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© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 11Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health System, Detroit
Creating a Culture of Continuous Improvement
Creating a Culture of Continuous Improvement
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 2
Lean is not a program; It is not a quick fix;
it is not a responsibility that can be delegated.
Rather, Lean is a cultural transformation that changes how an organization works…
It requires new habits, new skills and often a new attitude throughout the organization.”
-John Toussaint, MD
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 3
Organizational Culture
Toyota Production System
HumanDevelopment
Philosophy
Tech
nica
l Managerial
….An Integrated System
Philosophy1. Customer first2. People are the most valuable resource3. Kaizen (continuous improvement)4. Shop floor focus
Stability of Manufacturing Processes
tools
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 4
Toyota’s culture built on pillars of continuous process improvement,
founded in respect for people,
sets an expectation and facilitates
empowered workers to contribute to the ever-improving enterprise.
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 5
What is Empowerment and How Do You
Sustain It?
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 6
Empowerment
Definition “Employee empowerment is a strategy and philosophy that enables
employees to make decisions about their jobs.
Employee empowerment helps employees own their work and take responsibility for their results.
Employee empowerment helps employees serve customers at the level of the organization where the customer interface exists.”
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 7
Empowerment Can’t Be Willed
“An empowered workforce is something that is highly desirable in an improvement culture.
Unfortunately, just because we want it, it doesn't make it so.”
“Leaders of the organization must create the conditions for empowerment.”
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 8
Empowerment rarely succeeds
Why?•Management comes up short
– Culture, philosophy– Managers discomfort with new leadership style– Leadership and team training– Leadership and team structure– Incentives for behavior change– Incentives for engagement– Sustaining mechanisms
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 9
Culture
Culture is a desirable but secondary outcome to changing structure and
process
that enables and expects employees
to work differently
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 10
How
Philosophy
Management principles
Reporting relationships
People structures
Sustaining tactics
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 11
As leader, I don’t have all the answers
“Doing your best is not good enough.You have to know what to do.
Then do your best.” -W. E. Deming
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 12
Mindset forContinual Improvement
“We know from the changes that have already been brought about that far greater changes are
to come, and that therefore we are not performing a single operation
as well as it ought to be performed ”
- Henry Ford
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 13
Never Pass a Defect‘The Mantra’
“Quality is doing it right when no one is looking."
-Henry Ford
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 14
Blameless
“On the internet, nobody knows you’re a dog.”
“Don’t find fault, find a remedy; anybody can complain.” -Henry Ford
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 15
Expose DefectsThe Visual Workplace
“Even a mistake may turn out to be the one thing necessary to a worthwhile achievement.”
-Henry Ford
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 16
The Power of Integrated TeamsAligned Path of Work Flow
“Systems do not produce quality, people do.”
-anonymous
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 17
Waste, Rework, & Inefficiency
"It is not possible to repeat too often that waste is not something
which comes after the fact” -Henry Ford
“My theory of waste goes back of the thing itself into the labour of
producing it”-Henry Ford
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 18
EXPECTATIONOF
MANAGERS
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 19
Deming CultureDeming Culture
“In companies that have embraced Deming’s vision,
management’s job is to ‘work on the system’to achieve continual product and process improvement.
Deming’s Redefinition of Management
The Deming-style manager must-ensure a system’s consistency and reliability, by bringing
level of variation in its operations within predictable limits, then by
identifying opportunities for improvement, by
enlisting the participation of every employee, and by
giving subordinates the practical benefit of his experience
and the help they need to chart improvement strategies.”
(A. Gabor)
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 20
Managers Weekly Checklist
"You get what you inspect not what you expect”
1. Deviations/Non-conformances outliers and trends
2. Temp humidity checks -completeness of documentation, root cause and corrective actions
3. 5S activity documentation
4. Posted job aides and all visuals reviewed and updated
5. New or revised procedures reviewed with staff and staff competencies verified
6. New problems of risk (mis-ID, safety) and resolutions discussed
7. DM Board metrics review leading to interventions and process improvements
8. Ongoing and planned process improvements reviewed
9. Inventory and kanban check
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 21
STRUCTURETHAT SUPPORTS
PEOPLE
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 22
Workcell 1 Workcell 2 Workcell 3 Workcell 4 Workcell 5Work
Product
Silo 1 Silo 3Silo 2
Team Leader
Team Leader
Team Leader
Team Leader
Team Leader
Group Leader Group Leader Group Leader
QUALITY SYSTEM STRUCTUREORGANIZATION CHART
For Worker Driven Continuous Improvement
How is change authorized and made?
