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Lean 102

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Title: Lean 102


1
Lean 102
  • Coverdell Learning Community
  • Dean Bliss
  • Iowa Healthcare Collaborative

2
Tools
  • Value Stream Mapping
  • 5S
  • Standard Work
  • Visual Controls
  • Error Proofing

3
What Is a Value Stream?
  • Defines value from the customers perspective
  • All of the actions and tasks, both value added
    and non-value added, required to bring an item
    (an idea, information, product or service) from
    its inception through delivery.
  • These include actions to process information from
    the customer and actions to transform the product
    on its way to the customer.
  • Value streams vary in scope reach beyond the
    enterprise to single process size

4
What Flows Through the Value Stream?
  • Products, information, or services flow through
    a value stream
  • In manufacturing or distribution, materials are
    what flow
  • In health services, patients are what flow
  • In office areas, information is what flows
  • In service areas, external customer needs flow
    through the value stream
  • In administration, internal customer needs flow
    through the value stream
  • In many cases, the item flowing in service or
    administration is a document, an order, or a
    request

5
Purpose of Value Stream Mapping Analysis
  • Develop a common understanding of the current
    process
  • The relationship of process steps
  • A true picture of the process
  • Create a baseline to measure improvements against
  • Define a vision of the future process
  • Establish common leadership objectives
  • Identify opportunities for improvement
  • Design an implementation plan for improvements

If you cant describe what you are doing as a
process, you dont know what youre doing.
W. Edwards Deming
6
Emergency Room Current State
7
Lean Training
  • 5S

8
The Five Ss
  • Sorting separating the needed from the
    not-needed
  • Simplifying a place for everything and
    everything in its place, clean and ready to use
  • Systematic Cleaning or Sweeping cleaning for
    inspection
  • Standardizing developing common methods for
    consistency
  • Sustaining holding the gains and improving

9
The First S - Sorting
  • Separating the Needed from the Not-Needed
  • Eliminate not-needed items and perform an initial
    cleaning
  • Establish criteria/handling of items
  • Identify not-needed items
  • Move not-needed items to holding area
  • Conduct a white-elephant sale
  • Conduct an initial cleaning

10
The Second S - Simplifying
  • A place for everything and everything in its
    place, clean and ready to use
  • Arrange workplace for safety and efficiency
  • Identify key equipment and supplies
  • Determine location for each item
  • Outline locations and zones
  • Develop shadow boards, label items
  • Document layout, equipment, supplies

11
The Third S Systematic Cleaning
  • Cleaning for Inspection
  • Perform daily cleaning and inspection to
    understand work conditions
  • Identify points to check for performance
  • Determine acceptable performance
  • Determine visual indicators/controls
  • Mark equipment/controls
  • Conduct daily cleaning/inspections

12
The Fourth S - Standardizing
  • Developing Common Methods for Consistency
  • Make abnormal conditions noticeable and document
    agreements
  • Document agreements and checks
  • Establish/document standard methods across
    similar work areas
  • Document new standard methods

13
The Fifth S - Sustaining
  • Holding the Gains and Improving
  • Maintain the gains from other 5S activities and
    improve
  • Determine 5S Level of Achievement
  • Perform routine checks
  • Analyze results of routine checks
  • Measure progress and plan for continuous
    improvement

14
Whats an example?
15
Whats an example?
16
Whats an example?
After
Before
17
Whats an example?
18
Whats an example?
19
Questions?

20
Lean Training
  • Standard Work

21
What is it?
  • Standard work represents the best, safest, and
    easiest way to do a job

22
Whats it for?
  • Standard work allows an organization to
  • Create consistency and predictability
  • Preserve know-how and expertise
  • Prevent recurrence of errors
  • Improve staff satisfaction and productivity
  • Improve patient and physician satisfaction

23
How does it work?
  • Standard work is a documented record of how to do
    a job
  • It must be followed by all those performing that
    particular task
  • All associates
  • All shifts
  • Creating standard work involves several steps

24
Evaluate Current Situation
  • To implement standard work, the current process
    needs to be understood
  • Direct observation is the best way to know the
    current process
  • Dont rely on procedures
  • Dont rely on memory or brainstorming
  • This process frequently follows a mapping exercise

25
Identify areas of opportunity
  • There are many ways to identify areas for
    opportunity
  • 7 forms of waste
  • Spaghetti diagrams
  • Value added vs. non-value added activities
  • These methods highlight steps in the process that
    can be modified or eliminated

26
Quantify Improvements
  • Once opportunities are identified, changes to the
    work processes can be tested, evaluated, and
    selected
  • Improvements should be measured in a live
    environment to ensure that they work and that
    they are an improvement
  • The new standard work can now be documented and
    implemented

27
Standard Work in Practice
From Dr. Richard Kunkle in Toyota Talent, Jeffrey
Liker and David Meier, McGraw-Hill, 2007, pg. 187.
28
Whats an example?
  • How to write your name on a flip chart
  • 1. Stand up
  • 2. Go to the flip chart
  • 3. Pick up the marker
  • 4. Write your name
  • 5. Put down the marker
  • 6. Return to chair
  • 7. Sit down

29
Whats an example?
STANDARD WORK SHEET STANDARD WORK SHEET STANDARD WORK SHEET STANDARD WORK SHEET STANDARD WORK SHEET STANDARD WORK SHEET  
PROCESS Secretary workflow prior to start of new facilitators To be accomplished as soon as possible but no less than 1 week prior to arrival of new facilitator PROCESS Secretary workflow prior to start of new facilitators To be accomplished as soon as possible but no less than 1 week prior to arrival of new facilitator PROCESS Secretary workflow prior to start of new facilitators To be accomplished as soon as possible but no less than 1 week prior to arrival of new facilitator PROCESS Secretary workflow prior to start of new facilitators To be accomplished as soon as possible but no less than 1 week prior to arrival of new facilitator  
  Trigger Receive an email with notification of new facilitator from Lead Facilitator
  Work with lead facilitator to assign workspace/cube
  Contact New Facilitator to complete an equipment/supply/access needs assessment
  Assess PC needs and log a help desk call if necessary
  Obtain home phone and extension number for secretaries and modify the facilitator phone listing
  Setup a meeting with new facilitator on the first day from 8-10am with the department secretary Etc. Etc.
30
Whats an example?
Admission packet instructions
31
Whats an example?
32

Report Form For ED Admissions
33
Questions?

