File - John Bennett

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VA Pittsburgh Healthcare System
Veterans Engineering Resource Center (VERC)
&
Office of Systems Redesign (OSR)
Last Updated: June 2012
1
Introductions

Who are you?

Why are you here?

What do you want to learn?
2
Overview of Training Objectives
Learn Process Improvement
 Understand Lean principles
 Use strong problem solving methodology

 VA-TAMMCS

Participate in hands on learning activities
3

Insanity: doing the same thing over and
over again and expecting different results.
We are here to change the way you think!
4
Process Improvement Throughout Time

Measured Work
 Taylor,
Gilbreaths, etc…
Toyota Production System
 Total Quality Management

 Plan
Do Check Act (Deming)
Six Sigma
 Lean

5
Systems

The term ‘System ‘ is frequently used in
professional conversation

What does it mean ?

What system characteristics
are important to understand
from a process improvement
view?
6
Systems
•
System: A collection of elements that
function together to achieve a desired goal
•
•
Key issue: functions as a ‘Whole’
Systems thinking : The attempt to
understand and describe the system as a
whole by analyzing not just the individual
components , but by understanding the
complex structure of interrelationships among
the components
•
Systems thinking is often counter-intuitive
7
Process Orientation




Systems Thinking – understanding the
interconnections and pathways that define the
system
Process Orientation – system resources and
activities are organized around processes rather
than functional tasks
Connections are complex in functionally oriented
operations making systems thinking difficult if not
impossible
Process orientation facilitates systems thinking by
placing emphasis on connections (handoffs and
flow)
8
What is Lean?
LEAN:
• Eliminates waste to create more value with
less work.
• Proven program derived mostly from the
Toyota Production System (TPS) used to
improve work processes.
• Allow us to improve our organizational
culture.
• Enable teams to define problems and
create solutions.
9
Lean Improvement Model
Team/AIM
Goals:

o
MAP
o
o
Measure
o
Change
Sustain
o
Define the problem
Evaluate current processes related to
the project focus areas
Utilize Lean tools and methodologies to
identify operational barriers and process
failure modes
Apply Lean tools to improve systems
Implement control strategies to insure
long term sustainability of process
improvements and spread adoption
10
What is Lean?
“Lean provides a way to specify value, line
up value creating actions in the best
sequence, conduct these activities without
interruption whenever someone requests
them, and perform them more and more
effectively.”
-from Lean Thinking, by James Womack and Daniel Jones (1996)
11
Lean Concepts

Value
o

Identify and eliminate waste
o

Identify ideal patient experience – streamline process and eliminate
waste to achieve
Allow customer to “pull” value from process
o

Anything that does not add value from the patient’s perspective
Value flows without interruption
o

Value is determined by the “end customer” – the patient
Available when they want it – one piece flow
Continuous pursuit of perfection
o
Reliable and sustainable systems design
(Must know who the customer is…)
12
What is Waste?
The basis for Lean thinking is
systematically eliminating or minimizing
waste in a process or system
 Waste is defined as any resource
expenditure that Does Not ADD VALUE
 Value is an activity or expenditure of
resource directly contributing to patient
care

13
Eliminating Waste
Start
Step 1
WASTE
WASTE
Step 2
Finish
Total Cycle Time
Start
Step 1
Step 2
Finish
Total Cycle Time
Lean is a systems redesign methodology that
shortens the time between start and finish of any
given process by eliminating sources of waste.
14
VA Systems Redesign
•
System Redesign provides a team
approach for VA staff to plan, redesign,
map, measure and integrate processes
and systems to deliver real-time
improvements in VA Health care systems.
•
System Redesign expands on the
concepts established in Advance Clinic
Access to broaden the scope to include all
clinical and administrative processes.
15
Systems Redesign: Goals
• Empower the workforce to make improvements
• Improve Access To Healthcare
• Improve Work Processes
• Eliminate Waste
• Focus improvement on customer needs
• Evaluate centralization vs. decentralization of
functions
16
VA - TAMMCS
Following a systematic process greatly increases
the chances for successful implementation of
systems redesign.
Team based approach.
To that end, VHA offers VA-TAMMCS, as a SOLID
framework for success.
17
Vision
Role of leadership at the outset of process improvement and identifying the
project's mission.
Analysis
The analysis portion of the framework covers establishing priorities to
identify the most important areas on which to focus improvement efforts
and in evaluating performance.
Team
Teams work best when they have clear sponsorship, consist of front-line
staff, are passionate around improvement, possess a facilitator, and are
unified around a common aim or goal.
Aim
An aim is an explicit statement summarizing what the team hopes to
achieve during the project.
Map
Mapping serves to identify a process clearly by clarifying the start, end, and
key decision points.
Measure
Measurement is important in order to know if changes teams make are
really an improvement and fulfill our obligation to manage by fact not feel.
Change
All improvement requires making changes, but not all changes result in
improvement.
Sustain /
Improvements that can be sustained will continue to provide value to
veterans and employees who serve them.
Spread
18
“Tools” Used In Systems Redesign
Basic Tools:
• Lean
• Smooth flow
• Eliminate waste
• Rapid cycle change PDSA
• Small tests of change
• Staff engagement
• Theory of constraints
• Efficiency
• Throughput
• Advanced Clinical Access
Advanced Tools:
• Six sigma
• Reliability
• Queuing theory
• Matching supply and
demand
• Human factors
engineering
• Error proofing
• Simulations
• Modeling complex
solutions
19
VA-TAMMCS Framework
Value Stream
Mapping
A3 Worksheet
20
Basic Lean Exercise
21
VA-TAMMCS Framework
Value Stream
Mapping
A3 Worksheet
22
Defining the Problem