Customer-Supplier Interaction
Shared members
Find Your Role
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 23
EXPECTATIONOF
WORKERS
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 2424
Redefine the Expectation of Redefine the Expectation of ““WorkWork””
Never Accept, Make Never Accept, Make or Pass a Defector Pass a Defect
“It’s the work, not the man that manages.”
-Henry Ford© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 24
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 25
Transform approach to work– Not just showing up for work, but arriving to do the
work better
The Engaged Worker
Empowered workers who see their daily work in the context of-
Continually learning
Constantly communicating
Making effective process improvements
Designed and tested by scientific method
Culture
“Most doctors prescribe pills, I prescribe empowerment” –Jay Parkinson, MD
Empowered Personnel, Correcting One’s Own Errors, Accountable For Solving Problems in Teams & Creating Standard Work
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 26
Ultimate SolutionsDepend on the
Viewof the
ProblemsExecutive Leader
Supervisor/Manager Line Worker
Why empower the worker?
“There are no big problems, there are just a lot of little problems.” -Henry Ford
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 27
Workers Deal with WasteEveryday
• Anything that adds cost to the product without adding Value
• Non-Value added task that will go unpaid by patients and payers
• We only get paid for the work one time, then often poorly at best
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 28
Reality Testing
• Juran Institute estimates that 30% of direct healthcare outlays are due to poor process quality
Midwest Business Group on Health, Juran Institute, & Severyn Group, Inc (2003)
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 29
Type of Waste Definition Examples in Healthcare
1.Transportation Unnecessary movement of products/material/documents from one place to another
Moving documents/specimens/supplies from room to room
Moving equipment for testing to and fro for treatment
2. Inventory Excessive stock than needs handling or stock outs when needed
Over stocking office supplies/reagents/medication
on units due to standing orders, or stock outs due to expiry dates /back orders
3. Motion Unnecessary movement of people/patients/staff from one service to another
Staff walking to printers/fax machines
To get inventory that’s kept far away
Patient services/departments far away from each other or different buildings
4. Waiting Idle time created when information, equipment or material is unavailable
Missing information on Documentation/Prescriptions/Lab Requisitions/ Physician Note etc
Delays- Bed assignment, ER/Clinic admission, Test result
Patient backup due to equipment downtime or failure
5. Overproduction Producing more than what is required for next step
Printing/emailing/faxing the same document multiple times
Duplicate charting by different staff
Preparation exceeding schedules for the day/shift
6. Over-processing Performing repeated (rework) or redundant work that does not add value to the customer
Ordering more diagnostic tests than the diagnosis warrants, Re-checking or Retesting just to be sure. Duplication of paper trails, excessive charting
7. Defective product or service
(process mistakes)
Any activity that does not conform to customers expectation/specification
Wrong patient demographic labels attached to incorrect specimen containers- mismatches
Specimen collected in incorrect containers/tubes
Incorrect billing/ No billing Ohio Lean- 29
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 30
VARIATIONUnderstanding
&Minimizing
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 31
What is My Role in Lean?
• Yearly Lean education
• Identify defects on a daily basis
• Brainstorm and get involved to eliminate defective processes
• Work in teams with your leadership to propose and test solutions
• Take pride in your work knowing your idea was recognized and acknowledged
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 32
What is a defect?
Poor quality of service or product that makes you:• Stop your work• Reject it• Return it to sender• Delay your work to fix it yourself • Not pleased, could be better
= hurts someoneError
= WASTE= REWORK
Mea
sures
of Varia
tion
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 33
Defect Comparison 2006 to 2007
24
17
99
151
2
66
13
1
85
50
72
61
9
2
8
123
0 20 40 60 80 100 120 140 160
Spec.Receiving
Rehab
Accessioning
Grossing
Histo Slides
Immuno Sp.Stain
Recuts
AmendedReports
PR
E-A
NA
LY
TIC
AN
AL
YT
ICP
OS
T-
AN
AL
YT
IC
Sta
tio
ns
in t
he
pro
ce
ss
Totals
2007
2006
Power of People Seeing
97%
62%
31%
62%
96%
42% Top 4 defects Lab made
89%
“My theory of waste goes back of the thing itself into the labour of producing it”
-Henry Ford
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 34
EXPOSEDEFECTS
VISUAL WORKPLACEBLAMELESS CULTURE
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 3535
Visual Workplace “No Problem is a Problem”7 Wastes 5 Why’s Process
Wednesday’sWords
of Quality
Daily Resolution of Defects Rapid (Defects corrected on the spot)
A3 (PDCA analysis and customer-supplier involvement)
Communication & Education All shifts(New policy, standard work, hours, competency, quality tool)
4 Work Rules
Capture Daily Defects1. Wrong patient identification2. Ran out of gloves- size medium3. Not enough specimen collected for lab test
Leader
Ohio Lean- 35
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 36
SYSTEMATIC PROCESS to
FIX DEFECTS
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 37
Identify Defect
OngoingPDCA
Resolution
The Process of Process Improvement
Daily Resolution
PDCA-A3 Resolution
Customer-SupplierCommunicationat level of work
Team LeaderFacilitation
Standard Work,Connections, Pathways
Share the Gain Learnings
Rapid Fixpolicy, procedure, document control
HENRY FORD PRODUCTION SYSTEM
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 38
SYSTEMATIC WORK RULES
FROM TPS
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 39
Standardization is the Cure-Observe & Reinforce-
Systematic Work Rules
“Today’s standardization, instead of being a barricade against improvement, is the necessary foundation on which tomorrow’s improvement will be based.”
