PRINCIPLES OF LEAN

1
PRINCIPLES OF LEAN
2
Lean Awareness Workshop Outline

• Introduction and Welcome
• Background to Lean
• Lean Principles
• Flow Exercise
• Value-stream Mapping
• Waste Spotters Exercise
• Lean Toolbox
• Rapid Improvement Events (RIEs)

3
The Six Challenges

• Re-engineered care processes
• Effective use of information technology
• Knowledge and skills management
• Development of effective teams
• Co-ordination of care across pathways
• Making change possible

Institute of Medicine Crossing the Quality Chasm
A new Health System for the 21st Century
Corrigan JM 2001
4
Timeliness
Safety
Dimensions of Quality
Efficiency
Effectiveness
Equity
Patient -centeredness
5
Where Does Lean Originate?

• Developed by Toyota as the Toyota Production
  System (TPS) over the last 50 years
• Study of TPS led to academics defining the
  approach as Lean
• The application of Lean is not new principles
  have been used in many industries.
• In the last ten years, increasing application of
  the Lean approach in healthcare

6
Lean Strategy for TPS...

• Requires a focus on whole systems and processes
• Relentless focus on delivering services/products
• which meet the needs of the customer, or in
  healthcare,
• the patient
• The application of the PDSA (Plan, Do, Study,
  Act)
• rapid change cycle

7
Lean PrinciplesJones Womack, Lean
Thinking-Revised, 2000
8
Why is Lean Relevant?

• Lean thinking is not a manufacturing tactic or a
  cost reduction programme, but a management
  strategy that is applicable to all organisations
  because it has to do with improving processes.
  All organisations including healthcare
  organisations are composed of a series of
  processes, or sets of actions, intended to create
  value for those who use or depend on them
  (customer/patients)
• IHI Going Lean in Health Care, 2005

9
Lean in Healthcare

• Virginia Mason USA
• Theadacare - USA
• Bolton NHS - England
• Gwent NHS Wales
• NHS Tayside, NHS Lothian - Scotland

10
The Nun and the BureaucratA book and DVD
outlining how 2 hospitals used Lean principles to
transform their systems

• The fact is that a patient is not a car, and
  never will be. So. If that were the problem we
  were trying to solve, wed be stopped.
• However, the Toyota system is set up to identify
  customer needs in very clear ways and to meet
  those needs in explicit, efficient, rapid
  supplier-building methods.
• Theyre quite superior in the world of work, so
  if you said there was no work in healthcare then
  weve got a gap. But as long as you confess that
  works there, then Ive got a solution.
• G. Kenneth Turnbull, Ph.D.,
• Executive Vice President of Alcoa Business Systems

11
Economies of Flow
Mass/Volume Thinking Economies to Scale Lean thinking Economies of Flow
Big is good/cheap fast production rates Right size is good rate-based production
Focus on operation doing the job (s) Focus on process gluing jobs together
Specialists have skills centralised in few people Everyone has skills and expected to use them
Information need to know? Information visual
Performance is about tradeoffs example better quality costs money Performance is about root cause example better quality is cheaper
Manage by variety by batching together similar items Manage variety by skills to rapidly change from item to item
12
Sources of variation in a clinical system
GP
80 is under our control
13
Resulting in..
Systemic issues
Poor Scheduling of appointments and resources
Absence of process ownership and control
Unquantified capacity and demand
Overly complex pathways built in waits and delays
Few defined processes and no standard working
14
Healthcare processes are all about flow.
Toyota revolutionised our expectations of
production Federal Express revolutionised our
expectations of service. Processes that once took
days or hours to complete are now measured in
minutes or seconds. The challenge is to
revolutionise our expectations of healthcare to
design a continuous flow of work for clinicians
and seamless experience of care for patients
Don Berwick, Reducing Delays and Waiting Times
Throughout the Healthcare System IHI 1996
15
Value-Stream Thinking

• Stop looking at aggregated activities and
  isolated machinesStart looking at all the
  specific activities and see how they interact
  with each other.
• Womack and Jones

16
What does it do to our patients?

• When a patient experiences a service it is either
  good - and therefore what they expect - or it is
  bad. Patients do not experience averages
• As consumers in the outside world we have
  expectations of good quality and service, if
  these expectations are not met then we take our
  business elsewhere
• In health our patients do not readily have that
  choice.