What are you trying to fix?

How do you know you need to fix it?

Who are the best candidates to fix it?
23
Theory of Constraints Definitions

Flow: The rate at which patients or item related to patient
care (paperwork, materials, and information) are able to
progress through the patient treatment processes.

Constraint: Any process step that limits the overall patient
treatment flow

Missing or incomplete information
 Materials or supplies
 Limited staffing capacity
Constraints are also referred to as ‘bottlenecks’.
24
Theory of Constraints (TOC)
Developed by Eli Goldratt to describe the impact of process
constraints on flow through a system or process
Flow: The rate that items
move through the ‘process’
The neck of the funnel
is the Constraint or
Bottleneck.
Process and system throughput cannot be increased unless the
throughput is increased at the bottleneck within the system.
25
Theory Of Constraints
5 Steps To Focus Improvement at a Constraint
1.
2.
3.
4.
5.
Identify the constraint
• Physical Constraints
• Policy Constraints
Decide how to exploit the constraint
• How will the constraint be eliminated or managed?
Subordinate everything else in the process to the
constraint
• Adjust the rest of the system to enable the constraint to
operate effectively
• Elevate the constraint
Invest time, energy, and money to eliminate the constraint
Go back to Step 1, but beware of inertia.
Source: H. William Dettmer, Goldratt’s Theory of Constraints: A Systems Approach to
Continuous Improvement, ASQC Quality Press, 1997, p. 11.
26
Voice of the Customer

Voice of the customer (VOC)

A term used to describe the in-depth process of
capturing a customer's expectations, preferences
and aversions.
 VOC is:

Market research technique that produces a detailed
set of customer wants and needs, organized into a
hierarchical structure, and then prioritized in terms of
relative importance and satisfaction with current
alternatives.
 Determine
what the customer thinks of your
product or service
27
Value Stream Map

A Value Stream Map is
used to visually represent the
current state of the process.

The Value Stream Map includes
information about processing steps,
processing times, wait times and # of items
within the process.

Information and material flow may be added to
provide a complete snapshot of the process.
28
Value Stream Symbols
Process
Box
Data
Box
Physician/
Service
Chief
Pull System
Flow
Information
Flow
Physical
Flow
Electronic
Information
Flow
Hospital
Queue/
Inventory
Information
/Computer
System
6
29
Value Stream Map

Steps to creating a Value
Stream Map:
1.
Flow Chart the Process at
a very high level
(5-7 processing steps)
2.
Add Suppliers and Customers
3.
Collect/Add information about process
times, wait times and queues.
30
Value Stream Map
??
Physician
??
Physician
Screening
Cancer
Diagnosis
Work-up
and
Surgery
ChemoTherapy/
Radiation
Therapy
Surveillance
31
Key Value Stream Metrics: Time

Process time (PT)
 The
time that is actually takes to perform the work, if
the work can be performed uninterrupted.
 a.k.a ‘Touch Time’ (physical process) & ‘Think Time’
(analytical process)

Cycle Time (CT)
 The
total elapsed time from entry into a processing
step until exit from that step and/or ready to go to the
next processing step.
 a.k.a – cycle time, turnaround time