34
Lean Training
  • Visual Controls

35
What are they?
  • Visual controls are tools that are used to ensure
    that a process is running smoothly

36
What are they for?
  • They are used for several purposes
  • Visual Management - How are we doing?
  • Process Compliance Are we doing it right?
  • Location Where are things we need? Where should
    things be?
  • Information What do we need to know? What
    things can help us?

37
How do they work?
  • Information is displayed in a common area
  • Message is simple and easy to interpret
  • A good or bad condition is easy to see

38
When do you use them?
  • Visual Controls are best used when they are
  • Obvious
  • Well understood
  • Used for decision-making
  • Maintained

If visuals arent used, or are out of date,
remove them
39
Whats an example?
40
Whats an example?
41
Whats an example?
42
Whats an example?
43
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46
Whats an example?

  • July August
  • Floorspace (sq.ft.) 100,000 65,000
  • Pictures or words?

47
Questions?

48
Lean Education
  • Error Proofing

49
What is it?
  • Error Proofing is a method of identifying ways to
    eliminate or reduce errors in a process
  • There are multiple levels of solutions
  • Level 1 total elimination
  • Level 2 reduction of error rate (when
    elimination not possible)

50
Error Proofing Is it Needed?
Between 44,000 and 98,000 people die each year
nationwide as a result of avoidable errors in
hospitals Safety does not reside in a person,
device or department, but emerges from the
interactions of components of a system. Errors
can include problems in practice, products,
procedures and systems. The usual responses to
such errors focus on preventing recurrence by
punishing or retraining individuals. These
responses tend to be ineffective because they
ignore the system and instead focus on one
particular set of circumstances that are unlikely
to reoccur. To Err is Human Building a Safer
Health System, Institute of Medicine (IOM)
Read for Free at http//www.nap.edu/books/0309068
371/html/
51
Error Proofing Is it Needed?
Kidney Transplant wrong side
Unnecessary radical jaw surgery
Surgical sponge and gauze left in breast
Surgical tool left in stomach
The New York Times Magazine, March 16, 2003
52
Error Proofing Is it Needed?
OLD
CNN, November 21, 2007
NEW
53
How does it work?
  • Weaknesses in processes are identified by
    observation, measurement, or other methods
  • Ideas for eliminating errors are collected,
    evaluated, and tested
  • The most effective and practical solution(s) are
    implemented

54
When do you use it?
  • When errors are identified and are causing a
    process to be inefficient
  • When harm is coming to patients, regardless of
    frequency or difficulty of correction

55
Level 1 Total PreventionDefect cannot be made
Outlets for various types of gases are keyed in
such a way that wrong connections can not be
made. All connectors have a pin at the 12
oclock position, but differ on the second
position.
Level 1 Keying
Level 2 Color Coding
Condition H (Shadyside, Patient/Family call for
RRT
Credit to John Grout, Berry College,
www.mistakeproofing.com/medical
56
Level 1 Total PreventionDefect cannot be made
  • Error esophageal intubation (putting a tube into
    a patients stomach which was intended for their
    lungs)
  • Error proof Squeeze bulb and put on tube. If
    bulb inflates, the tube is in the lungs. If
    not, tube is incorrectly placed in the esophagus.

Credit to John Grout, www.mistakeproofing.com/medi
ndex.html
57
Level 2 Hand Washing Before Entry
Stop/Go Arm is Up
Light Sensor under Sanitizers both inside room
and out raises the Stop arm
Kevin Frieswick at MetroWest Medical Center
http//www.leanblog.org/2009/04/leanblog-podcast-6
5-error-proofing/
58
More Error Proofing Examples
NG tube cannot be connected to an IV port
Yellow tubing is attached to all epidural meds
and serves as a visual indicator
http//mmpp.wikispaces.com/
59
Error Proofing in Practice
Lab Barcode scanner was implemented to scan and
identify specimens quickly and without errors.
ER Pyxis-for all critical supplies not just for
drugs
60
Error Proofing in Practice
  • Sanjay Saint, MD, Univ. of Michigan Healthcare
    System implemented a reminder system for
    physicians to remove the urinary catheters of
    hospitalized patients.
  • Indwelling urinary catheters are placed in 25
    of hospital patients.
  • Estimated 40 of infections developed during
    hospital stay are urinary tracts infections, most
    due to urinary catheters.
  • The reminder system error proofs the process by
    helping the doctor know which patients have
    catheters, how long they have been in, and when
    to order removal. Study results showed that each
    patients hospital stay that involved a catheter
    went down by 7.6 on the reminder wards. And,
    the written-reminder system isnt expensive.
  • Dr. Sanjay Saint UMHS in BCBSMs Highlights
    Newsletter

Read for Free at http//www.bcbsm.com/foundation/
pdf/05highlights.pdf
61
The Bottom Line
  • The Lean philosophy and tools can be valuable in
    improving processes and patient safety
  • Analyzing information, handoffs, physical
    layouts, and opportunities for standardization
    can make work easier and safer

62
Questions?
  • Dean Bliss
  • Iowa Healthcare Collaborative
  • blissd2_at_ihconline.org
  • 319-329-1440
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