Post on 15-Nov-2014
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Ricardo Leaño, MD, MBA, CSSBB
s Physician. Board Certified Anesthesiologists Master of Business Administration. Specialization
in Health Administration and Policy. University Of Miami.
s Leading Teams and Organizations, Effective Leadership, Executive Leadership Strategies. University of Notre Dame. Mendoza College of Business
s American Society for Quality (ASQ) Certified Six Sigma Black Belt.
s Co-Chair Educational Committee ASQ-HCDs American College of Healthcare Executives-ACHE
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Ricardo Leaño, MD, MBA, CSSBB
s Clinicals Managerials Leaderships Quality
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“It is not the strongest that survive,
nor the most intelligent,but the one
most responsive to change”
Charles Darwin (1809-82)
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Why you are here
"Change happens by listening and then starting a dialogue with the people who are doing something [you don't believe]
is right.“Jane Goodall
InformationWeek Daily Newsletter www.informationweek.comWeekend Edition: Saturday, March 28, 2009
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HEALTHCARE
ORGANIZATIONS
SIX SIGMA
EMPOWERMENT.
H.O.R.S.E. LEANRicardo Leaño, MD, MBA, CSSBB
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s Healthcares ORganizationss Six sigmas Empowerment
H.O.R.S.E. Lean
horse [v. to haul or hoist energetically]
Webster’s II New Riverside University Dictionary
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H.O.R.S.E. Concept
The H.O.R.S.E. principles greatly emphasize leadership and
strategic management together with Lean Six Sigma
methodologies so as to hoist energetically our healthcare
system in the right direction.
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H.O.R.S.E. Concept
s Every internal organization must understand how and why other individuals/organizations work, how and why they make decisions and unite them to keep the mission, vision and goals of their institution as part of their own missions, visions and goals.
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Lean Six Sigma
Leadership
H.O.R.S.E.
Principles
Strategic Managemen
t
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Positive Financial Impact
Process
Improve
ment
Increased Productivity
Waste
Reduction
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Lean, Six Sigma and Lean Six Sigma
Jing, G.G. “A Lean Six Sigma Breakthrough”
Quality Progress. May 2009
Lean:Improvement approach
aimed at improving efficiency by removing
wastes
Six Sigma:Improvement approach
aimed at improving process capability by
reducing variation
Lean Six Sigma:Improvement approach aimed at
combining both Lean and Six Sigma to improve efficiency and capability primarily by removing wastes and
variation
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primum non attero [first do no waste]
primum non nocereFirst do no harm
secundus non atteroSecond do no waste
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ISO 26000 Defines Social Responsibility
“responsibility of an organization for the impacts of its decisions and activities on society and the environment, through transparent and ethical
behavior that contributes to sustainable development, health and the welfare of society;
takes into account the expectations of stakeholders; is in compliance with applicable law and consistent with international norms of
behavior; and is integrated throughout the organization and practiced in its relationships”
Vincent, C. “Back in Circulation”
Quality Progress. May 2009
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…in healthcare…
wasted
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Margin
Revenue = Outputs x Prices Expenses = Inputs x Costs
Profitability = Productivity x Price Recovery
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Margin
Margin Compression ↑ Revenue = Outputs x Prices Expenses = Inputs x Costs ↑ ↑
Margin Looseness ↑ ↑ ↔ ↑ Revenue = Outputs x Prices Expenses = Inputs x Costs ↓ ↓ ↓
Profitability = Productivity x Price Recovery ↑ ↑ ↑
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Budget
Profit is determined by revenue and expenditures
Financial position is determined by profit and capital expenditure
These are determined by Market share Price Customer satisfaction Quality Worker satisfaction
Griffith J, White K “The Well-Managed Healthcare Organization”. 6th Edition
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DRA (Deficit Reduction Act of 2005)
Beginning October 1, 2008, Medicare will no longer pay the higher MS-DRG for these HACs (Hospital Acquired Conditions)
s pressure ulcer stages III and IV; s falls and trauma; s surgical site infection after bariatric surgery for
obesity, certain orthopedic procedures, and bypass surgery
s vascular-catheter associated infection; s catheter-associated urinary tract infection; s administration of incompatible blood; s air embolism; and s foreign object unintentionally retained after surgery.