Total Cycle Time:
 The
total time that it takes to go from entry to exit
within a system
32
Cycle Time vs. Process Time
Cycle Time
Patient
Entry
into
Process
step
Patient
Exit
out of
Process
step
Cycle Time = Process Time + Wait Time
(all blue)
(all red)
33
Key Metric: Reliability
% Complete and Accurate (%CA)
%
of the time that the downstream customer
can perform the processing step without
having to:
 Correct information or materials
 Add information or materials
 Clarify information
34
Value Stream Map
??
Physician
??
Physician
Screening
Scheduled
Occurred
Results
Documented
Cancer
Diagnosis
Work-up
and
Surgery
ChemoTherapy/
Radiation
Therapy
Surveillance
%CA = % of patients that specific
treatment(s) were documented
within the step
35
Value Stream Map
??
Physician
Primary Care
Physician
Cancer
Diagnosis
Work-up
and
Surgery
ChemoTherapy/
Radiation
Therapy
PT=2 hrs
PT=4 hrs
WT=10 hrs
PT= 4 hrs
PT=8 days
PT=2 hrs
WT= 44 hrs
%CA=60%
WT=4 hrs
WT=52 days
WT=10 hrs
%CA=90%
%CA=20%
%CA=50%
%CA=80%
Screening
Colonoscopy
27 days
5 days
.5 days
2 days
81 days
.3 days
Wait Time Between Steps
Surveillance
Colonoscopy
90 days
60 days
.5 days
36
Value Stream Map
??
Physician
Primary Care
Physician
Cancer
Diagnosis
Work-up
and
Surgery
ChemoTherapy/
Radiation
Therapy
PT=2 hrs
PT=4 hrs
WT=10 hrs
PT= 4 hrs
PT=8 days
PT=2 hrs
WT= 44 hrs
%CA=60%
WT=4 hrs
WT=52 days
WT=10 hrs
%CA=90%
%CA=20%
%CA=50%
%CA=80%
Screening
Colonoscopy
27 days
5 days
.5 days
2 days
81 days
.3 days
Cycle Time through each step
Surveillance
Colonoscopy
90 days
60 days
.5 days
37
Value Stream Map
??
Physician
Primary Care
Physician
Cancer
Diagnosis
Work-up
and
Surgery
ChemoTherapy/
Radiation
Therapy
PT=2 hrs
PT=4 hrs
WT=10 hrs
PT= 4 hrs
PT=8 days
PT=2 hrs
WT= 44 hrs
%CA=60%
WT=4 hrs
WT=52 days
WT=10 hrs
%CA=90%
%CA=20%
%CA=50%
%CA=80%
Screening
Colonoscopy
27 days
5 days
.5 days
2 days
81 days
.25 days
Total Cycle Time = 266 days
Surveillance
Colonoscopy
90 days
60 days
.5 days
38
ACTIVITY
Create a Value Stream Map and
then ID the constraints
39
ACTIVITY
40
VA-TAMMCS Framework
Value Stream
Mapping
A3 Worksheet
41
Successful Teams
•
•
•
•
•
•
Need Senior Support, Front Line and staff
empowered to implement change
Need Coach and Team Leader
Need Team Facilitator
Define roles and rules
Have a schedule and plan
Meet frequently
42
Developing a Team Charter
Project Charter
• States the scope, objectives and participants
• Defines the team membership
• Provides a preliminary description of roles and
responsibilities
• Identifies the main stakeholders
• Serves as a reference for team members and leadership
• It is a working document…
43
AIM = S.M.A.R.T. Goals
•
•
•
•
•
Specific
Measurable
Achievable
Realistic
Timely
(time, $, units, or %)
Example: The number of routine work orders greater than 30
days in the AC shop at UD will be no more than 50 by
September 1, 2009.
44
ACTIVITY
Review Team Charter
 Team
 Problem Statement
 AIM(s)
45
Facility Name:
Date Chartered:
Measure:
Service Line / Department:
What will you be measuring?
Submitted By:
Project Title:
Team Member Name:
Where will the data come from? (ie. Data Warehouse, VISTA, CPRS,
Observations, etc.)
Project End
Date:
Project Start Date:
Phone
Title
Position within Team
Project Owner
Project Facilitator
How will you collect the data? (Manual collection, Automated Data
Warehouse report, etc)
SR Point of Contact
Member
What is your current baseline data?
Member
Member
Project Scope:
Where does the process under investigation start?
Member
Problem Statement: (Problem & Plan)
Where does this process stop?
Describe the problem, opportunity, or objective in concise, measurable terms.
Include a summary of the problem and impact (a.k.a. PAIN).
What is inside of the project scope?
Problem:
Linkage to Strategic Priorities:
What is outside of the project scope?
Deliverables:
What end result(s) do you expect to achieve from this project?
Goal/Aim Statement: (SMART – Specific, Measurable, Attainable, Relevant, Timely)
Describe the team’s improvement objective (What is the team GOAL)
Begin with the words “reduce, increase, eliminate, control”
AIM #1:
How will you know that any changes have resulted in improvements?
Plan for Achieving Results:
46
VA-TAMMCS Framework
Value Stream
Mapping
A3 Worksheet
47
Process Flow Map
•
A flow map is a graphical representation of a
process. It represents the entire process from
start to finish.
•
Mapping a process out helps you clarify your
understanding of the process, and helps you
think about where the process can be improved.
•
The team then identifies value added and nonvalue added tasks.
48
Process Flow Map
Why map out the process?
• Sometimes there are surprises
• Problem areas
• Unnecessary steps
• Rework
• Group consensus on how the process really works: a
meeting of the minds
• Understand the present before you define the future
• Decide where data can be collected and investigated
49
Steps in Creating Flow Map
• Map the process “as is” (not what you want it to
be)
• Identify scope of process to flow map
• Write each step on a Post It note
• Each color Post It can depict a different Service Line,
Department, position, or owner involved in the
process
• Identify Internal and External Customers
• Internal = other employees, Service Lines, etc…
• External = patients, vendors, etc…
50
Steps in Creating Flow Map








