© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Building a Profound Lean Infrastructure for Durable Success
Sam Carlson, MD, FACPChief Medical Officer and EVP,Park Nicollet Health Services
John Black, John Black & Associates, LLC
Revised 2/28/08
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Conflict of Interest
John Black of John Black and Associates LLC (JBALLC)
John Black is President of JBALLC and his consulting firm consults to Park Nicollet Health Systems on Lean, Global Production System. The presentation could be perceived as a conflict as JBA receives payment for services for consulting to Park Nicollet on the Lean, Global Production System principles presented in this presentation.
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Park Nicollet Health Services is…
Non-profit integrated care system
8000+ employees
600+ employed physicians
Over $1 billion annual revenue
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Park Nicollet Health Services is…
Park Nicollet Clinic - 45 medical specialties and sub-specialties in 25 clinic locations in suburban Minneapolis
3 million patient visits annually
Park Nicollet Methodist Hospital – 426 bed facility 26,000 admissions annually
Park Nicollet Institute – Engages in research, education and innovation to improve quality and public and private decision making in healthcare.
Park Nicollet Foundation – The fund-raising arm of Park Nicollet Health Services, using philanthropy to build healthy communities by supporting patient care, research and education.
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
We realized we were far short of where we needed to be
We knew we had lots of ineffective, non-value-added processes and activities
AND we knew the U.S. healthcare industry as a whole was not “world class”
Prior improvement methodologies weren’t having traction
Why is PNHS Aiming at World-Class Performance?
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Because we knew we weren’t delivering “world class” health care
Because we had heard promising reports about implementation of the Virginia Mason Production System (Lean) at VM’s Medical Center in Seattle
We were intrigued with its potential, but wanted to do a test run at Park Nicollet before departing from our six sigma improvement strategy
Why Did We Take a Look at Lean?
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
What Does Infrastructure Mean? Why Is It Important?
I35W Bridge, Minneapolis, MN, before and after collapse
PROBABLE CAUSE: Federal investigators have concluded that steel
plates on the [I-35W] bridge that collapsed last summer in Minneapolis were inadequate to hold the structure together…
Design changes in 1977 and 1998 added additional pavement and concrete barriers that increased the weight of the bridge…
Gusset plates are flat steel structures used to bolt together the steel girders that carry the weight of a bridge. Bridge engineers typically design the plates to be far stronger than the girders because if one fails, the whole bridge will collapse.
In the wreckage of the I-35W bridge, investigators found 16 gusset plates that were fractured… Eight of the plates were in the location on the south side of the bridge where the collapse began… What [engineers] found was that the half-inch thick plates should have been an inch thick – double the size…
USA Today, 1/15/08
Construction of theBridge in 1967.
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Creating the Vision
“Everyone caring every day, creating with the individuals we serve optimal health and greater value”
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Our Strategic Plan
#1 regionally in state of the art measures of quality & safety for high impact conditions
Patients respond positively to: “I get exactly what I want (and need), exactly when I want (and need) it”
Reduce total risk-adjusted per capita cost of care relative to other MN care systems to below average
Operating margin ≥ 3.5%
By 2012, # unique patients served grows by 20%
2012
Traditional PN Organization Chart
Prototype Lean Organization
MarketingMarketing FacilitiesFacilities Human ResourcesHuman Resources
PurchasingPurchasingOperationsOperations KaizenKaizenPromotionPromotion
OfficeOffice
Healthcare Lean Organization
LeadershipLeadershipFellowsFellows
FinanceFinance
PresidentPresident
CEOCEO
JBA ConsultantsJBA Consultants
Surgery Surgery KOTKOTHospitalHospital KOTKOTCancerCancer KOTKOT
KOTKOTAdministrationAdministration
Model LinesModel Lines Special Ops KOTSpecial Ops KOT
KOTKOTSurgerySurgery
CancerCancer KOTKOT
HospitalHospital KOTKOT
ClinicsClinics KOTKOT
10
10
10
10
10
15
10 10 10
25
20
Se
rvic
e L
ine
s
*KOT-Kaizen Operations Team
Implemented
Underway
Not Started
Pat. Returns to Function
In Patient Hospital
TBDPre-Op Preparation
Pre-visit L/T
Day ofClinic
Visit L/T
Post-Visit L/T
Day ofSurgery
L/T
Pre-SurgeryL/T
Daily Management Boards
Materials Flow
Use of Non-Surgeon Clinicians
Staggered Starts
OR Scheduling Process
Staggered Starts
Case Carts: Standardize, Waste
Standardize Rooms
Staff Cross Training
Visual ControlPull Signals
PrimaryCare
7days
Total Surgical SpecialtiesPatient Lead Time
/
208 minutes
8days
TBD
22minutes
Accurate Surgery Times
Interoperative Standard Work for MDs
Pre-Op Preparation
Defining Best Practice Guidelines
PICIS: Surgery Information
SystemInstrument room
Pre-Op Patient PrepLoad Level During Day
Load level by DOW
Turnover Time
Reduced Surg./staff NVA Time
OR 21
Standard Rooming
Med. Rec.
