LEANing ing Healthcare - Emerging Health Leaders · such as Six-Sigma, ... Catapult exercise on...

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Camille Camille RozonRozon, , MHA, CHE, PMP, IAMPMHA, CHE, PMP, IAMP--DD

20 October 201020 October 2010

LEANLEANinging Healthcare... Healthcare... the evolution of quality concepts the evolution of quality concepts (and where all those buzzwords come (and where all those buzzwords come from) from)

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What we are here to talk aboutWhat we are here to talk about

• The history of quality, from inspection to Continuous Quality Improvement, and its modern branded interpretations such as Six-Sigma, LEAN and beyond.

• The difference between quality tools and quality culture

“Quality has to be caused, not controlled.”Philip Crosby

http://thinkexist.com/quotation/quality_has_to_be_caused-not_controlled/11741.html

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PPlan lan DDo o SStudy tudy AAct ct

•• Francis Bacon Francis Bacon –– 1620s 1620s

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Walter Shewhart -1920s•• First sketch of a modern control chartFirst sketch of a modern control chart

“Assignable causes of variation may be found and eliminated.”

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W. Edwards Deming W. Edwards Deming –– 1950s 1950s

14 Key Principles of Management14 Key Principles of Management

Leadership for change

Transformation is everybody's job

Improve constantly and forever

"The worker is not the problem. The problem is at the top! Management!"

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1st major International 1st major International Quality Control ConferenceQuality Control Conference

•• ““Total quality controlTotal quality control includes not only includes not only workers but all level workers but all level of managementof management”” Cause and Cause and

Effect Diagram Effect Diagram

Kaoru Ishikawa - 1969

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• Key ConceptsDecentralizationWorkers are assets &

knowledge workerCompanies are nothing w/o

customersSubstance over style

Peter Drucker Peter Drucker -- 19501950--1970s1970s“Management is doing things right; leadership is doing the right things.”

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Toyota Way 1948 Toyota Way 1948 -- 1975 1975 The The Toyota WayToyota Way is is management management commitment to commitment to continuously invest in its continuously invest in its people and promote a people and promote a culture of continuous culture of continuous improvement.improvement.

The The Toyota Production Toyota Production SystemSystem, also known as , also known as LEANLEAN, is the most , is the most systematic and highly systematic and highly developed example of developed example of what the principles can what the principles can accomplish.accomplish.

““The highest form of LEAN cannot The highest form of LEAN cannot be achieved unless the be achieved unless the CULTURECULTURE is there to support it.is there to support it.””

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LEAN Principles LEAN Principles

•• LEAN is not an event it is a lifestyle!LEAN is not an event it is a lifestyle!

1.1.Long term Long term -- even at the expense of short term gaineven at the expense of short term gain

2.2.Continuous improvement Continuous improvement -- includes the 8 wastesincludes the 8 wastes

3.3.Use Use ““PULLPULL”” systems systems -- downstream signals need for moredownstream signals need for more

4.4.LevellingLevelling

5.5.Stop & fix the problems so you get it right the first timeStop & fix the problems so you get it right the first time6.6.Standardize wherever possibleStandardize wherever possible

7.7.Use visual controls Use visual controls -- includes 5Sincludes 5S10

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LEAN PrinciplesLEAN Principles8.8. Use reliable tested technologyUse reliable tested technology

9.9. Grow your leadersGrow your leaders

10.10. Develop exceptional teamsDevelop exceptional teams

11.11. Help your partners and suppliers to improveHelp your partners and suppliers to improve

12.12. Go & See Go & See -- the power of direct observationthe power of direct observation

13.13. Make decision slowly Make decision slowly -- implement quicklyimplement quickly

14.14. Never stop asking Never stop asking ““How can we be better?How can we be better?””

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5 steps in a LEAN improvement event5 steps in a LEAN improvement eventSpecify value Specify value –– from the patientfrom the patient’’s s perspective (what are they willing perspective (what are they willing to pay for)to pay for)