Plan to use a different colored post-it for each
department doing the task
No open-ended tasks (all paths must terminate)
Use decision symbol for two choices or yes/no decisions
Use brackets with multiple lines if there are more than
two choices or paths
Use pencil for connectors at first
Make copy of each document used in the process and
tape to bottom of map
Once you are satisfied that it is finished and correct, go
over connectors with sharpie
Make critical notes on map
51
Questions to ask when creating Process Flow Map
•
Maintain process perspective
•
What, where, how, role – not why
•
Does this step work like this all the time?
Do some people do things differently than others?
Where does the information / material come from?
How does the material or information get into the
process?
Who makes the decision?
What happens if the decision is “yes”
What happens if the decision is “no”
What test or checks are done?
•
What happens if the test or check fails?
•
•
•
•
•
•
•
52
Situations to consider when creating Flow Map
•
Flow of people, information, equipment
•
Inventory or supply problems
•
Unnecessary motion
•
Waiting / delays
•
The right amount of information at any step
•
Work that may not be necessary from the customer’s
standpoint
•
Errors
53
Process Flow Map Symbols
-
Process: Show a Process or action step.
-
Decision Point: Usually two options (yes/no, pass/fail, etc).
-
Terminators: Shows the start and stop points in a process.
-
Document: Step that produces a document.
-
Storage of Information: Electronic storage of data.
-
Connector: Shows a jump from one point in the process to
another.
54
Example of Process Flow Map: VAPHS Work Order
Process
55
Example of Process Flow Map
56
Swim Lane Diagrams
57
Metrics Based Process Map
◦
Type of process map depicting process flow,
process durations and staff members and/or
departments involved in processing steps.
◦
More detailed representation of a sub-process
within a Value Stream Map, often used to
investigate specific sub-processes
58
Metrics Based Process Map

1.
2.
3.
4.
Steps to creating a MBPM
Review the process under investigation and establish
boundaries as outlined in the project charter.
Using brainstorming techniques, identify steps in the
process as well as personnel/departments involved in
the process.
Arrange the processing steps in order, align to
resources.
Validate the process flow either by showing the
process map to a non-team member involved
in the process, or by physically observing the process.
59
Out-Patient Registration Processes
Patient
Registration Arrives
At
Clerk
Registration
Desk
Clerk
Requests
ID
and
Medical
Card
Yes
Patient
Preregistered?
No
Patient
Assigned
To Registrar
Wait for
Registrar
Registrar
Registrar
Enters
patient
information
Wait for
Escort
Escort
Patient
escorted
to
radiology
PT = 1 min
PT = 2 min
PT = 5 min
PT = 1 min
WT =12 min
WT =2 min
WT =13 min
WT =12 min
%CAC=10%
%CAC=30%
%CAC=30%
Fishbone: Cause & Effect
61
ACTIVITY
Create:
- Process Flow Map
62
Lean
•
•
•
Proven process improvement method that
considers the expenditure of resources for
any goal other than the creation of value
for the end customer to be wasteful
Focuses on the continual reduction of nonvalue added activities
Directly improves speed and productivity
63
8 Sources of Waste
The Eight Forms of Waste
1. Defects
2. Overproduction
3. Waiting
4. Not Utilizing Employees
5. Transportation
6. Inventory
7. Motion
8. Extra Processing
64
Defects










Hospital-acquired illness
Wrong-site surgeries
Medication errors
Foreign objects remaining in patient
after surgery
Problem orders
Misfiling documents
Dealing with service complaints
Mistakes resulting from miscommunication
Illegible, handwritten information
Collection of incorrect patient information
65
Overproduction






Too many meal trays delivered
Asking the patient the same questions
multiple times
Large supply of forms
Extra floor space utilized
Unnecessary carbon copying
Batch printing patient labels
66
Waiting






