MUDA MUDA - Saskatchewan Health Authority · Goals and Deliverables The goal and theme of the 3P...

1 ©1996-2013, John Black and Associates LLC

Licensed Materials – USA Copyright Laws Apply

Mod 27 – 3P

27 3P v20130529

Global Production System

Product/Patient Quantity Analysis

Kaizen Kaikuku

Just-in-Time

Measures

Standard

Operations

Heijunka

(Leveling)

Continuous

Flow

Total

Productive

Maintenance

Poka-yoke (mistake

proofing)

Kanban

Setup Reduction

Changeover

Multi-process

Operations

Jidoka (human

automation)

GPS

MUDA MUDA

Visual

Control

Andon

TAKT TIME ONE PIECE FLOW PULL PRODUCTION

R

e

d

e

p

l

o

y

m

e

n

t

Committed Leaders

Profit =

Price - Cost

TAKT Time Map

Capacity Tables

Cost Reduction By Eliminating Waste

GPS Depth Study

NVA/VA-

Functions/Mgrs

Quality Cost Delivery

Morale Safety

Value Stream Mapping

5S • Sorting

• Simplifying

• Sweeping

• Standardizing

• Self Discipline

3P Prod Prep

7 Flows Medicine

7

Wastes

RPIW

7 Flows

Factory

4 No’s

© 1996-2013, John Black and Associates LLC

(modified from Hiroyuki Hirano, Productivity Press).

3P:

Production,

Preparation,

Process

©1996-2013, John Black and Associates LLC

Licensed Materials – USA Copyright Laws Apply 2

Mod 27 – 3P

27 3P v20130529

“You should submit

wisdom to the company.

If you don’t have any

wisdom to contribute,

submit sweat. If nothing

else, work hard and don’t

sleep. Or resign.”

Taiichi Ohno



Mod 27 – 3P

27 3P v20130529

“Perhaps you are asking yourself,-

How can a manufacturing model be

applied to healthcare? Patients aren’t

products put together on an assembly

line.

That is certainly true and a perspective

never to be forgotten. But the patient

isn’t the product - they are the customer.

The product is defect-free healthcare.

And high quality, defect-free healthcare

is susceptible to the same improvement

methods (Lean) as other products or

services. No different from building cars

or airplanes.”

John Black

President -

John Black and Associates, LLC

www.johnblackandassociates.com



Mod 27 – 3P

27 3P v20130529

“Toyota revolutionized our

expectations of production; Federal

Express revolutionized our

expectations of service. Processes

that once took days or hours to

complete are now measured in

minutes or seconds. The challenge is

to revolutionize our expectations of

health care: to design a continuous

flow of work for clinicians and a

seamless experience of care for

patients.” Donald M. Berwick, MD

Former President and CEO, Institute for Healthcare Improvement

Mod 27 – 3P


Licensed Materials – USA Copyright Laws Apply 27 3P v20130529

Half of Everything

Lean = ½ Less

½ the human effort.

½ the space.

½ the equipment.

½ the inventory.

½ the investment.

½ the engineering hours.

½ the new product development time.

Mod 27 – 3P



Customer

Dissatisfaction

Misalignment

Bureaucracy

Waste

Non-value added

Breakdowns

Lost opportunity

MUDA

World-Class Paradigm

The Important Number is Zero



Mod 27 – 3P

27 3P v20130529

Taiichi Ohno’s Seven Wastes

Time on Hand (Waiting)

Transportation

Defective Products

Processing

Movement

Stock on Hand

(Inventory)

Overproduction

7



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27 3P v20130529

People

Money

GPS – Foundation Principle

A Single Goal: NO WASTE

Continuous

improvement

without adding:

Large Machines

Space

Inventory



Mod 27 – 3P

27 3P v20130529

Impact of Lead-Time Reduction

Typical

Company

Non-Value Added Value Added

Traditional

Improvement

Kaizen

Waste

Reduction

NVA VA

NVA VA

Major

Improvement

Time

Minor

Improvement

Original

Lead Time

9



Mod 27 – 3P

27 3P v20130529

Value Stream Network

1.Identify value stream

2.Make value flow

3.Pull value through

from supplier’s supplier

to customer’s customer

4.Remove waste

5.Pursue perfection

Steps

Health Care Enterprise

Hospital

OR Right Size

Equipment

3P

3P

VSM Mapping

VSM

VSM

Kaizen

Kaizen

Kaizen

Kaizen

Kanban

Kanban

Kanban Standard

Work: SW

SW

SW SW SW SW SW



Mod 27 – 3P

27 3P v20130529

The Best Quality

Service At The Demand

Volume

Proper Timing

(TAKT Time)

Proper Cost is a by-product of these other factors.

The model process for designing quality services

and appropriate production processes while best

embracing Rapid Process Improvement culture.

Q D T

Production Preparation Process

Building Quality into Our Production System

What is 3P?



Mod 27 – 3P

27 3P v20130529

Creating the Links for Building In Quality

Inspection Systems

Medications

Instruments



Mod 27 – 3P

27 3P v20130529

To Our Services To Our Processes

One-Piece-Flow

Takt Time

U-Shaped Cells

Jidoka

Simple/Flexible

Poka-Yoke Waste Elimination

Ergonomics

HON INDUSTRIES

Pull

Rectified Flow

Applying the

Principles of

Rapid Process

Improvement

13

Mod 27 – 3P



Ted Gachowski’s Journey Ted Gachowski

Retired engineer

Lymphoma since 1999

Chemotherapy 6 hours each week

SEATTLE -- Up until five months ago, Ted Gachowski's weekly chemotherapy

appointment was one long, tedious slog through the Virginia Mason Medical

Center. Today, chemotherapy at Virginia Mason is a much shorter trip: The

distance from lab to exam room to treatment is less than 12 feet. Once

Gachowski is hooked up to his IV, he never has to leave the cheery private

room -- flat-screen television, computer, nursing supplies and bathroom are all

right there. And his physician, Henry O. Otero, is so close, "I can almost shout

to get him," said Gachowski, seated in a reclining chair as the drug dripped into

his arm. - Ceci Connolly, Washington Post, 2005



Mod 27 – 3P

27 3P v20130529

And the bottom line is… Ted’s

Journey Before After % Change

Lead Time

(Arrival to

Start of

Treatment)