17
Process Map

• A process map answers questions, such as
• What is the waste in the process?
• Where are any blockages to flow?
• How long does each process step take?
• How many handovers are there?

18
Mapping and analysis of the Process
Increasing level of detail
19
Two Elements to Every Job
Value Adding Valuable Effort Costs Time Costs
Money Adds Value VALUABLE
Non-Value Adding
Valueless Effort
Obvious Waste
Costs Time Cost Money Adds No Value
WASTE
20
Types of Waste

• Toyotas Seven Wastes
• Transport
• Inventory (work in progress)
• Motion
• Waiting Time
• Over-processing
• Over-production
• Defects
• TIMWOOD

21
Wastes in a Healthcare Process
Lean waste Examples in radiology
Defects Running unnecessary scans forms not being signed, faxes sent that are illegible
Overproduction Undertaking multiple scans
Excess inventory Extra supplies
Excess processing The process for ringing porters in the evening is to ring the Help Desk and then to be routed to the porters entering duplicate information printing paper reports to send in post
Unnecessary motion Time spent looking for staff entering duplicate information looking for parts and forms interruptions from other staff
Unnecessary transportation Transportation of scan results in post
Waiting Waiting for referrals/scans waiting for reports/signatures waiting for patients, doctors, porters
Underutilised staff Helpers in waiting rooms secretaries waiting for reports to be signed
Lean Thinking Improving flow and eliminating
waste - Neil Westwood, NHS Institute for
Innovation and Improvement
22
Standardisation

• This is an important challenge in healthcare
• delivery
• It requires agreement from all groups in the
• pathway of the best way to do the job
• Requires a clear way in which this is shared
• Needs a clear procedure for agreeing any
• process changes
• Performance management to track adherence

23
Lean Tools

• Value-stream mapping
• PDSA cycles
• Understanding Demand, Capacity and
  Variation
• Root Cause Analysis often called 5 Whys and How
  (5W H)
• 6S/Visual management
• Glenday Sieve
• Rapid Improvement Events (RIEs)

24
Lean PrinciplesJones Womack, Lean
Thinking-Revised, 2000
25
Flow in health care
Progressive uninterrupted movement of patients,
information and equipment between departments,
staff groups or organisations as part of their
care pathway. -
NHS Modernisation Agency, 2005
26
Effective flow is a property of the entire system
Patient Pathway
Micro-system
Micro-system
Micro-system
Micro-system
Teams make day to day, minute by minute decisions
in their own micro-systems without a view of the
whole system. Even if they have optimised their
own system it may do nothing for the whole
patient pathway.
Patients need to flow through the healthcare
system, however if underlying processes are
inefficient we will not manage patients
effectively.
27
Effective flow in action Unscheduled Care
Collaborative 5 Patient Flows
Group 1 - Minor Injury Illness
Group 2 Acute Assessment
Group 5 - Out of Hospital Care
Group 3 Medical Admissions
Group 4 Surgical Admissions
28
Advantages of Improving Patient Flow

• Improved patient outcomes and improved service
  quality
• Reduced time that patients stay in hospital,
  improving patient experience and freeing up
  inpatient capacity
• Reduced DNAs, improved resource utilisation and
  improved overall value for money
• Improved discharge pathways and reduced variation
  in length of stay
• Improved appropriateness of care to make sure
  that patients get the right treatment, from the
  right professional, in the right place, at the
  right time
• - Planned Care Improvement Programme, Patient
  Flow in Planned Care, IST, 2007