Idle machines/people
Large waiting rooms
Patients waiting to see physician, nurse,
etc.
Waiting on the phone to schedule patients
Early admissions for procedures later in
the day
Waiting for internal transport between
departments
67
Not Utilizing Human Potential





Not using people’s mental, creative, and
physical abilities
Staff not involved in redesigning processes in
their workplace
Workarounds
Nurses and Doctors spending time locating
equipment and supplies
Staff rework due to system failures
68
Transportation




Poor workplace lay-out for patient
services
Carrying files from location to location
Moving equipment in and out of
procedure or operation room
Patient transportation
69
Inventory and Inspection






Office supplies stored in hallways
Charge slips piled up to be dictated
Physician orders building up to be entered
Unnecessary instruments contained in
operating kits
Multiple quality control checks
Much rework
70
Motion




Leaving patient rooms to
o get supplies or record
o document care provided
Large reach/walk distance
Documenting in more than one place
Nurse checking electronic medication
record to see if order entry is completed
71
Extra Processing






Multiple signature requirements
Extra copies of forms
Multiple information systems
entries
Printing hard copy of report when
digital is sufficient
Multiple steps to get pre-approval
for urgent treatments
Overstocking inventory
72
Non-Value Added
73
Identify Non-Value Added Steps In Flow Map
Identify each step with the following:
Red Tag = Non-Value added process
Yellow Tag = A required process, but not value
added
Green Tag = Value added to customer
74
Activity
Evaluate each step in the Flow Map with either a
red, yellow, or green dot
75
“If you keep doing what you are
doing, you will keep getting what
you’ve gotten.”
Unknown author, heard it on WIBC Radio morning show, Indianapolis, Indiana
76
Designing the Ideal State



Eliminating all waste, barriers, obstacles,
variation, and non-value adding
necessary, and non-value adding
unnecessary process steps in the current
state
The ideal state is designed
in the pursuit of perfection
A constant goal
77
Example Ideal State Map
MD
determines
need for blood
draw
LP draws
blood from
patient
Core
lab tests blood
sample
78
Future State Mapping
79
Designing the Future State


The future state is designed to the best
known process – pursuit of perfection
Consistently brings value (what the patient
needs) to the patient when they need it
(pull)

Requires elimination or minimizing of as
many non-value adding process steps as
possible
 Must be achievable

Continuous improvement required
80
Detailed Process Map – Current State
81
Process Map: Future State
Future State With Elimination of Non-value Adding Steps = 6 Steps
92% of the process steps were identified as non-value adding
82
Activity
Create a Future State Map
83
Gap Analysis:
Future State vs. Current

What is stopping us from reaching the future state?
o Non-value
added process steps
The eight forms of waste
o Bottlenecks/backups
o
o Process
variations
84
Activity

A rapid generation of ideas by all group participants.
AVOID DISCUSSION! AVOID SOLUTIONS!


o
Remember team dynamic rules
Write down as many ideas as possible on the
star-shaped post-its of the waste, bottlenecks,
obstacles, barriers, variation present in the
current state
Place “Star Shaped Post-It” on the current state
map where they occur
85
Prioritizing Opportunity
•
Affinity Diagram
A simple process of identifying and grouping
like information
o Powerful tool to use when working as a group
o The Process
o


Brainstorm ideas (completed earlier)
Group like ideas
86
Affinity Diagram Example
87
Prioritizing Opportunities Multi-voting


Multi-voting is used to prioritize greatest
to least
Each participant has 10 points
o
o
o
Each participant votes on the opportunities
with their points
Each participant can use all the points on one
opportunity or spread it across multiple
opportunities
Point totals will be added to determine
priorities
88
Activity
1) Complete Affinity Diagram
2) Vote
89
VA-TAMMCS Framework
Value Stream
Mapping
A3 Worksheet
90
Einstein on Data Collection
“Not everything that counts can be counted,
and not everything that can be counted counts."
-- Albert Einstein
91
Sources of Data:

IT System
 VSSC (VHS Support Service Center)
 Data
Warehouse
 CPRS (Computerized Patient Record System)
 VistA
 etc…

Manual Collection
92
Check Sheet
Description

It measures frequency by unit of time
 A check sheet is a structured, prepared form for collecting and analyzing data. This is a
generic tool that can be adapted for a wide variety of purposes.
Check Sheet Procedure

Decide what event or problem will be observed. Develop operational definitions.

Decide when data will be collected and for how long.

Design the form. Set it up so that data can be recorded simply by making check marks or
Xs or similar symbols and so that data do not have to be recopied for analysis.

Test the check sheet for a short trial period to be sure it collects the appropriate data and
is easy to use.