240

minutes 90 minutes -63%

Non-Value

Added Time

194

minutes 52 minutes -73%

Distance

Traveled 748 feet 181 feet -76%

Mod 27 – 3P



DEVELOPEFFECTIVE SERVICES AND PROCESSES

A COMPETITIVE WEAPON IN OUR INDUSTRY

RAPID CONTINUOUS IMPROVEMENT

Why Do 3P?



Mod 27 – 3P

27 3P v20130529

Time

Imp

rove

me

nt

Kaizen - Evolutionary Change

Kaikaku - Revolutionary Change

Kaizen Alone May

NOT Get Us

Where We Need

to Go

Vision



Mod 27 – 3P

27 3P v20130529

Process

Design

Changes

New Service

Introductions

Changes

In

Demand

Production

Preparation

Process

Improve Service

Delivery

When is 3P Used?



Mod 27 – 3P

27 3P v20130529

The New Way of Creating

Healthcare Services or Cells

The Patient (internal or external)

Must be the Center of 3P Efforts

1

2

3

Pro

du

ct

Develo

pm

en

t Assured Quality

TAKT Time

Ease of Service

Delivery



Mod 27 – 3P

27 3P v20130529

Develop a 3P Designed Machine for Cell X

Reduce floor space by 50% for new Oncology unit.

Develop a Flow line for Lab W

Design a Children's Hospital with no waiting rooms, 50% reduction

in walking for patients and families, 65% reduction in storage, the

coordination of the 7 Flows of Medicine to optimize quality and

safety, and to not exceed the target cost of $200 million.

What do you really

want to accomplish?



Mod 27 – 3P

27 3P v20130529

1. Determine Function

What is the Theme & Scope of Your Event

Post on Wall/Board

Think about what you wish to accomplish...

NOT what is currently being used.

HON

Allstee

Product Process



Mod 27 – 3P

27 3P v20130529

K

E

Y

WORDS

Clamp

staple

turn spin

slide

Sketch What is Happening.

2. Define the Essence of the Function What are the Key Words?



Mod 27 – 3P

27 3P v20130529

Hinge

Move

Cover

Attach

Attach Cling

Cling

Grip

Float

Shear Spin

Resist All Attempts to Use Man Made Examples.

Nature’s Examples are Often Simple and Pure.

Adhere

3. Look for Examples of Keywords in Nature

Nature has spent millions of years refining these phenomena



Mod 27 – 3P

27 3P v20130529

Do Your Homework

Attach Hinge

Group Common Examples

Shear

Sketch the Examples

Nature

Examine in Detail

You MUST Look Deep into the Phenomenon to Understand.

What Must Take Place for This Phenomenon to Happen?

4. Sketch Examples, Examine What is Happening Group Common Examples.



Mod 27 – 3P

27 3P v20130529

From This:

Socket Lining

Force uniform

105 degrees

rotation

To This:

48- 94 degrees flex

What is now

happening or must

happen in the

surroundings for this

function to take

place?

Muscle (Vastus Lateralis)

Muscle (Gracilus)

5. Sketch Background and Conditions of Function You must understand HOW the natural Phenomenon Operates



Mod 27 – 3P

27 3P v20130529

Seven Proposals

Fly

Be Creative.

Do NOT Be Afraid to Propose Anything!

6. Combine Ideas from Nature to Create Sketches Each Team Member Develops Seven Designs or Seven Ways



Mod 27 – 3P

27 3P v20130529

190

PROOF

MOONSHINE

Use Readily Available Materials To Build Your Prototypes.

Do NOT Make This Step Overly Complex.

7. Moonshine: Pick 7 Proposals to Build Quick and Crude Beats Slow and Elegant



Mod 27 – 3P

27 3P v20130529

The Data

Document

Collect Real Data

#3

Even Though Your Model is NOT Perfect, it will Give

You Valuable Data on How to IMPROVE Your Design.

8. Conduct Experiments to Collect Real Data How does each design perform against our criteria?



Mod 27 – 3P

27 3P v20130529

Top 3 Designs

Established

Criteria

Design

Evaluation Design #3

Demo/Explain

Design

You MUST Understand the Quality Required.

Keep Thinking...“Dimensions, Tolerances and Gauges.”

9. Select the Three Best Designs, then… Conduct MOONSHINE on the TOP 3 Designs



Mod 27 – 3P

27 3P v20130529

If Problems Arise...

Fix Them Right on the Spot, Don’t Talk About Them.

Keep TRY-storming....NOT Brainstorming.

Improve Designs

10. Evaluate Data on Top 3 Designs Keep MOONSHINING and Improving Design



Mod 27 – 3P

27 3P v20130529

Have Models and Data Prepared for Viewing By Evaluation Committee.

These are Your Customers...They have to Buy the Designs From You

Proposal #1

Process Design

Sales

Equipment Proposals

Patient Flow Material Control

Production Engineering-Presenter

Quality

Hospital Layout

Evaluation Committee

Finance Controllers

Information

System

Safety

11. The TRIAL: Presenting to Management Present the Best Product Designs

Mod 27 – 3P



What is a Medical 3P Workshop? It is a week-long process where the complete production flow for a

service or group of services is mapped out in depth. Alternative process

methods are tried and tested, ranked in several categories, and modeled.

The result is often breakthrough production methods with drastically

improved efficiency, reduced cost and improved quality.