– Henry Ford
1. Activities2. Connections3. Pathways4. Method of Improvement
Variation is the Enemy of Quality
Spear S, Bowen HK: Decoding the DNA of the Toyota Production System. Harvard Business Review, 1999.
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 40
WORKERKAIZEN
SOLUTIONS
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 41
Continual Improvements Toward Goal
60 6368
80 84
7984 85
93 95
50
90
Process Change...
% B
NP
TA
Ts M
ee
tin
g G
oal
TATs < 45' TATs < 60'
BNPB-natriuretic peptide
Repetitive PDCA Cycles
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 42
But it’s ALL about them
Now empower them!
Teamwork
“The day you become a leader, It becomes about them.”
-Jack Welch
You may lead it……
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 43
WORKPRINCIPLES
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 44
Work Flow, Pull & Smoothing OpportunitiesStructure and managementStructure and management
Horizontal management across work stations, divisionsDefined workcells, team leaders, teams along path of work, partnerships
Workplace physical redesignWorkplace physical redesignU or linear workstations to reduce motionInventory relocated to workstations
Work redesign for continuous flow and pullWork redesign for continuous flow and pullSensitization to time waste and in-process defectsReduction cycle timesFront loading work in the path of workflowElimination of loops, forksReduction of stepsMaintenance of sequenceLoad leveling across shifts and hoursBatch size reductionVisual workplace to surface defectsStandardized activities, connections, pathways
Kanban system Kanban system Production kanbans to promote pull production & communicationInventory kanbans for JIT, recovery of stock room space
Metrics to monitor and target variationMetrics to monitor and target variationDaily metrics to monitor performance variationWhiteboards to identify in-process defects and outliersFeedback loops to inform defect repair in real-time by empowered teams
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 45
MANAGINGby
METRICS
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 46
“What's measured improves”
Peter F. Drucker
“The only things that evolve by themselves in an organization are disorder,
friction and malperformance”
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 47
TTime
(Delivery)
QQuality
Visual Management At-a-GlanceDAILY Gemba Rounds with workers
• Each square has all days of month • Color each per performance• RED: METRIC FAILED THRESHOLD• GREEN: METRIC MET THRESHOLD
Trendlines• Trend challenging metrics• Day, week, month, year…• BLUE: THRESHOLD• RED: TIME OF FAILURE• GREEN: TIME PASSING THRESHOLD
Pareto Charts, RCA etc.
Countermeasures:Corrective & Preventive ActionsAssign responsibility andAccountability for completion
Associated PDCA - A3 Projects
What When
Why How
IInventory or
WIP
PProductivity
SSafety
Daily, Weekly, Monthly, Annual Trends
Work Group Specific Metrics
Root Cause Analysis
Daily Management Board
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 48
# of amended reports# of result modifications
Jane Doe
John Smith
May
11 am
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 49
Histology Core Lab
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 50
Chemistry Core Lab
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 51
So Honey, How’s Your Day Goin?
