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Lect 3c The Lean Enterprise
Lect 3c The Lean Enterprise
What Is Lean?
Japanese : Kai school, Zen wisdom Elimination of waste Toyota Production System (TPS) Philosophy Produce only what is needed, when it is needed, with no waste ensure swift, even flow through the process of system, through continuous improvement The least wasteful way to provide better, safer healthcare to patients with no delays Providing exactly what the patient needs, safely, when needed, in precisely the right quantity and without waste Making common sense common practice Methodology Determination of value added in the process Tools Five Ss, kaizen event, standardized work, etc.
KAIZEN
JAPANESE continual improvement Goal: To change the process so that people cannot go back to the old way of doing business. Focus is on the entire value stream with specific improvement technique focused on a particular process Employee-led suggestions for improvement made and implemented quickly Existing team used and provided with tools to deliver on the metrics and goals with better problem solving capabilities as a group. No or minimum investment. Creates a foundation and motivation to drive continuous improvement in the process. Business leaders like it, can see tangible change quickly.
Useful for implementation of larger scale improvement & driving smaller local change quickly. Results are achieved in 5 days & change is typically visible. Examples include in pre registration, admitting area, medical records, processing patients, financial services, or a clinical area. Assumptions: Everything can be improved Many small incremental changes will result in a better system Even it isn't broken, it can be improved The elements addressed in a kaizen are: Wastes Flow Non essentials Process Improvements
2. Understand your process 3. Smooth the flow 4. Shift from Push to Pull - ER triaging 5. Continue to attack waste seek perfection
Process map of the value stream - measures process in terms of time, work in process, etc. and identifies the source of waste Information processing and transformational processing steps included Value adding steps customer willing to pay? Non-value-adding Necessary Unnecessary Non-value-added activity waiting time, patient will not pay to wait non-value-adding necessary activity is employee payroll no value addition to customer, but employees have to be paid. Examine and determine whether any such activities can be eliminated Eliminate non-value-adding unnecessary activities
% value added =
Non-Value-Added Activity?
Multiple areas for medication storage 1 Organizational Opportunity
Interruptions?
1. 2. 3. Phone Window Door
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Nurses time sp
Process map
Pictorial representation of a process Assists with identifying and planning improvements Useful basic flowcharting symbols
start Delay
Activity/task/step
Decision point
Tools
Takt time Throughput time Five Ss Spaghetti diagram Kaizen blitz or event Jidoka Andon Standardized work Kanban Single minute exchange of die (SMED) Flow Pull Heijunka Poka-Yoke
TAKT TIME
German word meaning rhythm or beat The speed with which customers must be served to satisfy demand for the service Takt time = Available work time/Day Customer Demand/Day Throughput time : the time for an item to complete the entire process, includes waiting time, transport time as well as actual processing time. E.g. OPD patient movement Cycle time is the actual time taken to accomplish a task in a system System cycle time is the longest task-cycle time in the system the rate at which the customers or products exit the system, the drip time. In Lean Cycle time = Takt time
If cycle time is greater than Takt time, demand will not be satisfied and pts will have to wait If cycle time is less than Takt time, resources will be underutilized in a service environment and inventory will be generated in a manufacturing environment.
Available worktime/ physician=5 hrs Number of physicians = 8 Pts expected/day (Demand) = 100
Takt time = 8 phy x 5 hrs/day = 0.4 phy hrs/pt 100 patients/day = 0.4 x 60 = 24 phy min/pt Move to examining room 2 min
Wait 15 min
Wait 15 min
Wait 10 min
Visit complete
Longest cycle time = 20 minutes % Value added time = 20/70 minutes = 28% Lean : - increase value added time %
Five Ss 5S - Visual order is the foundation of excellence in manufacturing. When it is in its place on the production floor, work gets done efficiently and effectively. When it is not in place, work still gets done but at a level of cost that is hard to justify Benefits Improved safety Reduced waste Improved morale Ownership of workspace Improved productivity Improved quality Improved maintenance Better impression on customers
5ss pre-Lean
Scrounge Steal Stash Scramble Search
Lean 5S strategy
Sort Set in order Shine Standardize Sustain
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21
Symbol
Brown GI / Ostomy supplies Blue Orange Green White Respiratory supplies ADL supplies Dressing supplies Miscellaneous
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23
Shine
Work area cleaned, straightened and organized
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This cart was well-organized but it was still difficult to find some items. Labeled each shelf and bin as to its contents. Saved staff time looking for items.