Steps: 1. Define the project scope.

2. Define the cross-functional team membership.

3. Gather PQA data, lead times and cycle times.

4. Fishbone and analyze current processes.

5. Keeping the 7 flows of medicine in mind, create multiple (ideally 7) new

preferred processes.

6. Using the 7 flows, evaluate the options.

7. Narrow the options and present the results.

8. Model/simulate the preferred options with mock ups, models, flow

diagramming and time measurements.

9. Determine what equipment is needed to support the preferred processes.

10. Complete and implement the design.



Mod 27 – 3P

27 3P v20130529

3P Results

Mod 27 – 3P



3P:

Virginia Mason Hospital Campus

Team member representation included:

Nursing, Pharmacy, Hospitalist Service, General

Surgery (VM and Group Health), Anesthesia, Graduate

Medical Education, Administration, Clinical Information

System, Facilities, Radiology, Peri-operative Services,

Cardiology, Emergency Services, Oncology,

Cardiac Cath Lab, Equipment and Supplies,

Kaizen Promotion Office.



Mod 27 – 3P

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Goals and Deliverables The goal and theme of the 3P was:

Design an incremental plan for campus development. At the plan’s core will be placement of our

inpatient services, from which required adjacencies (support services, departments, etc.) will be located to

meet our vision and 3P targets. The plan will focus on East Campus and Madison site development, and the

relationship of hospital based services to the ambulatory settings.

Boundaries: Develop a campus plan that is flexible to meet patient needs for the next 25-50 years.

Focus will not be placed on specific space requirements or design within units or departments, but rather on

the relationship between departments and services on Main Campus.

Scope will be within the current design of the East Campus Building (“shell” design must be used), approved

permitting specifications.

We are licensed for 336 inpatient beds. Design will not incorporate any additional beds.

The East Hospital Wing is to remain in place short term to meet bed capacity needs. Considerations for this

building can be made in the long term plan. Hospital Main wing will not be used for future patient care

activities. All seismic specifications currently defined will be followed.

Sale or lease of current space is not within the scope of the 3P.

All available space (including 1000 Madison) is to be considered to meet the future demand of inpatient care

services and must be designed within current entitlements (timelines, physical constraints, etc.)

Deliverables Determine primary bases for patient care.

Plan for transition of patient care services to the East Campus.

Determine focus of next 3P addressing planning for ongoing campus development.

Targets Facilitate care givers’ ability to provide safe, defect-free care.

Promote progression of care and reduce patient lead time.

Reduce lead time and travel distance for each of the 7 Medical Flows.



Mod 27 – 3P

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Preparation Prior to the Event A planning team prepared 6 weeks in advance of the 3P to ensure that the

time of the team was value-added and focused on the goals and

deliverables for the week. Key preparation work included:

Development of Hospital Takt Time – The hospital Takt Time was

complete with 2004 volumes for the key portals to the facility (ED, OR and

Direct Admissions) and high volume support areas (GI, Radiology, Heart and

Lab). Lead time calculations for each area were included. The spreadsheet

was setup with formulas to accommodate increases or decreases in volumes.

Value stream maps were gathered for the above portals.

Future projections were completed for changes in population for

the region and Medical Center extending to 2025. Point of use technology

information was collected for projections.

Stakeholder feedback was obtained from all departments.

Three 1/16th scale campus models were constructed for the team to measure

the seven flows in the current campus and determine future state.



Mod 27 – 3P

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Identifying flow challenge

Using the tools of 3P The team began the week by learning the basics of 3P. Key concepts

covered included: Seven flows of medicine, patient (PQ) analysis and use of

the Takt Time spreadsheet. Key learnings:

Understanding the 7 Flows is the foundation of 3P work.

PQ Analysis is a method to group the flow of the patient by sequencing of

services. This is the first step to cell development and determination of

collocation of services.

Takt Time is the key tool to determine the number of beds, rooms or

resources needed to provide service. This tool is critical to anticipate impact of

changes in volume.

The team learned tools to help illustrate flow by using pictures instead of

words. Tools included fishbone, the seven ways exercise, and idea forms. The

team broke into four sub-teams by the high volume portals to the facility to flow

the current state:

ED flow.

Direct Admission.

Inpatient and outpatient surgery.

Outpatient procedure team.



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Translating the flow into the space In order to understand the current state a sub-team flowed the 7 flows of medicine for the ED admission,

direct admission, inpatient and outpatient surgery, and procedural care on a model with a different yarn color

for each flow. The current state visually showed wasted time traveling for patients, providers, equipment,

supplies and medications. It also showed “bottlenecks” in space and multiple handoffs causing opportunities

for defects.

Each team continued to develop the future flow through the use of the fishbone, integrating idea forms from

the entire group and flowing the future state on a “hospital map” with yarn. The results of this work

continued to demonstrate innovation ideas to look at how the flow can determine how space is used.

Additional ideas integrated to future state include:

ED Flow: Observation/admission unit collocated by ED to keep the patient moving. Flexibility to expand or contract based on

volume.

Elevators adjacent to ED for flow of patients, supplies and equipment

Direct Admit Flow

Expand use of “smart card.”

Use of information technology for information flow.

Surgery Flow:

Design of Surgical Plan center with MD offices integrated in space.

Design of an outpatient center for any procedure from short stay surgeries to GI/Cardiology procedures.

Continued design of CCU surgeries that would not go to recovery but direct to CCU.

Procedure Care Flow Integration of “smart card” technology and expand to all services during stay.

Supplies delivered by “interstitial core” and use of mechanical space.

Interchangeable rooms used for all procedures.

No nursing stations.