Map the Value Stream Map the Value Stream –– Map all Map all the steps in the processthe steps in the process

Identify waste Identify waste –– using the list of using the list of 8 wastes8 wastes

Eliminate wastes Eliminate wastes –– identify identify strategies (not work arounds)strategies (not work arounds)

Analyze success, adjust and Analyze success, adjust and repeat cyclerepeat cycle

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Value Stream MapValue Stream Map

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What does waste look like?What does waste look like?DDefectsefects

OOverproductionverproduction

WWaiting aiting

NNonon--utilized talentutilized talent

TTransportationransportation

IInventoriesnventories

MMotionotion

EExtra processingxtra processing

•• Incorrect testing, errorsIncorrect testing, errors

•• Prepare more stock than requiredPrepare more stock than required

•• Pts waiting for tests, Docs waiting for results Pts waiting for tests, Docs waiting for results

•• Technicians photocopyingTechnicians photocopying

•• Moving patients to testsMoving patients to tests

•• Tests batched, waiting for equipmentTests batched, waiting for equipment

•• Looking for information, equipment, suppliesLooking for information, equipment, supplies

•• ReRe--testing, resending informationtesting, resending information

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How can you tell if there is waste?How can you tell if there is waste?

•• RemeasureRemeasure

•• RemakeRemake

•• ReRe--evaluateevaluate

•• RecallRecall

•• RedoRedo

•• RepeatRepeat

•• RedesignRedesign

•• ReviewReview

ReshipReship

RetypeRetype

RetestRetest

ReissueReissue

RejectReject

ReviseRevise

ReturnReturn

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Waste ManagementWaste Management

Go and see Go and see –– direct observation direct observation -- A3 reportA3 report

Timed observation Timed observation –– 11-- 2 weeks, 3 to 10 observations2 weeks, 3 to 10 observations

Circle of Work Circle of Work –– time for motion, wait, travel, waste (think time for motion, wait, travel, waste (think ““rere””), ), actual workactual work

Spaghetti maps Spaghetti maps –– staff and patient movementstaff and patient movement

5S 5S –– Sort, set in order, shine, standardize, sustainSort, set in order, shine, standardize, sustain

Visual controls Visual controls –– lights, signage, colour codinglights, signage, colour coding

KittingKitting

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A3 ReportsA3 ReportsGraphic representation of the Graphic representation of the ““problemproblem””Basis for root cause analysisBasis for root cause analysis

The 5 whysThe 5 whysCountermeasures are identifiedCountermeasures are identifiedNew ideal state is then describedNew ideal state is then describedHow to implement the countermeasuresHow to implement the countermeasures

WhatWhatWhoWhoWhenWhenOutcomeOutcome

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A3 Report TemplateA3 Report Template

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KittingKitting

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Circle of WorkCircle of Work

•• Identify the major Identify the major activities in your activities in your job and track for job and track for 11--2 weeks to 2 weeks to identify areas for identify areas for improvementimprovement

29% of the time is spent waiting to consult with physician

Example: COW for Sonographer in Antenatal Testing Unit

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Visual controls Visual controls –– lights, signage, lights, signage, colourcolour codingcoding

KittingKitting

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How to create a spaghetti mapHow to create a spaghetti map

Tool that helps identify waste / physical bottlenecksTool that helps identify waste / physical bottlenecks

Show where staff/patients move during processShow where staff/patients move during process

Things to rememberThings to remember

Get as accurate space plan as possibleGet as accurate space plan as possible

Observe then followObserve then follow

Do not lift pencil Do not lift pencil –– continuous flowcontinuous flow

Measure total distanceMeasure total distance

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KittingKitting

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Conducting 5SConducting 5S

SortSort: separate needed from unneeded: separate needed from unneeded

Set in OrderSet in Order: arrange how remaining items will be : arrange how remaining items will be usedused

ShineShine: Repair / replace all necessary items: Repair / replace all necessary items

StandardizeStandardize: system to maintain order: system to maintain order

SustainSustain: Periodic checks for continued maintenance: Periodic checks for continued maintenance

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KittingKitting

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Visual ControlsVisual Controls

The workplace is set- up with signs, labels, colour-coded markings, etc. so anyone unfamiliar with the process will know what is going on, understand process, and know what is being done correctly and what is out of place.

