Minimally Invasive Lean Six Sigma 7 2012

Introduction

© 2012, AptoLean LLC All Rights Reserved 1

www.AptoLean.com

John Muka, Ph.D June 14, 2012

609-238-3360 [email protected]

Adaptive Lean Six Sigma

®


The Waste and Delay Organization

Injuries

The Official Organization Admit Test Treat Bill

Healthcare isn’t just business --- it’s personal!

Discharge

“…with so many different kinds of employees and so many interrelated systems and functions, it is a small wonder that hospitals work at all, much less as well as they do. With the multitude of tasks performed every day by the hundreds of employees in a busy hospital, misunderstandings and information breakdowns in patient care are inevitable…”

Healthcare USA, page 85 Textbook often used in Hospital Administration Courses



Nurses "Always" communicated well.

Doctors "Always" communicated well.

"Always" received help as soon as they wanted.

pain was "Always" well controlled

staff "Always" explained about medicines before giving it to them

room and bathroom were "Always" clean.

"Always" quiet at night

Given information about what to do during their recovery at home

Overall rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest).

“Definitely recommend the hospital.”

http://www.hospitalcompare.hhs.gov/ Survey of

Patients’ Hospital Experience HCAHPS: Hospital Consumer Assessment of Hospital Providers and Services

http://www.hospitalcompare.hhs.gov/

http://www.hospitalcompare.hhs.gov/


RWJUH PHCS Virtua

Nurses "Always" communicated well. 75% 73% 76%

Doctors "Always" communicated well. 77% 80% 72%

"Always" received help as soon as they wanted.

60% 56% 61%

pain was "Always" well controlled 68% 68% 70%

staff "Always" explained about medicines before giving it to them

58% 56% 55%

room and bathroom were "Always" clean. 63% 62% 69%

"Always" quiet at night 49% 49% 45%

“Always” given information about what to do during their recovery at home

82% 82% 78%

rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest).

67% 61% 63%

definitely recommend the hospital. 75% 69% 71%

‘…Jefferson Regional Medical Center in Pittsburgh expects all employees, from maintenance workers to doctors, to respond to a patient’s call light or find someone to offer assistance. In Los Angeles, Cedars-Sinai is testing new patient call buttons that ring directly to nurses’ cellphones. If the nurse’s line is busy, the call automatically rolls over to another worker’s phone. Many hospitals have devised detailed scripts that doctors and nurses follow when interacting with patients, telling them what to expect and often extolling the care they are getting. This fall, the University of Toledo Medical Center launched an internal “iCARE University” dedicated to training employees on improving patients’ experiences. …” Test for Hospital Budgets: Are the Patients Pleased? NYT, 11-8-2012

http://utmc.utoledo.edu/icare/index.html



My work is frequently interrupted OR There are large blocks of time when I am not interrupted

I frequently have to invent new ways to handle an issue or keep the work going

OR

Most issues are covered by an understood procedure and exceptions are infrequent

The same problems come up over and over again

OR

Most problems are solved permanently

I’m never sure what my work load will be OR

Usually work arrives at an expected rate

Priorities change continually OR

Priorities are set and then the work proceeds consistently toward accomplishing the tasks needed

6 © 2012, AptoLean LLC All Rights Reserved

Choose the statement in each row that best describes what you are used to:

I often don’t know if the results of the work are what is really wanted OR The criteria for completing the work are clear

Meetings often waste a lot of time OR Meetings are usually valuable

The emphasis is on getting results OR The emphasis is on strong processes focused toward results

When the work backs up its up to me to deal with it OR

When things get busy there is an accepted way to get help

Stress is usually high OR There is a sense of urgency but usually not an overly stressful environment


Choose the statement in each row that best describes what you are used to:


Current Behaviors

Challenge

Invention

Sustain

Define and Measure:

Analyze & Improve

Control

Ideal Behaviors

Challenge: ◦ List Issues ◦ Prioritize what to work on ◦ Breakdown the Problem ◦ Investigate and Survey ◦ Create a well defined Challenge

description ◦ Authorize Invention Phase

(Charter)

Invention: ◦ Deeply understand the problem ◦ Identify Root Causes and Obstacles ◦ Develop and Test Countermeasure

Sets ◦ Pilot and Prove the best

Countermeasures

Sustainment ◦ Implement Countermeasures ◦ Update Standardized Work ◦ Train ◦ Monitor Process Closely



Jeffrey Liker and David Meier, The Toyota Way Fieldbook, p307

…The Toyota Way is not a natural behavior. The Toyota philosophy relies on the “system”, and adhering to its concepts will force people supporting the system into uncomfortable situations. The choices presented then are to either remove the obstacles or to fail.”

Build on the Toyota Production System

Make Problems Visible: ◦ Visually ◦ Immediately ◦ Urgently

Activate short term mitigation Trigger 2nd Level Problem Solving (Prevention) Continually Develop People as Problem Solvers


Improve Service by Preventing “Work-Arounds”

Activities All work shall be highly specified as to content, sequence, timing and outcomes

Connections All Supplier-Customer connections shall be direct, one-to-one, with unambiguous ways to send requests and receive responses

Pathways Process flow will include all necessary steps and no un-necessary steps

Improvement Any improvement will be done using the Scientific method, under the direction of a Teacher, as close in time and location to the problem as possible.