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To err is human
“medical errors do not result from … a ‘bad apple’ problem. More
commonly, errors are caused by faulty systems, processes, and
conditions that lead people to make mistakes or fail to prevent them. “
I N S T I T U T E OF M E D I C I N E November 1999
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Institute of Medicine
Six Aims for Improvement1. Safety – Avoiding injuries2. Effectiveness – Services based on scientific
knowledge3. Efficiency – Avoiding waste4. Patient-centered care – Care that is respectful of
and responsive to individual patient preferences, needs and values
5. Timeliness – Reducing waits and harmful delays6. Equitable care – Equal care to all regardless of
gender, ethnicity, location and socioeconomic status Institute of Medicine
Crossing the Quality Chasm:
A New Health System for the 21st Century
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Healthy People 2010 goals…
“…safe, effective, patient-centered, timely, efficient, and equitable care
that extends the quality [and length] of life and reduce health disparities”
Griffith, J.R., White, K.R.
“The Well-Managed Healthcare Organization”
6th ed. Health Administration Press
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Concepts
s Sigma (). Standard deviation. Provides an estimate of the variation in a set of measured data
s Sigma level. Describe the performance of a process relative to the specification limits.
s Process: Sequence of activities that transform inputs into Outputs
s Quality: “Is a predictable degree of uniformity and dependability, at low cost and suited to the market”
Deming, W.E.
s Defect: Failure to meet customer requirements
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Sigma
Narrow VariationNarrow Variation Wide VariationWide Variation
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Sigma Level
Performance of a process relative to the specification limits Yield Defects per
million opportunities
Sigma Level
69.1500% 308,500 2.0
84.1300% 158,700 2.5
93.3200% 66,800 3.0
97.7300% 22,700 3.5
99.3800% 6,200 4.0
99.8700% 1,300 4.5
99.9770% 230 5.0
99.9970% 30 5.5
99.9997% 3.4 6.0
International Survey Supported by the Commonwealth Fund 2007
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s One in three of U.S. respondents reported experiencing medical mistakes, medical errors, inaccurate or delayed lab results.
s Highest rate of any of the six countries in the survey.s U.S. 32%s Canada 28%s Australia 26%s New Zealand 22%s Germany 16%s U.K. 24%
s Most patients (61% - 83%) in each country said health care providers did not tell them about the errors.
(Schoen, et. al. Health Affairs, Web Exclusive; W5-509-W5-525)
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Process. Y = f(x)
Everything is a Process
“A systematic series of actions directed to the achievement of a goal” J.M. Juran
Method(x)
Man(x)
Material(x)
Machine(x)
PROCESSING(f)
Environment
(x)
Output(Y)
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Lean Six Sigma
Blame the processnot the individual
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To err is human
“medical errors do not result from … a ‘bad apple’ problem. More
commonly, errors are caused by faulty systems, processes, and
conditions that lead people to make mistakes or fail to prevent them. “
I N S T I T U T E OF M E D I C I N E November 1999
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Quality Definitions
s “…a predictable degree of uniformity and dependability, at a low cost and suited to the market” W.E. Deming
s “…any characteristic that improves the product or service in the eyes of the buyer.” J. Griffith, K. White
s Hard to define, but you recognize it when you see it ACHE Congress 2008
s “The least cost to Society” Genichi Taguchi
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Lean Six Sigma Definitions
s “A comprehensive and flexible system for achieving, sustaining and maximizing business success”
MoreSteam University
s “…relentless and rigorous pursuit of the reduction of variation in all critical process … that impact the bottom line … and increase customer satisfaction”
H. Gitlow. University of Miami
s “a disciplined, data-driven approach and methodology for eliminating defects (driving towards six standard deviations between the mean and the nearest specification limit) in any process”
iSixSigma.com
s An objective journey toward process improvement
Ricardo Leaño
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Lean Six Sigma
s Structured methodologies for sustained process improvement
s Both are complementary processes, not competitive approaches
s Both represent a cautious compilation of previously developed quality tools and a framework for action with the particular and common objective of improving quality by performing relative to customer requirements and eliminating waste.