Each time the targeted event or problem occurs, record data on the check sheet.
93
Process Observation Worksheet
Process Observation Procedure
 List the steps from the process map in sequential order.



Identify the specific activities, decisions, motion and transport steps
Observe the process and collect information on process step durations, wait
times, and travel distances.
Perform multiple observations in order to determine the range of variation in
processing steps and times.
94
Spaghetti Diagram

Helps to visually identify wasteful steps
95
Spaghetti Diagram: Office Layout and Traffic Flow
►
►
►
Acquisitions and Contracting
Lean Project Team
Relocated Offices
Eliminated 36 Hrs/Yr from AO task
by moving printer
Eliminated 2 Hrs/Yr from Lead PA
task by moving printer
Original
After 5S
96
Why Develop Measures of Success?
•
This answers the following question:
How do you know that you made an
improvement?
•
It allows for continuous monitoring
(Sustaining)
97
ACTIVITY
Determine Measurements:
(Go Back to Project Charter and complete)
1. Measure
2. Project Scope
3. Deliverables
98
VA-TAMMCS Framework
Value Stream
Mapping
A3 Worksheet
99
Change

Types of Change
 External
(Imposed by outside force or
condition)
 Planned Change


Our Topic of Interest
Going from a current state or condition to
a proposed state or condition
 Change
management requires strategic
thinking, planning, decisive implementation
and stakeholder consultation
100
Change

At this point in the improvement process
your team has:
 Defined
the current process state
 Analyzed the current process and determined
causes of waste and ineffectiveness
 Designed a desired future state
 Now
what?
101
Change

Designing an implementation plan
 It

must be thoughtful and specific
The following elements are essential:
 What
 Who
 When
Sequence
 Duration

 How
 Resources
needed
102
Change

Thoughts on Planning:
 “If
you don’t know where you are going, any
road will get you there”

Lewis Carroll
 “If
you don’t know where you are going you
will probably end up somewhere else”

There is no substitute for a well thought
out specific objective
103
Change
Root Cause Analysis
 Aims improvement at root cause
 Avoids addressing symptoms
 Performed systematically
 Continuous improvement tool
 Systems focused
o
The “5 Why’s” not the “5 Who’s”
104
5 Why Example
The Washington Monument is deteriorating
o
Why?
•
o
Why?
•
o
Spiders eat gnats and there are a lot of gnats here.
Why?
•
o
Pigeons eat spiders and there are a lot of spiders here.
Why?
•
o
To clean up after the pigeons.
Why?
•
o
The use of harsh chemicals on the surface.
Gnats are attracted to the display lights at dusk.
Why?
•
We never change the timers during different seasons.
SOLUTION: Program the lights to come on later.
105
5 Why Example
 Multiple needle sticks are occurring with piggyback
intravenous medications
o
Why?
•
o
Why?
•
o
To safely unscrew the needle from the IV tubing so the needle can
be placed in the sharps container without getting stuck by the needle.
Why?
•
o
Staff are recapping the needles.
All needles are to be disposed of by placing them in the sharps
container.
Why?
•
To avoid who ever is handling the trash from being stuck by a
needle.
SOLUTION: Needleless intravenous medication administration system
106
ACTIVITY
Identifying Solutions

Brainstorming technique:
 Each
participant to write down as many
SOLUTIONS as possible
 There are NO bad ideas

No gate keeping or filtering
 Individual
activity (No talking, just write)
107
Activity: Solution Impact/Effort Grid
Highest Priority
IMPACT
High
Quick Wins
(Focus on
these as much
as you can)
(LH)
Fill Ins
(Quick Fix)
(LL)
Low
Major Projects
(Complex/Time
Consuming)
(HH)
Thankless Tasks
(Time Wasters)
(HL)
EFFORT
High
-Take each solution and place it in the quadrant that best reflects the impact
expected and the effort it would require.
- Establish priority by using Multi-voting technique if needed.
108
Integrated Lean Exercise
109
Change

PDSA (Plan, Do, Study, Act)
 Small
scale experimental in nature
Improve your solutions
 Improve implementation skills
 Uncover barriers that need to be addressed
 Elevate organizational receptivity to change

 Pilots
Sometimes used interchangeably with PDSA
 Generally larger in scope


Implemented to demonstrate proof of concept
110
Change

On PDSA’S and Pilots
 “proven
results speak loudly”
 “Creating initial success sets the table for
long term success”
Demonstrating success is a critical
element of successful implementation
 Failure is an educational experience