Mod 27 – 3P

27 3P v20130529



Mod 27 – 3P

27 3P v20130529

Daily % tot. Time WALT

GI 60 58 45 26.5

IR 15 15 60 8.82

Bronch 3 3 45 1.32

EP 11 11 62 6.69

Cath 13 12 63 8.03

total 102 51.33

Functional Units for Future State Design

Assumptions for space were made for each area based on Takt Time. Note many of the calculations are based on

current lead time. Assumptions with decreased lead times are noted

1. Direct Admit Pt Calculation assumptions:

TT = 279’ LT = 6192 Demand: 1885 Time Available = 24 hrs/day

Functional Units – 22 beds

2. ED Patient Flow: Peak time 1100 – 2100

TT = 8’ LT= 190’ Time Available = 600 minutes (peak 10 hours of the day)

Functional Units = 25 rooms (* at current lead time at 50% improved lead time = 11 – 12 rooms), X-ray (plain) –

need 2.7 machines, CT scanners 2, Chemistry TT 11.5, Heme 3.

Adjacency: Radiology and lab in ED, parking, food services for patients and families, elevators for moving pts and

supplies Flexible monitored rooms for procedures, overnight stays. Supplies and equipment dropped down from

the ceiling

•Current state lead time

Functional Units: LT/TT = 114.98/5.8 = 19

rooms (current state lead time)

Daily % tot. Time WALT

GI 60 58 89 52.4

IR 15 15 180 26.5

Bronch 3 3 89 2.62

EP 11 11 142 15.3

Cath 13 13 143 18.2

total 102 114.98

•TT = 600/102 = 5.8 min.

•Future state – 50% reduction in lead time

•Procedure Rooms: LT/TT = 51.333/5.8 = 8.9 rooms for current

volumes (future state)

•TT = 600/102 = 5.8 min.

WALT = weighted average lead time



Mod 27 – 3P

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Flow Before After % Change

Provider 1696 feet 442 feet 74 %

ED Patient w/CT scan 1208 feet 460 feet 62 %

Cardiac Cath Patient 580 feet 403 feet 30 %

Inpatient Surgery Patient 1180 feet 740 feet 37 %

Clinic Patient Admit 1050 feet 680 feet 35 %

Supplies 45,000 feet 3750 feet 92 %

Reductions in Travel-Distance-Based

Flows in New Locations are:

Innovative concepts: “Library Walls”– to expand and contract co-located spaces with utilities in the ceiling to allow for inexpensive cell

changes.

Flexible space based on “grid” delivery of power, medical gases, air, etc., from the ceiling using “quick connect”

connections. Get plumbing and electrical out of cement to keep the lower space maximally flexible for the

future.

“Lunchable” supplies for surgical/procedure kits. Drop into the room from above and then “drop” in the floor

(chutes and ladders) for disposal.

Design a bed that has all the information attached –Cerner connection, equipment etc.

1000 Madison Future ideas: Looking to the Horizon for our Future: Retail (food service) to support staff/patient needs/amenities and local neighborhood needs/amenities.

Health/wellness center (Spa).

Below grade parking with access to ED.

Migrating OP Services here with above and below grade access.



Mod 27 – 3P

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Work Plan and Key Learnings: The team completed a work plan summarized in newspaper (attached):

Timeline and implementation of ideas to do immediately.

Review with design team to translate concepts into designs and validate assumptions for beds and

space.

Test the feasibility of ideas by implementing a process for patient feedback.

Implement plan for April 3P to build on this work.

In addition the key learnings for the team were: We are limited by our own reality and current view of the world as we look to the future.

There is much that can and should be done that does not have to wait for construction for the

changes to start. We need to create our own sense of urgency today to eliminate waste

today. Our goal is to NOT build a new hospital with wasteful processes.

“If you build it you will fill it” – we don’t want to do this!!

Need to provide good parking - accesses into and out of the facility.

Co-location makes a difference – we have not designed our plant to meet the needs of the patient.

Shared resources and spaces – multi-use and multi-purpose rooms: vs. department ‘owned’.

When you stretch something out you have to have something stick it there – It will snap back – we

will not sustain the changes.

Flows have memory – or habits.

Different view of “teams” – palette of care team members created for every patient.

Separate patient flow from other flows.

Patient flow follows parking.

Tools help figure out the difference between what you think you need vs. what you really

need.

The process is the foundation of what you are building.

Mod 27 – 3P



Saskatoon Children’s Hospital 3Ps

Mod 27 – 3P



Saskatoon Children’s Hospital 3Ps Theme: Design a facility with care processes reflecting the same

scope and level of services as defined by the project in approximately

25,000 sq. m space and while respecting the planning principles

established.

Service Line Areas: Surgical Services

Emergency

Adult

Child

Maternal / Child

Pediatric Outpatient

NICU

PICU

Labor and Delivery

Materials Management

Support Services

Food and Nutrition

Laboratory

Mod 27 – 3P




Targets:

Decrease Space:

Reduce surgical theaters from 5 to 3.

Eliminate waiting rooms.

Reduce Walking:

50% reduction for patient in maternity department.

50% reduction for patients in pediatrics department.

Reduce Storage:

Reduce Intrapartum ward storage by 65%.

Reduce administrative/office areas by 50%.

Improve Patient Flow:

Reduce lead time for patients moving through all departments.

Coordinate 7 flows of medicine into the ideal state to add quality and

safety.

Mod 27 – 3P



Saskatoon Children’s Hospital 3Ps Data sets us free

Mod 27 – 3P



Saskatoon Children’s Hospital 3Ps Understand the current state so we can build for the future

Mod 27 – 3P




Setting and Understanding Criteria Adjacencies:

What departments must be co-located next to each other?

What should be on the main floor versus top floor?

Keeping patient care centralized on one unit (i.e. don’t move

laboring mom to numerous floors).

Delivery Aspects: Just in time delivery of supplies, food products, medications.

Minimal storage for equipment and supplies.

Patient Safety: Design family-centered areas instead of waiting rooms.

Easy way-finding.

Staff Safety: Embed touchdown space as teaching space.