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How they work
s Identify and eliminate non value-added activities
s Identify and reduce variations Understand and optimize
processes by focusing on inputs
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DMAIC
s Defines Measures Analyzes Improves Control
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Define (DMAIC)
s Dashboard - Scorecards Project charter (Business Plan)s SMART project (specific, measurable, achievable,
relevant, time bound)
s SIPOC analysiss Process Flow Charts Voice of the Customer (VoC) analysis
Affinity Diagram Operational Definitions
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Mission: To provide safe anesthesia in a pleasant enviroment and create a cost-effective Operating Room
Anesthesiologist OR Management
Key Objectives Key Indicators Key Oblectives Key Indicators Tasks or Projects
Provide Safe Anesthesia having updated equipment, bringing patients in the most optimized condition and having detailed information about patient's condition
Number of patients arriving to pre-op area not optimized per day
Have patients in the best of her medical condition prior to surgery
Number of patients in pre-op area not optimized due to delay in executing MD orders
Develop, with ward nurses, a system to prioritize patients going to OR and more effective communication with PMD
Number of patients in pre-op area not optimized due to lack of PMD evaluation
Develop with PMDs a set of minimum parameters in terms of lab results before taking the patient to an elective surgery
Number of patients without a complete cardiac clearance per day
Medical clearance should include complete and objective information useful to the anesthesiologist
Number of incomplete cardiac evaluations per day
Develop, with cardiologists, a format to fill up the information required prior to an elective surgery
Age of anesthesia monitors and machines per room
Anesthesia equipment and monitors must be updated
Age of anesthesia monitors and machines per room
Install modern equipment that is compatible in all the perioperative areas
Create a Cost-effective OR with less sub-utilized OR time
Number of cases that are not properly booked in terms of length of surgery and start time
Booking process must be revised and improved to eliminate unused Ors
Number of cases that are not properly booked in terms of length of surgery
Surgical time per especific surgery has to be determined by surgeon's historical data and as an average for new surgeons
Number of cases that are not properly booked for other reasons
Develop a detailed flowchart and analisys to improve process through PDSA cycle.
Time in minutes of unused OR rooms per day Eliminate time of non-used OR during the 7-3 shift
Time in minutes of delay per case Delays should be eliminated Number of delays due to late patient arrival per day
Improve patient's understanding the importance of on-time arrival and help solving difficulties they may have
Number of delays due to hospital reasons (anesthesia, nursing) per day
Identify and improve processes shown to create delays
Number of delays due to surgeons, per day Identify and improve processes shown to create delays
Average time between cases per day Decrease turnover time Average turnover time at AM, at lunch time and PM
Improve processes to decrease turnover time
Average tardiness time in minunes per surgeon per day
Arrival time should be controlled Record arrival time of surgeons if first case in AM vs. later case
Develop and implement polices to encourage surgeons to be on-time
Number of cancellations per day Cancellations should be avoided Number of cancellations by surgeon by surgery type per day
Find and correct the reasons that lead to cancellations
Surgeon satisfaction survey by quarter Estimulate surgeons to have this OR as his/her most important one
Survey surgeons the degree of importance of each of the hospitals they go
Estimulate loyal and managed surgeons. Avoid policy breakers. Create a pool of "good customers"
Pleasant enviroment Average working hours of personnel per day Improve employee satisfaction. Avoid work
overloadAverage working hours per position per day Avoid work overload. Hire personnel for several shifts if
necessary.
Number of cases performed after hours that are not true emergencies
Avoid work overload. Avoid elective cases after hours
Employee satisfaction survey per quarter Improve employee satisfaction. Maintain morale Number of resignations per quarter Empower certain employees Create and implement policies regarding any form of abuse
Employee survey regarding verbal or other form of abuse
Improve employee satisfaction. Maintain respect Survey patient satisfaction periodically Create and implement policies regarding any form of abuse. Specialized trainning to satisfy surgeon's demands
Suppliers Inputs (Xs) Process (Xs)
Outputs (CTQ) Customer
Surgeon/ResidentAnesthesiologistOR staffRR/ICU nurseRN/Scrub techPt/familyHolding RN
Closure. Next pt readyPt emergenceTransfer pt/clean roomAccepts ptOpen next caseSign consentsNext pt ready
Pt will leave the OR and the next pt will be in the OR safely and in compliance with the regulatory agencies
Patient and relativesNursing Staff (OR)Scrub tech/OR staffPhysiciansSurgeons AnesthesiologistsManagementRegulatory agenciesPayers
Pt emergence Pt out of OR Clean room Case open Next pt ready Next pt to OR
Anesthesiologist decides pt is ready to safely leave the OR
Pt is safely transferred via stretcher with all necessary monitors. Room available in PACU/ICU
Instruments are removed and the room is cleaned according to protocol
New instruments and necessary equipment is ready available in the room
Holding nurse has the next pt ready. Consents are signed. Surgical site marked.