Intended Direction
Actual Experience*
*Note: YMMV(Your actual mileage may vary)
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 52
RECOGNITION
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 53
“Share the Gain”
2013
Clinical Pathology 6:30AM & 2:30PMShare the Gain presentations
2011
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 54
Total Process ImprovementsPathology & Laboratory Medicine Service Line
500
1000
536
2009
13921128
Lean Year 4
2010
Henry Ford Production System Henry Ford Production System
2011
1794
1323
2000
Key
Henry FordHospital
Laboratories
All Laboratories, Hospitals
and 30 clinics
Lean Year 5(4 hospitals)
Lean Year 6(6 hospitals)
Empowered
Work Teams
1230
828
Lean Year 7(4 hospitals)
2012
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 55
Tactics That Sustain a New Work Culture
GOAL SETTING Hoshin kanri strategic planning and goal setting Quality goals identified, prioritized & pushed to level of worker
PEOPLE ROLES & RESPONSIBILITIES Identified workstation teams and leaders Employees in charge of own jobs, design standardized work
METRICS Expect metrics of reliability & consistency in each workstation
COLLABORATION CULTURE Promote horizontal cooperation, customer-supplier, team focus
MANDATORY EDUCATION & RE-EDUCATION Include competency assessment in CQI for all workers
LEADER FACILITATED MEETINGS Expect routine leader & worker meetings, no exceptions
PERSONAL ACCOUNTABILITY FOR PROGRESS Visual trackers of daily defects and improvements Monthly worker presentations of their improvements Performance evaluations leaders & workers, include behaviors
PUBLIC PRESENTATION & RECOGNITION EVENTS
GOAL SETTING Hoshin kanri strategic planning and goal setting Quality goals identified, prioritized & pushed to level of worker
PEOPLE ROLES & RESPONSIBILITIES Identified workstation teams and leaders Employees in charge of own jobs, design standardized work
METRICS Expect metrics of reliability & consistency in each workstation
COLLABORATION CULTURE Promote horizontal cooperation, customer-supplier, team focus
MANDATORY EDUCATION & RE-EDUCATION Include competency assessment in CQI for all workers
LEADER FACILITATED MEETINGS Expect routine leader & worker meetings, no exceptions
PERSONAL ACCOUNTABILITY FOR PROGRESS Visual trackers of daily defects and improvements Monthly worker presentations of their improvements Performance evaluations leaders & workers, include behaviors
PUBLIC PRESENTATION & RECOGNITION EVENTS
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 56
Lean Leader’s Checklist• Set Lean leadership and management expectation for all leaders• Set high performance expectation goals and pace of continual change• Integrate people, process, tools, technology that support the new manner of work• Engage and empower your people to solve problems• Create organizational structure with identified team leaders to allow continuous change to happen• Form core teams with strong leader and team members along the path of workflow• Breakdown barriers between artificial silos of control so improvements can occur horizontally• Foster regular communication within and between workcells within your control as well as outside your department (customer-supplier relationships)• Drive reduction in variability by standardizing the work activities, connections and pathways
• Set Lean leadership and management expectation for all leaders• Set high performance expectation goals and pace of continual change• Integrate people, process, tools, technology that support the new manner of work• Engage and empower your people to solve problems• Create organizational structure with identified team leaders to allow continuous change to happen• Form core teams with strong leader and team members along the path of workflow• Breakdown barriers between artificial silos of control so improvements can occur horizontally• Foster regular communication within and between workcells within your control as well as outside your department (customer-supplier relationships)• Drive reduction in variability by standardizing the work activities, connections and pathways
Zarbo RJ: Creating and sustaining a Lean culture of continuous process improvement. Am J Clin Pathol 138:321-326, 2012.
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 57
Lean Leader’s Checklist• Implement visual management, with posted daily metrics of value for each work unit reflecting opportunities for change or stability of process• Stabilize processes through a continuous focus on waste reduction• Move to continuous flow, innovate triggers to ‘pull’ work or patients etc, • Identify opportunities for front loading and work simplification• Continually push to reduce time waste• Leverage PDCA as a way of thinking and the operational engine of continual improvement• Create structure and incentives to sustain the new cultural change of work• Educate to improve the overall quality and efficiency of work for the system, not for any one unit• Create opportunities for your direct reports to work effectively together and manage horizontally for the greater good. Somebody gives, somebody takes, but everyone wins• Celebrate your teams’ successes and learnings• Make this new approach to work fun!
• Implement visual management, with posted daily metrics of value for each work unit reflecting opportunities for change or stability of process• Stabilize processes through a continuous focus on waste reduction• Move to continuous flow, innovate triggers to ‘pull’ work or patients etc, • Identify opportunities for front loading and work simplification• Continually push to reduce time waste• Leverage PDCA as a way of thinking and the operational engine of continual improvement• Create structure and incentives to sustain the new cultural change of work• Educate to improve the overall quality and efficiency of work for the system, not for any one unit• Create opportunities for your direct reports to work effectively together and manage horizontally for the greater good. Somebody gives, somebody takes, but everyone wins• Celebrate your teams’ successes and learnings• Make this new approach to work fun!
Zarbo RJ: Creating and sustaining a Lean culture of continuous process improvement. Am J Clin Pathol 138:321-326, 2012.
© 2013 Henry Ford Health System, Pathology and Laboratory Medicine
Ohio Lean- 58