Mod 27 – 3P



Saskatoon Children’s Hospital 3Ps Listen to the voice of the patient

Mod 27 – 3P




Mod 27 – 3P




Creative Thinking

“Problems cannot be solved

by the same level of thinking

that created them.”

Albert Einstein

Mod 27 – 3P



Saskatoon Children’s Hospital 3Ps Using the 7 ways

Mod 27 – 3P



Saskatoon Children’s Hospital 3Ps Our 12-year-old Mind Set

Mod 27 – 3P




Outcomes and Lessons Learned

Have defined scope/goal from the start.

Clearly articulate/communicate your scope/goal to team.

Measurement and good data are critical to the process.

Participation from patients is essential.

Standard work is necessary for efficiency.

Flexibility is achieved by breaking down department barriers.

Interdisciplinary groups should always design facilities.

Visualization is a key to understanding flow and processes.

Simulation is enlightening, it changes peoples’ views on flow.

We could have institutionalized poor processes in the facility design

& customers (external & internal) would not always be served well.

Internal “expert" opinions are often wrong. Data and modeling

proved this.



Mod 27 – 3P

27 3P v20130529

Global Production System

Product/Patient Quantity Analysis

Kaizen Kaikuku

Just-in-Time

Measures

Standard

Operations

Heijunka

(Leveling)

Continuous

Flow

Total

Productive

Maintenance

Poka-yoke (mistake

proofing)

Kanban

Setup Reduction

Changeover

Multi-process

Operations

Jidoka (human

automation)

GPS

MUDA MUDA

Visual

Control

Andon

TAKT TIME ONE PIECE FLOW PULL PRODUCTION

R

e

d

e

p

l

o

y

m

e

n

t

Committed Leaders

Profit =

Price - Cost

TAKT Time Map

Capacity Tables

Cost Reduction By Eliminating Waste

GPS Depth Study

NVA/VA-

Functions/Mgrs

Quality Cost Delivery

Morale Safety

Value Stream Mapping

5S • Sorting

• Simplifying

• Sweeping

• Standardizing

• Self Discipline

3P Prod Prep

7 Flows Medicine

7

Wastes

RPIW

7 Flows

Factory

4 No’s

© 1996-2013, John Black and Associates LLC

(modified from Hiroyuki Hirano, Productivity Press).

7 Flows of

Medicine

Module 22

Mod 27 – 3P



7 Flows of Medicine

1. Flow of Patients

2. Flow of Family

3. Flow of Providers

4. Flow of Information

5. Flow of Supplies

6. Flow of Medications

7. Flow of Equipment



Mod 27 – 3P

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1. Flow of Patients A. No patient waits.

B. Minimize patient walking; bring the

services to the patient.

C. Problems must force the process to stop.

D. Patient flow is in only one direction with

successive steps in order of processing.

E. Incorporate quality checks at each step of

the process with mistake-proofing

methods.

F. If there is single-piece flow,

schedulers/planners are not needed for

the process.

G. Understand Takt Time – meeting the

demand.

H. Use “between processes” time to

complete indirect patient care tasks.



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27 3P v20130529

A. Family and important relationships are

defined by the patient.

B. Family travels with the patient where

appropriate and as the patient desires.

C. Family is a respected part of the

patient care team.

D. Family concerns stop the process until

addressed.

E. Family is a respected source of

information about the patient.

F. Information should flow to the family

throughout the process as desired by

the patient.

2. Flow of Family



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27 3P v20130529

A. Understand Takt Time and cycle times of the

work.

B. Look for standard work – it is critical to people

flow.

C. Do not isolate people in “islands.”

D. Understand people movement especially if

across several process steps.

E. People are part of the process – when they

stop, the process should stop.

F. All supplies, instruments and materials should

be as close to the provider as possible.

G. Examine motion of hands, feet, and eyes.

H. Stand when possible – do not use chairs!

I. Do not tolerate rework!

J. Avoid unreasonableness (i.e., Muri).

3. Flow of Providers



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A. Single-piece flow with signal/pull from

provider.

B. Introduce point-of-use. Get as close as

possible to the point of use.

C. Kit medications where possible.

D. Make smaller, specialized “satellite”

pharmacies where possible.

E. Bring medications to the patient, no patient

walking.

F. No waiting for medications.

4. Flow of Medications



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27 3P v20130529

A. Do the supplies flow to point of use?

B. Just in Time – only material on-hand needed at

the right place and at the right time.

C. Make the flow visual for simple control.

D. Introduce min/max, or “2 bin” strategies to re-

supply point of use.

E. Presentation of materials and sequencing is key.

F. Quality is critical.

G. Inventory reduction strategies – use kanban for

total inventory reduction.

H. Think of flow upstream – to suppliers – is it Just

In Time? (JIT)

5. Flow of Supplies



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A. Information travels with patient.

B. When information flow stops, the process stops.

C. When designing the process, consider how

information flows.

D. Only the minimum information necessary to

perform the process should be released.

E. Introduce mistake proofing and go/no go gauges

to ensure the flow of correct information.

F. Information can come in many forms – signals,

lights, sounds, music, spaces, etc.

G. Information must facilitate pull processes, not

push.

H. “Open room” arrangements facilitate the flow of

information between providers and staff.

6. Flow of Information



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A. Arrange equipment in a sequence that facilitates

the flow of patients, providers and information.

B. Separate people from machine work (i.e., Jidoka).

C. Use equipment with narrow frontage. Think

“townhouse” not “ranch house.”

D. Operation in front – maintenance in back.

E. Right-sized, small, economical equipment on

wheels that is home-made.

F. “No money” and “no time” are just excuses.

G. Use of small, single-purpose machines with

in-process checks.

H. “No roots, no ivy, no anchors.”

I. Equipment must facilitate flexible arrangements

as demand and processes change.