111
ct
A

an
Pl
PDSA Cycle
Plan the improvement:
 Select

o
D
y
ud
St
a process to improve
 Flow Chart the process
 Write aims (goals)
 Develop an action plan to track improvements
Remember: it’s a cycle
112
PDSA
Duct Tape to
wall outside
three rooms
Does placing sanitizer outside
room increase hand-sanitizing?
113
PDSA
Place table outside
door with sign
(ignore clutter)
Does having a place to put things
down increase hand-sanitizing?
114
PDSA
Do color-coded labels help to
differentiate lotion from sanitizer?
115
PDSA Cycle

Act on the knowledge:
 Adapt
(Adjust): Improve the change and
continue testing plan (additional PDSA
cycles)
 Adopt: Select changes to implement on a
larger scale and develop an implementation
plan and plan for sustainability
 Abandon: Discard this change idea and try
a different one
116
Use of the Rapid Cycle
A P
Changes That
Result in
Improvement
S D
Implementation of
Change
Wide-Scale Tests
of Change
A P
S D
Follow-up
Tests
Very Small
Scale Test
117
Rapid Cycle Change
Daily DC Discharge
Planning appts.
Doc. DC
plan Day 1
Inpt. priority
x-ray studies
118
“It’s better to get a little
better today than to
wait months for
perfection”
– Brent Seeley, Seattle
119
PDSA: Plan, Do, Study, Act
120
121
ACTIVITY
Develop PDSA’s
122
Implementing Change

A critical element for success
 Stake
holders and process owners must be
involved in the entire problem solving
process; with special emphasis on
development and implementation of solutions

Ignoring this will generate failure
The best change is what people think they did
themselves
Lao Tzu
123
Implementing Change

Educate and Communicate Relentlessly
 Stake
holders and those effected by proposed
change
 Include organizational leaders:
Develop sponsorship
 Create a sense of urgency

 Uncover
leadership personalities and give
them special focus

They can exert positive or negative influence
124
Implementing Change

Sustaining change requires fundamental
shifts in mind set and behavior by the
process owners
 Process
owners must believe the change
benefits them
 WIIFM (What’s in it for me)
“People cannot be expected to support and care
for things they do not own”
125
5S
SORT
• Eliminating unnecessary items from the workplace
• Team tags everything as follows:
•
Red Tag (Never used), Yellow Tag (Not often), Green Tag
(Critical)
SET IN ORDER
• Focuses on efficient and effective storage methods
• A place for everything and everything in its place
SHINE
• Thoroughly clean the work area
STANDARDIZE
• Concentrate on standardizing best practice in your work area
SUSTAIN
• Make 5S a part of daily activity so it becomes part of culture
• Continue 5S of all areas within the process
126
How to get started with 5-S
• Select team (appropriate size for the project)
• Including the “owner” of space, their supervisor, and project team
member.
• Determine Area for 5-S
• Conduct walkthrough of Area
• Detail all problems and supplies needed for the
5-S
• Start a timeline for the 5-S
Note: Begin and End 5-S with photo timeline
127
5-S Examples
Before:
After:
Before:
After:
128
5-S Examples
Before:
UD Warehouse
After:
129
5S Examples:
ED Reception Desk
Before
Placed all critical
numbers in one
location
After
Labeled drawer that stored
all commonly used forms
130
Pittsburgh VA – Equipment Room
BEFORE
IV Pumps
(4)
Always Plugged In
Whiteboard
indicates
location
Benefits
Clean equipment =
pathogen vector
Saves frustration, searching
Freed up $20K-worth of
unused equipment for use
elsewhere
AFTER
131
Benefits of 5-S
Improve safety
 Decrease down time
 Raise employee morale
 Identify problems more quickly
 Develop control through visibility

132
Action Item List
• Develop a Action Plan that defines who is
going to do what, and by when…
•
•
•
•
•
Monday
Week 1
Month 1
Quarter 1
Etc…
133
Example Action Item List
134
Te a m A s s i g n m e n t
Create Action Item List
Issues
Action Item
Benefit
Implement
High / Low
Easy / Diff.
Owner
Start
Completion
Date
Date
Status
135
VA-TAMMCS Framework
Value Stream
Mapping
A3 Worksheet
136
What is an Error?
“We make errors when our actions do not
agree with our intentions even though we
had the capability for completing the
intended action.”
- Institute for Healthcare Improvement
137
Poka-yoke (mistake-proofing)
“Any task that requires human intervention and
judgment to prevent mistakes is a mistake
waiting to happen.”

