© 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo,...

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© 2013 Henry Ford Health System, Pathology and Laborator Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health System, Detroit Creating a Culture of Continuous Improvement

Transcript of © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo,...

Page 1: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

© 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

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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

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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

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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.

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Ohio Lean- 5

What is Empowerment and How Do You

Sustain It?

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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.”

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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.”  

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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

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Ohio Lean- 9

Culture

Culture is a desirable but secondary outcome to changing structure and

process

that enables and expects employees

to work differently

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Ohio Lean- 10

How

Philosophy

Management principles

Reporting relationships

People structures

Sustaining tactics

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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

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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

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Ohio Lean- 13

Never Pass a Defect‘The Mantra’

“Quality is doing it right when no one is looking."

-Henry Ford

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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

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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

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Ohio Lean- 16

The Power of Integrated TeamsAligned Path of Work Flow

“Systems do not produce quality, people do.”

-anonymous

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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

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Ohio Lean- 18

EXPECTATIONOF

MANAGERS

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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)

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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 

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Ohio Lean- 21

STRUCTURETHAT SUPPORTS

PEOPLE

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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

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Ohio Lean- 23

EXPECTATIONOF

WORKERS

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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

Page 25: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

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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

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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

Page 27: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

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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

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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)

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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

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VARIATIONUnderstanding

&Minimizing

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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

Page 32: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

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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

Page 33: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

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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

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Ohio Lean- 34

EXPOSEDEFECTS

VISUAL WORKPLACEBLAMELESS CULTURE

Page 35: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

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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

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Ohio Lean- 36

SYSTEMATIC PROCESS to

FIX DEFECTS

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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

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SYSTEMATIC WORK RULES

FROM TPS

Page 39: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

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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.

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WORKERKAIZEN

SOLUTIONS

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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

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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……

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WORKPRINCIPLES

Page 44: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

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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

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Ohio Lean- 45

MANAGINGby

METRICS

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“What's measured improves”

Peter F. Drucker 

“The only things that evolve by themselves in an organization are disorder,

friction and malperformance”

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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

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# of amended reports# of result modifications

Jane Doe

John Smith

May

11 am

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Histology Core Lab

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Chemistry Core Lab

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So Honey, How’s Your Day Goin?

Intended Direction

Actual Experience*

*Note: YMMV(Your actual mileage may vary)

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RECOGNITION

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“Share the Gain”

2013

Clinical Pathology 6:30AM & 2:30PMShare the Gain presentations

2011

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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

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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

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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.

Page 57: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

© 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.

Page 58: © 2013 Henry Ford Health System, Pathology and Laboratory Medicine Ohio Lean- 1 1 Richard J Zarbo, MD Pathology & Laboratory Medicine, Henry Ford Health.

© 2013 Henry Ford Health System, Pathology and  Laboratory Medicine

Ohio Lean- 58