J. Is there wasted machine movement?

7. Flow of Equipment



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Mod 27 – 3P



The No’s of Health Care

No Silos “The World is

Flat”

Thomas Freidman

Mod 27 – 3P




No Excess

Inventory

Just-in-Time

Supply

# IN EXP.

ITEM COST STOCK DATE

Cochlear $50K ea 15 2008

Implant

Hospital/

Clinic

Implant

Factory

Mod 27 – 3P




Don’t Wear

a Blindfold

Look Everywhere

for Improvement

Opportunities

Mod 27 – 3P




No Anchor

Draggers

Get on Board!

Mod 27 – 3P




No Waste Use Returnable

Packaging

Mod 27 – 3P




Don’t stick

your head in

the sand

Be open to change

and new concepts

Mod 27 – 3P




Don’t Use

Money

Use Ideas

Mod 27 – 3P




If you fall down 7 times, get up 8

Mod 27 – 3P




People are the key to world class,

not technology

Mod 27 – 3P




Don’t hide Go and See

(Genchi Genbutsu)

Mod 27 – 3P




Don’t stop

asking “why?”

Ask “why?” five

times

Why?

Why?

Why?

Why?

Why?

Mod 27 – 3P




Never say

“never”

Make perfection

your goal

Mod 27 – 3P




Get out of

the rut

Let your

imagination soar!

Mod 27 – 3P




No chaos Follow standard work

1 2 3 4 5 6 7 8 9 10

6

8

Mod 27 – 3P



2025 TODAY


Don’t say

someday

Say NOW

Mod 27 – 3P




No more

band-aids

Find the root

cause

Mod 27 – 3P




No negative

thoughts

Only positive

ideas

Yes!

Mod 27 – 3P




Don’t batch One piece flow

I document

after each

patient visit

Mod 27 – 3P




Don’t waste

steps

Take out the

wasted steps

Mod 27 – 3P




Don’t have a

big mouth

Have big ears, big

eyes

blah

blah

blah

blah

blah

Mod 27 – 3P




Don’t ignore

the problem

Fix the problem

Mod 27 – 3P




Don’t keep

thoughts to

yourself

Be inquisitive and

persistent

Mod 27 – 3P




Get all the gears and processes

working together

Mod 27 – 3P




No ONE-WAY

Machines

Bring the part back to

the operator

No Dinosaur Machines.

We know what happened

to the dinosaurs

MACHINES

Mod 27 – 3P




Sacred Cows make the BEST Burgers

Mod 27 – 3P




Use Equipment Necessary to Permit

One Unit Flow

Mod 27 – 3P




Keep Height of all Items in the Workplace

Very Low

Mod 27 – 3P




Don’t Build

Big Ships with

Big Guns…

Think Small and

Responsible

Mod 27 – 3P




Explanation is NOT Necessary

Mod 27 – 3P




Keep an OPEN Mind to Change and

New Concepts

3

P

Mod 27 – 3P




Avoid Machines with Loads of Unneeded

Accessories

Think Bare Bones…Add Options when

Necessary

Machines

Mod 27 – 3P




Which is Smoother?

Pushing

Pulling

Mod 27 – 3P




No Catalog

Engineers

Get your hands

DIRTY

Mod 27 – 3P




Design Machines to be like

Townhouses, NOT Ranch-style Houses

Narrow & Deep

Closely Spaced

Wide

Frontages

Spaced far

apart

Mod 27 – 3P




Don’t use

Brainstorming

Use TRYstorming

Mod 27 – 3P




Don’t Attach Roots and Vines to

Machines - Make them Easy to

Relocate

Machines Machines

Mod 27 – 3P




Don’t think about CO$T

Shoot for BEST: Quality, Demand

Amount, and Timing

CO$T Q

D

T

Mod 27 – 3P



16 Catchphrases 1. Production Preparation should be lightning fast.

2. Equipment construction and layout should permit easy material flow.

3. Build additive equipment; no battleships.

4. Build equipment to allow easy changeovers.

5. Make equipment easy to disconnect and relocate.

6. Make versatile equipment that can easily be reconfigured.

7. Make operator stations narrow; deep is acceptable.

8. Both the equipment and layout should allow the operator to move easily. Open

room concept allows operators to see the big picture.

9. Eliminate machine waste; kaizen the motion of the machine.

10. Build equipment to fit into small, swift vertical flow lines.

11. Eliminate horizontal flow…this creates batch processing.

12. Production should be pulled along at Takt Time. Do not allow room or capability for

batching.

13. Build tooling/machines for rapid setups and quick changes.

14. Link machines to make work flow smoothly and avoid excessive WIP.

15. Use multiple lines to avoid constructed flow.

16. Continue pursuing the steps of jidoka by spiraling upward, continuously separating

machine tasks from human tasks.



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16 Catchphrases 1. Production Preparation should be lightning fast.



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16 Catchphrases 2. Equipment Construction and Layout should permit easy material flow.

Standard Work

①

②

③

④

Entry

Exit

Materials



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16 Catchphrases 3. Build additive equipment. No battleships.



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16 Catchphrases 4. Build equipment to allow easy changeovers.

Change-over Flowing gap Old product New product

5 4

3

2

A

RM

5 4

3

2

B

RM 1

1

5 4

C

RM 2 1

5

3 D

RM 2

1

3 E

RM 2

4

1

3 F

RM 2

4 5



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16 Catchphrases 5. Make equipment easy to disconnect and relocate.

Machines



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16 Catchphrases 6. Make versatile equipment that can easily be reconfigured.

Big Dedicated

Machines



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16 Catchphrases 7. Make operator stations narrow. Deep is acceptable.

Ranch

Style

Layout

Wide and Shallow

Townhouse

Style

Layout

Narrow but Deep

Reduced Walking

1 step - station to station

Principle of

Verticality

Reduced

Footprint



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16 Catchphrases 8. Both the equipment and layout should allow the operator to move easily.