Removing the possibility of human error
 Often

used in combination with visual controls
Examples:
 Decision
support/clinical reminders within the EHR
system
 O2 line fittings
138
Examples
139
Hierarchy of Controls
Eliminating the
Causes of Problems
Physically Changing
the Workplace
Warnings that
Problems Exist
Building Information
into the Workplace
Training and
Standards
140
A3

Provides step by step direction to problem solving
or improving a process
o

Is also effective in addressing continuous improvement
opportunities
Clear concise one page overview
o
Consolidates large amounts of information in
understandable format using visual display
o

Challenges user to use as little verbiage as possible
Multi-purpose tool
o
o
o
Presenting project proposal or recommendations
Sharing and reviewing progress
Final report and Storyboard
141
VA Hospital
1.
TEAM/AIM:
Date:
Define the problem
Author:
3.
MEASURE:
4.
CHANGE:
Identify operational barriers and failure modes in the current process
Improve systems
Create a future state process by applying Lean techniques to eliminate operational
barriers and failure modes
2. MAP: Evaluate current state
5.
SUSTAIN:
Sustainability strategy
Create a process control strategy – a strategy for insuring long term sustainability
and spread adoption
142
VA Hospital
1.
Date:
TEAM/AIM: Define the problem
Fill in the Problem Definition
• What is the standard or desired level
of performance?
• What is the current level of
performance?
• What is the current performance
gap?
• What is the extent of the
impact/pain?
Author:
3.
MEASURE: Identify operational barriers and failure modes in the
current process
Quantify Value, Non-value and Waste in Current State
Current State Value
VA:
Steps
NVAN :
Steps
NVAU :
Steps
Add Primary Barriers/
Waste
4.
2. MAP:
Evaluate current state
Fill in the Current State Map
CHANGE: Improve systems
Create a future state process by applying Lean techniques to
eliminate operational barriers and failure modes
• Assign Each Step With a Value Using Value Legend
• Add Time and Distance Required by Each Step
• Quantify Value and Non-value in Future State
Future State Value
VA:
Steps
NVAN :
Steps
NVAU :
Steps
Assign Each Step With a Value Using the
Color-Coded Legend
Future State Time/Distance
•
sec. total time for routine orders
•
sec. total time for STAT orders
•
total steps traveled
• Quantify Impact of Improvements
Value Legend
Add Time and Distance Required by Each Process
Step to the Current State Map as Applicable
Add Root Causes for Primary
Barriers/Waste
• Fill in the Future State Map
• Describe the current state for your assigned
scenario
o High level mapping of current state
• Summarize current state with a few brief
concise statements if needed
Value Adding (VA)
Non-Value Adding Nec. (NVAN)
Non-Value Adding Unnec. (NVAU)
Current State Time /Distance
•
sec. total time for routine orders
•
sec. total time for STAT orders
•
total steps traveled
o % ↓ process steps
o % ↓ distance traveled
5.
o % ↓ required time
o % ↓ NVAN and NVAU steps
SUSTAIN: Sustainability strategy
Create a process control strategy – a strategy for insuring
long term sustainability and spread adoption
Give high level summary of sustainability and
spread plan
143
144
144
Spread/Diffusion Background
 Some
innovations spread like wildfire
while others with great difficulty
iPods
vs. Zune (Microsoft version)
Hospitalists
EMR (Electronic Medical Record)
Innovations to improve quality of care
Klotz, K
145
Spread/Diffusion Barriers
Difficult to change old habits
 Resistance in changing longstanding
routines
 Perceived need to work harder
 What is the organization’s culture?

Klotz, K
146
Diffusion of Innovation Theory





How innovations spread throughout
cultures
How, Why, What rate
Highly studied
Used in product marketing, public health
Based on work by Everett Rodgers
147
Diffusion Curve
148
Adoption Process
149
Diffusion Rate Factors


Innovation attributes
 Relative advantage (Cost/Benefit)
 Compatibility, Complexity / Simplicity
 Trialability, Observability
Communication
 The “Early Adopter” Opinion Leader
 Subjective perceptions influence diffusion
150
Change Personalities
151
Concluding Remarks
“The significant problems we have cannot be
solved by the same level of thinking with
which we created them.”
“Vision without action is merely a dream. Action
without vision just passes the time. Vision with
action can change the world!”
Joel Barker
152
Remember
•
•
•
•
Keep an open mind
Set S.M.A.R.T goals
(specific, measurable,
attainable, realistic and
timely)
Develop a project timeline
Commit to an action plan
•
•
•
•
•
Engage leadership
support
Involve and educate endusers and staff who do the
work
Spread the program to
other departments
Recognition for success
Schedule a weekly team
meeting
153
Certification
Certification can be obtained in two ways:
1) Free certification through VA
2) Pay approximately $275 for Purdue University
Certification
Both Require:
- Completed A3
o Participation in improvement project
- Passing a certification test
154
For all your participation and hard work!
We look forward to your results!!!
155
Contact Information

Find us on our SharePoint Site
Contact information
found here (About
us) tab…
156
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