
boo-boo
fallacy
false step
fault
faulty
flaw
flub
foul-up
fumble
misprint
misstep
mistake
muff
off the beam
omission
oversight
rough spots
botch
goof
scare deformity
breach
bugs
bungle
clinker
clunker
cockeyed
crack
defect
deficiency
drawback
error
failing
failure
human error
illogical
imperfection
imprecise
inaccuracy
inadequacy
incomplete
incorrect
inexact
kinks
leak
louse-up
miscue
scratch
screw-up
shortage
shortcoming
slip-up
snafu
snags
spot
tear
trip
unsound
weak point
weakness
Overproduction
Characteristics:
Definition:
– Pills given early to suit
staff schedules
– Testing ahead of time to
suit lab schedule
– Treatments done to
balance hospital staff or
equipment workload
– Producing more
than needed
– Working ahead
– Producing at a faster
pace than needed
Waiting
Characteristics:
– Bed Assignments
– Admission to ED
Definition:
– Patient lab test results
– Idle time in which no – Discharge
value added
activities take place
– People wait time
– Product wait time
Not Best Use of Talent
Characteristics:
Definition:
– Injured personnel
– Poor flow of services
– Nurses supplying
– Work-related
personnel injuries
– Lack of training inhibits
flow of services
– Not encouraging
creativity and use of
problem-solving skills
Transportation
Characteristics:
Definition:
– Any unnecessary
material, patient
or staff movement
– Moving samples or
specimens
– Moving paperwork
– Moving patients for
testing or treatment
– Moving equipment
Inventory
Characteristics:
– Pharmacy stock
– Lab supplies
Definition:
–
Any unnecessary
supplies or
materials that do
not support just in
time delivery
– Specimens waiting
analysis
– Paperwork in process
Motion
Characteristics:
– Searching for meds
– Searching for patients
– Reaching for charts
Definition:
– Any movement
of people which
does not add
value to the
product
– Handling paperwork
Extra Processing
Characteristics:
– Multiple bed moves
– Excessive
paperwork
Definition:
– Unnecessary
process steps
– Unnecessary
procedures
– Multiple testing
– Scrap
Exercise: Identify eight
wastes in your work
Systematic, Repeatable
Improvement Approach
• The PDSA cycle is shorthand for
testing a change by:
1. Developing a plan to test the change
(Plan),
2. Carrying out the test (Do),
3. Observing and learning from the
consequences (Study),
4. And determining what modifications
should be made to the test (Act).
What Is A3?
A3 is 16.5 x 11.7 inches
A3 PDSA - Problem
Solving/Teaching Tool
• Executed on A3
size (11 x17) paper
• 9 steps (boxes)
that make problem
solving visual
• Fast, effective
consensus building
• An “artifact” that
tells the change
story
1
4
7
2
5
8
3
6
9
How to Achieve A3 Thinking
• Process is as inclusive as possible
– Hand drawn
– Pictures and text
• Work step-by-step
– Work with consensus
– Distill thoughts to fit each box
– Capture the essence
– Tell the story without “interpretation”
Where does it apply?
• A3’s work for all types of activities
– Personal development
– Sharing ideas/proposing change
– Problem solving/decision making
– Strategic planning
– Should become the default way of
making improvements
Blank A3 Form
1. Fill in
Description,
Process Owner,
Sponsor
2. Fill in Start Date
(start of A3) and
Current Date
(Date and Rev)
3. Record the
Team members
4. Select the
review team
(team that will
support the A3
team with
relevant
knowledge &
guidance)
P-D-S-A
Starting an A3
Box 1 – Reason for Action
• What is the problem
(no causes or
solutions!) and why
do I care?
• Who has the
problem?
• What is the scope
and are there any
limitations?
• What are the stop
and start “fence
posts”?
• P-D-S-A
Reason for Action:
The insurance payment posting process is
inefficient and is costing us more to do.
In Scope: The process begins with
submissions of insurance claims to payers
and ends with the accurate posting of these
payments in the billing system.
Out of Scope: The process does not include
the patient statement process or Collection
Agency process.
Trigger: Submissions of insurance claims to
payers
Done: The accurate posting of these
payments in the billing system
Box 2 – The Initial State
• What is happening now
in bullet points and a
picture?
• Express the situation in
time and units that can
later “prove the case”
• Graphically present
initial state with metrics
when possible
• P-D-S-A
Initial State
People: I am clear about my role and the roles
of others in my department. 2.5 (scale 1–5)
Quality and Safety:
MD - “At the start of the visit I had all information
needed to provide care. 2 (scale 1-5)
MA – “I had the information needed to assist
patient at check out.” 60% (0-100%)
Cost: Call cost per encounter (based on June
encounters & phone stats). 2.67 calls/encounter
@ $4.21 per call = $11.24 cost/encounter.
Service: Average speed of answer 187 sec.
Growth: Market share in primary service area
based on last 2 quarters is 18.5%
Box 3 – The Target State
• Record required
target not what we
‘think’ we can achieve
• Double the good or
half of the bad
• Wherever possible
use voice-of-thecustomer
• Graphically present
Target Condition
• P-D-S-A
Target State
People: I am clear about my role and the roles
of others in my department. Target 4.0
Quality and Safety:
MD - “At the start of the visit I had all information
needed to provide care. Target 4.5
MA – “I had the information needed to assist
patient at check out.” Target 90%
Cost: Call cost per encounter Target $6.00
Service: Average speed of answer 90 sec.
Growth: Market share in primary service area
based on last 2 quarters is 26%
Exercise: Write a problem
statement for box one and
identify a metric for box
two
Ideal
Eliminate the Waste
Target
State
Waste
Initial
State
Clearly Defined Problem
Box 4 – Gap Analysis
Root Causes!
• Identify all possible
causes for the
situation
• Conduct an
investigation find
“root causes”
• Ask the “5 whys?”
• Cause and effect
diagrams
• 8 wastes
• P-D-S-A
4. GAP ANALYSIS:
Box 5 – Solution Approach
• Use the “If we
did this, then we
would achieve
this” approach
to possible
solutions
• Use a 2x2
priority index to
“rack and stack”
Small
Payoff
Big
Payoff
• P-D-S-A
Hard
Easy
5. Solution Approach:
Box 6 – Rapid Experiments
• Ties to solution
approaches based
on actionable,
impactful root causes
• What happened
when we tried stuff?
Did it work?
• Conclusion?
• P-D-S-A
Rapid Experiments
1. Communication of flow and signage
throughout the department
2. Move printer closer to check out desk
3. Standardize and sort check out area to cut
down on motion waste
4. Test standard work for the secretary
5. Redesign the prep work space for X-rays
6. Standardize check out process and train MA
Box 7 – Completion Plan
• List activities
by projects,
events, do-its,
and stop-its
• List ‘What, Who
and When’ and
track progress
• P-D-S-A
Box 8 – Confirmed State
• Relates all the way
back to target
condition in box 3
• Have we achieved
and closed the gap
• Does the
confirmed state
in box 8 = the
target state in
box 3?
• P-D-S-A
Box 9 – Insights
INSIGHTS:
• Lessons earned/
breakthroughs/
reflections
• What new things
have we learned?
• P-D-S-A
Completed A3
Exercise: go back to work and
execute an A3 of your own
It’s Time for Jeopardy!!!
Thank You!
• For questions, contact me at
charles.derus@advocatehealth.com
• Are You Solving the Right Problem?
by Dwayne Spradlin, HBR,
September 2012
• Leading the Lean Enterprise
by Koenigsaecker