Pre-op meds including antibiotics are given and anesthesiologist and nurse transfer the pt to the OR
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Yes
MSAs clean the
room
Charge RN sends for next patient (Surgery)
Pt leaves the OR
OR tech removes
instruments
MSA leaves OR to pick up the
patient (Surgery)
OR RN goes to Holding to verify if
next pt is ready
Bring new instruments to the room
X-Ray tech
needed
Pgt arrives to holding area (Floor
or Same day Surgery)
Holding RN verify check list (Green
Check List)
Anesthesiologist OKs patient (Consent)
Surgeon sign consents and
mark site
Get X-Ray tech
Patient in to the OR
Voice of the Customer – Affinity Test
MSAs (10) Anesthesia (4) Surgeons (12)
Radiology (6) Instruments (8) Nurses (8)
CTQ TAT (Door to Door)
Lack of paper work readiness/Site not Marked.
Lack of adherence to original schedule.
Lack of communication among OR RNs with floor RNs and Residents
Shortage of RNs
Lack of Pre-op evaluation on time
Supply not stocked properly
Insufficient C-arms
Delay in the tech availability
Washer machine broken frequently
They are responsible for two different task (cleaning room and transportation) Short staff (3 MSA for 6 ORs)
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Measure (DMAIC)
“If you can’t measure it, you can’t improve it”
“Not everything that can be counted counts and not everything that counts
can be counted”Albert Einstein
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Measurement System Analysis
s Identify what to measures Determine how to measures Develop sampling plan and reaction
plans Validate measurement system (Gage R
& R)s Add to overall control plan
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SPC charts
9181716151413121111
300
200
100
0
Observation
Indiv
idual V
alu
e
_X=84.4
UCL=205.9
LCL=-37.1
9181716151413121111
300
200
100
0
Observation
Movin
g R
ange
__MR=45.7
UCL=149.2
LCL=0
1
1
1
11
1
1
1
1
11
1
TAT - June and July
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Analyze (DMAIC)
Identify and understand causal relationshipss Characterize the process (current state)
s Fishbone, Box plots, Regression Analysis,s Validate the suspects and compare treatments
(which action is more effective)s Hypothesis testing. Z-test, t-test, ANOVA, chi
squareds Model the process (understand relationships,
how X impact Y)s DOE (Design Of Experiments)
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Pareto Chart
C2 50 30 12 3 2 1 1 1Percent 50.0 30.0 12.0 3.0 2.0 1.0 1.0 1.0Cum % 50.0 80.0 92.0 95.0 97.0 98.0 99.0 100.0
C1 OtherORT/ReconENTTR/MSORT/FORT/HTCUORT/T
100
80
60
40
20
0
100
80
60
40
20
0
C2
Perc
ent
Pareto Chart of C1
Turn Around Time (TAT) Process. Direct Observation (minutes)
OR 825 13 12
26
OR 824 15 52
70
OR 84 2 11 24
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OR 854 24 18
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Instruments Out Mean: 3.2 min
Room is Clean Mean: 18 min
OR 86 26 14
36 Next Case Set-Up Mean: 24 min
Goal for TAT is less than 45 min Total TAT Mean: 41.8 min
11 12 Best times !24
3.2 18 24
Time average41.8
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Improve (DMAIC)
s Benchmarkings Brainstormings FMEA (Failure, Mode, Effect, Analysis)s Poka-yoke (Error-Proofing)s Continuous flows Quick changeoverss Theory of constrainss Pull scheduling/JIT (Just In Time)s Correction action matrixs Pilot a solution
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Improve - Benchmarking
Process of developing higher performance standards for your process based on a comparison to other processes, internal within your organization or external from competitors with better performance (most common)
s Industry publications & trade journalss Industry related meetingss Public financial reportss Third party studiess Company publications/ facility visits
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Improve - Brainstorming
s Brainstorming is a technique used to elicit a large number of ideas from a team using its collective thinking power”
Gitlow, HS “Six Sigma for Green Belts and Champions”
s The foundation of brainstorming is an atmosphere of suspended judgment (no criticism) so that a large number of ideas freely flow from the participants.