Open room concept allows operators to see the big picture.

Fixed Layout

Standard work may be changed to allow for increased demand without changing layout.



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16 Catchphrases 9. Eliminate machine waste. Kaizen the motion of the machine.

1. Switch on

2. Air cutting down (Muda)

3. Drilling

4.Air cutting up (Muda)

Only this part adds

VALUE

MUDA

Air

cutting



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16 Catchphrases 10. Build equipment to fit into small swift vertical flow lines.



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16 Catchphrases 11. Eliminate Horizontal Flow. This creates batch processing.

Vert

ical F

low

Press

Weld

Paint

Assy.

Press

Weld

Paint

Assy.

Press

Weld

Paint

Assy.

Press

Weld

Paint

Assy.

Horizontal Handling NO FLOW

Products

A B C D

Pro

cess



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16 Catchphrases 12. Production should be pulled along at takt time.

Do not allow room or capability for batching.

Don’t produce 7 units once per week when the customer wants 1 per day.

1

Day

1

Day

Takt Time = 1 Day



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16 Catchphrases 13.. Build tooling/machines for rapid setups and quick changes.

Ease of positioning



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16 Catchphrases 14. Link machines to make work flow smoothly and avoid excessive WIP.

Whoa!

NO MORE WIP

Five pieces

is Standard

5



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16 Catchphrases 15. Use multiple lines to avoid constructed flow.

B1

B2

B3

B4

F1

F2

F3

F4

P1

P2

P3

P4

A1

A2

A3

A4

Model A

Model B

Model C

Model D

B1

B2

F1

F2

F3

F4

P1

A1

A2

A3

Model A

Model B

Model C

Model D

B = Blank F = Fabricate P = Paint A = Assembly

Use Multiple and Rectified Flows



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16 Catchphrases 16. Continue pursuing the steps of Jidoka by spiraling upwards,

continuously separating machine tasks from human tasks.

7 Quality Check (Poka-Yoke)

Part Removal (Hanedashi)

Autonomation of Returns

Automation of Stops

Autonomation of Feed

Automation of Holding

Autonomation of processing 1

2

3

4

5

6

7

Jidoka



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QUESTIONS?



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27 3P v20130529

3P Contract

3P Architect Contract

The 7 Ways

Process-At-A-Glance Sheet

Product Design Evaluation

3P Process Evaluation Checklist

3P Project Form

3P Target Sheet


Construction / Building Supplies as Directed by JBA

Mod 27 – 3P



3P Contract ContractTo give full play to my team’s creativity

Creativity comes into existence by removing the hurdles in the way of

creative thinking and idea generation.

Therefore, as one who tries to be creative, I do hereby promise to do

the following to improve my creativity:

1) I will not judge (good or bad) another person’s idea.

2) I will make every effort to overcome the hurdles in my own

thinking in order to generate useful ideas.

3) I will not think in limited ways but will make every effort to

look at the problem from many angles and especially to get

ideas from nature.

4) I will make every effort to express my ideas openly and not fear

the laughter of others.

5) I will return to my 12 year old mindset and will use this style of

thinking to generate useful ideas.

Signature:______________________ Date:_______

Coach:__________________________________ Date:_______

Copyright 2013 John Black and Associates LLC

Permission not granted to copy

Each team member signs a

contract on Monday of the 3P

week to ensure full disclosure

of creativity and a non-

judgmental approach to

design.

Contracts are posted in the

room.

Mod 27 – 3P



3P Architect Contract

Each architect signs a

contract on Monday of the 3P

week to confirm their role in

the 3P. Form follows flow,

and the architect will hold

true to the designs created

by the participants.

Contracts are posted in the

room.

ContractThe Architect’s Commitment

The 3P is recognized as the inspired hard work from the participants. Therefore, as

the architect that will convert this creativity into a building, we do hereby commit

to the following:

1) We will hold to the designs created in the 3P.

2) We will not make any changes to the design without the approval of the 3P

participants.

3) When presenting any changes, no matter what the cause, we will listen to

and engage with the 3P participants always following their direction.

4) We will always respect the patient as the customer in the design process.

5) We will build in as much flexibility into the design as possible, understanding

and agreeing that Lean is about continuous improvement.

6) We will work throughout the design process to reduce or eliminate each of the

seven wastes, working from schematic design into the building details.

Signature:______________________ Date:_______

Coach:__________________________________ Date:_______

Copyright 2013 John Black and Associates LLC

Permission not granted to copy

Mod 27 – 3P



The 7 Ways Each member of the team should work

independently, using the ideas from nature

to develop seven designs for the desired

function.

There are no restrictions and all ideas are

considered – even if not truly possible.

Each team member is thinking with a

creative, unbiased, and curious mind. Draw

pictures and use enough detail to be able

to explain your ideas to the other team

members.

Normally the first two or three designs will

come easily, however, to be able to

generate the seven designs, you may want

to examine and combine the mechanisms

from nature to assist you.

1

2 3

4 5

6 7



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3P JBA Reporting Requirements Prior to Event Week

1. Create a Dropbox folder to hold all documents.

2. Ensure all logistics are confirmed with host site and supporting KPO: warehouse, clerical and

construction supplies, computer projector, 3P forms including contracts and evaluation tools,

posters of the No’s of Heath Care and 3P process, food, parking, maps.

3. Validate project form and target sheet completion at least 3 weeks prior to event week including

patient participants and architects.

4. Confirm all appropriate data has been collected.

5. Set all 30, 60, and 90 day conference calls.

6. Submit project form and target sheet to JBA consultant, Donna Kimball, 2 weeks prior to event

week.

During Event Week

1. Assist team lead with completion of newspaper.

2. Submit end-of-week report to John Black with “End-of-Week Report” in subject line of email at

the end of the week.