Spear and Bowen: Decoding the DNA of the Toyota Production System

Kenagy: Designed to Adapt


Category Delay & Waste Defects and Variation

Ideally, What we expect is: But what we have is: Therefore, the next steps are:

Cardiac Catheterization ◦ Increased effective capacity by over 25% ◦ Reduced Post-Procedure Holding time by 35% ◦ Reduced First Procedure delays to 5 minutes or less

ED Radiology: X-rays “Order to PACS” ◦ % in 30 min. or less: from under 45% to over 70%


1. Observe the actual work for at least 1 hour ◦ Do not make any changes ◦ Observe carefully

2. Team with people who do the work 3. Start with small glitches, workarounds, do-overs 1. Apply the 4 Rules of Process Design 2. Eliminate one or two issues 3. Use Sustainment to make the changes permanent


Build toward Supportive Observation


• Key Questions: • What is important about what you do? • How do you know what to do? When to start? • How do you know you are finished? • What problems do you have? • What do you do when you have a problem? • Where does your work (and information) come from?

Build toward Supportive Observation


Prep Procedure

Time “Cold Table”

Time

First Procedures

Start Start First

Procedures End

Holding

Discharge

Nursing Unit

Second Procedures

Start

Next Patient

On Table

Patient in

Clean Room

Setup, Restock Patient

out

Doctor in

Move Patient

Setup Room

Patient Ready in Holding

Move Patient

Doctor called

Start on time Room

Turnaround

Bed Availability Arrive

on Time

Focus Countermeasures Start on Time

Pre-mixed Heparin flush; Co-ordinate with Doctors’ offices to get all needed tests and documentation; Smooth Patient Check-in; Improve handoffs from Admitting to Prep Unit; Improve handoffs from Prep to CathLab; Express labeling for LabTests; Traveling Patient Checklists; Improve In-Patient prep; Improve CathLab shut down process; Notify Doctors of Patient ready; Arrange staff schedule to support startup;

Room Turnaround

Arrange lead aprons; arrange most frequently used supplies and equipment in or near rooms; Arrange less frequently used supplies to be easy to find; Re-stock rooms between cases; Co-ordinate room cleaning; Document Roles and Responsibilities for Room Turnaround and post in area; Staff involvement in improving methods.

Nursing Unit: Increase rate of Discharges

Designate “Interventional Beds”; insure 10 empty beds every Monday AM; Discharge 2 patients every 2 hours throughout the day; Reduce delay on reporting “bed empty”; Eliminate un-necessary electronic documentation; Reduce time for MedRec; Discharges by APN; Doctor availability for Discharges; Improve Nursing routines;


Focus Countermeasures Delay in Patient Prep and “Flags”

Improve Gowning and “Jewelry” routines; Unit clerk sets EDIM flag for transport; Clarify Location Signage; Improve signal to nurse that study has been ordered; develop transport rules based on Acuity Level; train nursing on new routines;

Delay in Transport

Assign dedicated Transport instead of from pool; Adjust number of Transporters to match demand; upgrade to cell-phone based dispatch; Patient Ready flags visible on Large LED screen in the ED;

Delay in Radiology Response

Move ED X-ray to CT area; add improved Portable X-Ray machines; improve charging routines; Install EDIM on Radoilogy PC’s; improve CT to X-ray flow; “Save a minute” urgency; Daily Accountability routines; Expediter/Value Stream Leader; Acuity Level transport rules; Surge routines; X-Ray room organization; Start of shift outreach to ED.



Do the study as fast as safely and Humanly possible.


Service Level

95% in 30 min. or less from “Patient Ready” Flag (Acuity 1,2,3)

Slack Normal Surge

“Save a Minute” Routines

• Practice Routines • Cross-Train • Start of Shift Huddle • Review Performance • Outreach to ED

• Monitor Flag Set • Check Queue • Co-Ordinate with ED • Co-Ordinate with

Transport

• Call “Code Surge” • Pull in offline staff • Teamwork to maximize

Throughput

Prevent Failure Modes Routines

• Improve Layout • Maintain Equipment • Restock Supplies

• Equipment Down • Transport missing • CT Handoff • Handoffs

• Anticipate special needs • Open up additional

equipment: • Stop Out-Patient

Services

Team Leader Role constantly assigned Visual Controls, Key Metrics, Workplace Organization (5S) Continuously improved Standardized Work and Training Immediate Response to problems and short term mitigation Second Level Problem Solving: Prevention Bundle for Kaizen Events and Projects Accountability Routines: ◦ Team Leader ◦ Area Supervisor ◦ Value Stream Manager ◦ Executives


Select Model Line or Area Team Leader Role: select, train, coach Solve small glitches and problems permanently Increase scope and support with resources: ◦ Move from activities, to connections, to pathways

Implement Visual Controls Implement Daily Accountability routines Use Value Stream analysis to focus on key bottlenecks Bundle issues for Kaizen Events and Projects


Adaptive Lean Six Sigma

®

John Muka, Ph.D AptoLean, LLC 609-238-3360


www.AptoLean.com Adaptive Lean Six Sigma

®

Minimally Invasive Lean Six Sigma 7 2012

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