s Brainstorming is intended to encourage fresh thinking and ‘crazy’ ideas
Moresteam.com/university
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Improve - FMEA
s Failure Mode Effect Analysis is a tool used to prioritize potential defects based on their severity, expected frequency, and likelihood of detection
s Scores are assigned to each potential defect mode of a process in 3 categories: Severity, Occurrence, Detection
s Scores will lead to a Risk Priority Number (RPN)
s The highest RPN would be the highest priority for improvement
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Improve – F.M.E.A.Causes Sev
erity
Occurrence
Detection
RPN
Action Plan Owners
Tardiness 8 7 5 280 (3)
Collect data. Analyze. Present to upper management
Lou, Carlos
Lack of anesthesiology protocol
9 10 5 450 (1)
Create perioperative protocol
John, Raul
Redundant paperwork
7 10 3 210 (4)
Create consolidated perioperative forms
Kevin, Juan
No enforced “Bumping protocol”
10 4 5 200 (5)
Readdress existing policy to surgeons
Alexander, Sandy
Shortage of anesthesia tech
9 8 5 360 (2)
Develop a process to tech to follow
Lou, Jose
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Improve – Poka-yoke
s Error-proofing or mistake proofing refers to the implementation of fail-safe mechanisms to prevent a process from producing defects
s The philosophy: It is not acceptable to make even a very small number of defects, and the only way to achieve this goal is to prevent them from happening in the first place
s FMEA, fishbone and brainstorming are used to organize efforts
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Improve – Quick Changeovers (SMORE)
s Single Minute Operating Room Exchange. From Shigeo Shingo’s SMED (Single Minute Exchange of Die)
s The foundation is the distinction between Internal Setup (work that occurs when the system is idle) and External Setup (work that occurs while the system is running)
moresteam.com/university
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Improve – Quick Changeovers (SMORE)
s Staged equipment (preference cards)s Operations conducted in parallel (emergence–bags
out)s Standardization (same tools, stretchers, 5S)s Quick attachments (laparoscopic equipment)s No-Adjust equipment and tooling s Duplicate equipment and tooling (double
instruments)s Assisted tool movement (for cleaning, equipment,
patient, etc)moresteam.com/university
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Improve – Continuous Flow
s In many ways, the term Continuous Flow defines Lean Methods by improving the movement of material or information through a process
s It means a service progresses through a series of value-added steps without delays (inventory), rework (defects) or non-value added operations
s Reducing cycle time requires achieving a more continuous flow to match the pace of demand with the pace of production
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Flow in a Healthcare Environment
s Flow of patientss Flow of clinicianss Flow of
medications Flow of supplies
s Flow of informations Flow of equipments Flow of process
engineerings [Flow of housekeeping]
Black, J with Miller D
The Toyota Way to Healthcare Excellence
ACHE Management Series. 2008
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Control (DMAIC)
s The goals of the Control phase ares 1. Sustain the improvement
s SPCs 5S [Sort, Set in order, Shine, Standardize,
Sustain]s Total Productive Maintenance (TPM). Goal: Drive
waste to zeros 2. Sharing the knowledge
s Best practices & Lessons learned s Project Close-Outs Maintain LEAN education and LEAN ambiance
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Waste (Muda) - Taiichi Ohno
s Overproductions Defectss Inventorys Motion primum non attero
s Overprocessings Transports Waitings [Underuse of talent]
Black, J with Miller D
The Toyota Way to Healthcare Excellence
ACHE Management Series. 2008
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primum non attero [first do no waste]
primum non nocereFirst do no harm
secundus non atteroSecond do no waste
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5 S
s Sort (seiri): Sort out necessary from unnecessary items
s Set in Order (seiton): Necessary items should be easily accessible
s Shine (seiso): Dispose of unnecessary items Standardize (seiketsu)s Sustain (shitsuke)
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The most essential tool
The least common of the senses..
the Common Sense
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Barriers to Lean 6
s Lack of knowledges Fearfulness of statisticss Lack of unification of information .
ASQs Stubborns Fear of physicians desertion
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Change
s Three types of Knowledges Awareness knowledge. Information that innovation exist s How-to knowledge. Information to use it properlys Principles knowledge. Information dealing with the
principles underlying how the innovation workss Equilibrium
s Stable equilibrium. Status Quos Dynamic Equilibrium. The rate of change occurs at a
rate that is equal with the system’s ability to cope with it
s Disequilibrium. The rate of change is too rapid to permit the system to adjust
Rogers, E. M. Diffusion of Innovations. 5th Edition
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To Remember
s Everything is a processs If you can’t measure it, you can’t
improve its Use data instead of ‘paper, scissors, rock’s Software will help with statistics
s Maintain Lean ambience and educations primum non attero - First do no Wastes Be Socially Responsibles Start a dialogue
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Why you are here
"Change happens by listening and then starting a dialogue with the people who are doing something [you don't believe]
is right.“Jane Goodall
InformationWeek Daily Newsletter www.informationweek.comWeekend Edition: Saturday, March 28, 2009
67
Be clear
s TEACHER: Maria, go to the map and find America MARIA: Here it is. TEACHER: Correct. Class, who discovered America?
CLASS: Maria. &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
s TEACHER: What is the chemical formula for water? DONALD: H I J K L M N O. TEACHER: What are you talking about? DONALD: Yesterday you said it's H to O.
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