Turned off the auto print option at the ED monitor station, and now only print when needed. Reduced clutter and saved paper and disposal costs. Also saved staff time and printer wear and tear. Estimated cost savings at $1000+ per year BEFORE AFTER
Before
After
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Spaghetti diagram
A visual representation of the movement or travel of materials, employees or customers. Movement from place to place and backtracking Can help to find and eliminate wasted movement in the system
Guidelines for Spaghetti diagram Note the time, date and process being evaluated, but not the name of the individuals Explain to the team what's being done and ask for a volunteer Trace the actual steps taken Note any stops with sequential numbers and mark the time for each stop Note any awkward elements in the line taken Mark any inherent interruptions in the path - such as gowning up Note why certain trips are made eg getting necessary supplies or signatures Ask questions and seek suggestions from the team - the best ideas often come from those who live the process
Spaghetti Diagram
Adding Value
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Spaghetti Diagrams
Current Condition
Pilot Condition
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Do
Andon is a visual or audible signaling device used to indicate there is a problem in the process.
A caregiver who believes that something is not right in the care process, she can and must stop the process., and inform the patient safety department, RCA will be done and problem sorted out. Examples: medication errors, problems with equipment and facilities, system issues
Standardized work
A written document of the specific way in which every step in a process should be performed Not a rigid system of compliance A means of communicating and codifying current best practices Provides a baseline form which improvements can be made to the process All relevant stakeholders to be involved, promotes employee buy-in and ownership of the process and responsibility for improvement Variation and waste minimized Can be used on clinical, support and administrative operations of h/c organizations Example: Evidence-based medicine documented treatment protocols, clinical pathways of care
Care path optimal sequencing and timing of interventions by physicians, nurses and other staff for a particular diagnosis or procedure, designed to minimize delays and resource utilization and at the same time maximize quality of care.
KANBAN
JAPANESE TERM meaning signal Controlling mechanism in a pull production system Containers of certain size used to signal the need for more production or service Example : supplies and pharmacy
Kanban
Kanban
Advanced Access
Patients are unable to obtain timely primary care appointments. Advanced access scheduling reduces the time between scheduling an appointment for care and the actual appointment. The goal is swift, even patient flow through the system.
Advanced Access
Advantages
Decreases no-show rates Improves patient satisfaction Improves staff satisfaction Increases revenue
Higher patient volumes Increased staff and clinician productivity
Advanced Access
Implementation
Advanced access challenges established practices and beliefs. Balance supply and demand:
Obtain accurate estimates of supply and demand. Reduce or eliminate backlog. Minimize the variety of appointment types. May need to:
Adjust demand profiles. Increase availability of bottleneck resources.
Lean Sigma
Lean and Six Sigma are focused on continuous improvement of the system.
Lean Eliminate waste Achieve flow and pull Six Sigma Eliminate defects Reduce variation in processes
6W
Poka-Yoke
Eliminates opportunities for mistakes Poka inadvertent errors Yokeru to avoid Examples:
Insertion of endotracheal tube:
Poka - error - to put the endotracheal tube into the oesophagus. Yoke - to avoid solution squeeze plastic bulb and put it on the tube end. If it inflates tube is in the respiratory tract, if not an error has occurred and tube is in the oesophagus
Wheelchair falls- solution is wheelchair lock when the person is attempting to sit
Impact Of Lean
Before Lean 29 process steps for refills Delay, Employee frustration Tools applied Value-stream mapping 5S, Point of use storage Impact Reduced process steps to 20 Streamlined work flow Eliminated non-value added time - refill time for 3 units from 1hr. 3 min. to 33 minutes
Spaghetti Diagram 5S