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KittingKitting

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KittingKitting•• Gathering tools Gathering tools

and supplies and supplies that are that are frequently and frequently and predictably predictably required for a required for a processprocess

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ISO 9000 ISO 9000 -- 1980s1980s

Off-the-shelf, canned, "just add water" quality solutions cannot generate the level of human commitment within the organization needed to succeed.Peters and Austin - A Passion for Excellence: The Leadership Difference

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Six SigmaSix Sigma19801980

Motorola Corp.Motorola Corp.

Reduce defects to 3.4 / Million Reduce defects to 3.4 / Million

or 99.99966% = to six standard deviations or 99.99966% = to six standard deviations σσ SigmaSigma

Thus Six SigmaThus Six Sigma

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DDefineefine MMeasureeasure AAnalyzenalyze IImplementmplement CControlontrol

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SixSix--Sigma ToolsSigma Tools••

5 Whys5 Whys

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Analysis of varianceAnalysis of variance

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ANOVA Gauge R&RANOVA Gauge R&R

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Axiomatic designAxiomatic design

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Business Process Business Process MappingMapping

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Catapult exercise on Catapult exercise on variabilityvariability

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Cause & effects Cause & effects diagram (also known diagram (also known as fishbone or as fishbone or Ishikawa diagram)

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Chi-square test of independence and independence and fitsfits

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Control chartControl chart

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CorrelationCorrelation

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CostCost--benefit benefit analysisanalysis

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CTQ treeCTQ tree

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Design of Design of experimentsexperiments

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Failure mode and Failure mode and effects analysis effects analysis (FMEA)(FMEA)

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General linear General linear modelmodel

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HistogramsHistograms

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HomoscedasticityHomoscedasticity

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Quality Function Quality Function Deployment (QFD)Deployment (QFD)

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Pareto chartPareto chart

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Pick chartPick chart

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Process capabilityProcess capability

Quantitative marketing research through use of Enterprise Feedback Management (EFM) systems

Regression analysis

Root cause analysis

Run charts

SIPOC analysis (Suppliers, Inputs, Process, Outputs, Customers)

Stratification

Taguchi methods

Taguchi Loss Function

TRIZ

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Six Sigma’s focus is measurement tools to help identify problems and establish when they are resolved.

Lean is operations tool to help define from a system-wide perspective the most effective way for work to be performed.

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Collaborative Collaborative Model 2003Model 2003

White PapersWhite Papers

LEAN 2005LEAN 2005

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Michael Hammer 1990

• Advanced the concept of Business Process Re- Engineering

“The major challenge for managers is to obliterate non-value added work.”

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“Reengineering Health Care gets to the core of transforming our current system by advocating the widespread use of IT, eliminating inefficient practices, and keeping the system focused on a healthy individual and not on a broken process.”Newt Gingrich, Founder of the Center for Health Transformation, and former Speaker of the U.S. House of Representatives

June 2010June 2010

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AgileAgile Methodology 2001Methodology 2001

Origins in software development Origins in software development

Iterative and incrementalIterative and incremental

Uses empowered teams, customer Uses empowered teams, customer involvementinvolvement

Quickly manage changes to project Quickly manage changes to project scope for optimal successscope for optimal success

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The Agile MethodThe Agile MethodAdapted from the iterative planning processAdapted from the iterative planning process

Cycles times of weeks rather than monthsCycles times of weeks rather than months

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ScrumScrum

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•• So whatSo what’’s s nextnext??

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Aristotle, Philosopher, Scientist and Physician, 384 BC-322 BC

Quality is not an act, it is a habit.

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