3. Summarize 3P evaluations, email to John Black and place in Dropbox folder.

After Event Week

1. Obtain target sheet from architect at 30, 60, 90 days and email copy to Donna Kimball.

2. Attend all follow ups as scheduled (i.e. 30, 60, 90 days).

3. Place 3P Event Report Out and all 3P documents in Dropbox folder and email Donna Kimball

to notify her of upload



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Process-At-A-Glance

Part:___________________ Process ________ of ________

Sequence

(1) Material Process Sketch

(2)

Process Method

(3) Poka-Yoke

No-Go Gauge

(4)

Tools

(5)

Jig/Fixture Hanedashi

(6)

Machine

Name

___________________.

Date

___________________.

Tact Time

One-Piece-Flow

Pull System

Process At A Glance



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Product Design Evaluation Product Design 3P Evaluation Product: _________________________________ Determine the criteria or attributes that are important to the “internal and external” customers. Many of these may have been discussed during Step 1 of the Nakao Method. Please select this criteria before creating designs. Vote each proposal against each of the criteria. Do one proposal at a time and base each score upon its own merit. Do not evaluate against each other. Everyone votes 1-5. Do not average. Most repeated score should be recorded. This evaluation is an addition to the 3P Process Evaluation Sheet to assist in narrowing the selection of alternative designs; it is not intended to replace the 3P Process Evaluation and should not be used for such.

Design Proposals

Criteria or Attributes 1 2 3 4 5 6 7

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Total:

Rating: 5 = Excellent; 4 = Above Average; 3 = Average; 2 = Below Average; 1 = Poor; 0 = N/A



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3P Process Evaluation Checklist 3P Process Evaluation Checklist Process:_________________________________ Vote each proposal one at a time based upon its own merit. Do not evaluate against each other. Everyone votes 1 -5. Do not average. Most repeated score should be recorded.

Proposals

Production Method Qualifiers 1 2 3 4 5 6 7

S-1 Properly Guarded - Safety devices in place.

S-2 Passes Ergonomic Evaluation (no postural deviations >1).

S-3 Proper waste collection. Maintains clean workplace.

S-4 Low level of regulatory issues (environment, fire, safety, etc.).

Q-1 Quality Requirements known - NOGO gauges.

Q-2 Defects less than .03%.

Q-3 POKA-YOKE built into the process.

Q-4 Level of Autonomation achieved. (Level 7 would be a “5”).

C-1 Capital Investment (less is better).

C-2 Low level of approval to obtain materials to build.

C-3 Known technology.

C-4 Top notch tooling is used in the process.

C-5 Minimum MOONSHINE time is required.

C-6 Smaller and Simpler than current process.

C-7 Maintenance free. Easy autonomous maintenance.

H-1 Ability of the Process to meet TAKT time.

H-2 Creates ONE-piece flow.

H-3 Creates a PULL system.

H-4 MUDA-less process.

H-5 Change-overs (less than one minute).

H-6 Fits the CHAKU-CHAKU concept.

H-7 THROW-IN loading. Max. 2 seconds operator time.

H-8 Space Utilization. Townhouse design.

H-9 Mobility: On wheels. No roots or vines.

H-10 Number of RPIWs conducted on this process (More is better).

Total:

Rating: 5 = Excellent; 4 = Above Average; 3 = Average; 2 = Below Average; 1 = Poor; 0 = N/A

S=Safety; Q=Quality; C=Cost; L=Your “Local” Production System



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3P Project Form

-3P Workshop Project Form-

3P Project# & Project Name: Date: If linked to past projects, note event #s & names here:

Sponsor: Current Situation: Team Leader:

Sub Team Leader:

Project Manager:

Audit Leader:

KPO Support:

Content Experts (if applicable) Department

1.

2.

3.

4.

Team Members (Participants) Department

Must be present all 5 workshop days – do not exceed 25 participants

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Takt Time Calculations: 3P Deliverables:

Process Flow: 3P Targets / Boundaries / Other Departments Affected:

This document is a summary of the information contained in the proposal. Its purpose is to give the judicator an “at a glance” look at the

proposal being evaluated. It contains summaries of the following documents contained in the proposal.

Roles and Participants: These are the core people and stakeholders involved in the event from the role of sponsor, team

and sub-team lead, project manager, audit leader and KPO support down to the content experts and participants including

patients and the architect.

Takt Time Calculations: Multiple Takt Times will be determined based on services provided and forecasted demands

spanning from 5 – 20 years.

Process Flow: The patient flow the 3P is focusing

on is documented here in a high-level format. Note

the other 6 flows are inherently involved but the

focus remains on the patient’s flow.

3P Targets / Boundaries, Other Departments

Affected: This defines the parameters of the 3P

and addresses any peripheral considerations.

3P Deliverables: The goal of the 3P is

articulated in enough detail to provide focus for

the 3P.

Current Situation: Provide enough detail to allow

the reader to understand the need and sense of

urgency for this project. Use data to support the

statements such as, “20% of patients are waiting

over 90 minutes to be seen”.



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3P Target Sheet

3P Target Progress Report and Results Sheet

3P # and Name: Report Out Date:

Departments: Sponsor:

Product/Process: Team Leader:

TAKT Time: Audit Lead / KPO Support : (assigned by Sponsor)

MEASURES BASELINE TARGET 30 DAYS 60 DAYS 90 DAYS FINAL PERCENT CHANGE

Space (Sq. Ft.)

Inventory

Walking Distance (ft)

Part Travel Distance

Lead time (h:mm:ss)

Quality (# Defects)

Productivity Gain Output

Input

5S-Envirnmntl, Health & Safety

Environment, Health & Safety

Set-Up

Cycle Time (mm:ss)

Capacity

Remarks:

MUDA MUDA - Saskatchewan Health Authority · Goals and Deliverables The goal and theme of the 3P...

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