Nurse Post-op Clinics
Model Line (Future) – Surgical Specialties
Implemented
Underway
Not Started
Pat. Returns to Function
In Patient Hospital
TBDPre-Op Preparation
Pre-visit L/T
Day ofClinic
Visit L/T
Post-Visit L/T
Day ofSurgery
L/T
Pre-SurgeryL/T
Daily Management Boards
Materials Flow
Use of Non-Surgeon Clinicians
Staggered Starts
OR Scheduling Process
Staggered Starts
Case Carts: Standardize, Waste
Standardize Rooms
Staff Cross Training
Visual ControlPull Signals
PrimaryCare
7days
Total Surgical SpecialtiesPatient Lead Time
208 minutes
8days
TBD
22minutes
Accurate Surgery Times
Interoperative Standard Work for MDs
Pre-Op Preparation
Defining Best Practice Guidelines
PICIS: Surgery Information
SystemInstrument room
Pre-Op Patient PrepLoad Level During Day
Load level by DOW
Turnover Time
Reduced Surg./staff NVA Time
OR 21
Standard Rooming
Med. Rec.
Nurse Post-op Clinics
Model Line (Future) – Surgical Specialties
Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)
Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)
JUST IN TIMEJUST IN TIME
Operate with the Operate with the minimumminimum resource required to resource required to consistentlyconsistently deliver deliver
• JustJust what is needed. what is needed.• In In justjust the required the required
amount.amount.• JustJust where it is where it is
needed.needed.• JustJust when it is needed when it is needed.
JidokaJidoka
One-by-one confirmation One-by-one confirmation to to detectdetect abnormalities. abnormalities.
StopStop and and respond respond to to every abnormality.every abnormality.
Separate machine work Separate machine work from human work. from human work.
Enable machines to Enable machines to detectdetect abnormalities and abnormalities and stopstop autonomously. autonomously.
Pull SystemPull System ProductionProduction
One Piece Flow Production
Supermarket System
Takt TimeProduction
AndonAndonOperational Operational AvailabilityAvailability
Standard Workin Process Kanban
StandardWork
Materials
MachinesMachines
People
Park NicolletSystem of CarePark Nicollet
System of CareTo Care for Patients the Right WayTo Care for Patients the Right Way
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)
Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)
JUST IN TIMEJUST IN TIME
Operate with the Operate with the minimumminimum resource required to resource required to consistentlyconsistently deliver deliver
• JustJust what is needed. what is needed.• In In justjust the required the required
amount.amount.• JustJust where it is where it is
needed.needed.• JustJust when it is needed when it is needed.
JidokaJidoka
One-by-one confirmation One-by-one confirmation to to detectdetect abnormalities. abnormalities.
StopStop and and respond respond to to every abnormality.every abnormality.
Separate machine work Separate machine work from human work. from human work.
Enable machines to Enable machines to detectdetect abnormalities and abnormalities and stopstop autonomously. autonomously.
Pull SystemPull System ProductionProduction
One Piece Flow Production
Supermarket System
Takt TimeProduction
AndonAndonOperational Operational AvailabilityAvailability
Standard Workin Process Kanban
StandardWork
Materials
MachinesMachines
People
Park NicolletSystem of CarePark Nicollet
System of CareTo Care for Patients the Right WayTo Care for Patients the Right Way
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Kaizen Office Locations
Park Nicollet Methodist Hospital Inpatient and Surgical/Orthopedic Services Visibility Room
Park Center Campus Specialty Services (CV/Onc/Medical Specialties); Primary Care Corporate Services KPO Offices Stand-up wall
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Strategy and Tactics
Kaizen Guidance Team CEO/CEO/CMO/VP and Chief of KPO/Consultants
evaluate the overall plan and progress
Kaizen Leadership Team All service-line chiefs/VPs with Sr. Leadership and
KDs: yearly plan/timeline and progress
CEO weekly “wall walk” and review Progress towards yearly goals
Working the visibility room Monthly reviews of corporate health, quality, and
access data; setting longer-term strategy
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
CEO Weekly Wall Walk
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Succession Planning and Replacement Tables
Succession Planning and Performance Management at
Park Nicollet Health Care Services
Senior Leader Replacement Table
Leader Replacement Ready Now
Replacement Ready in 1-3 years
Replacement Ready in > 3 years
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Park Nicollet Leadership Fellows at Boeing 777 Factory
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Developing Our Own “World Class” Leaders
RPIWs
5S
KEEP
3P
VSM
Daily Management Boards
Just-In-Time
Jidoka
Wall WalkLeadership Fellows
KPO
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
What Does “World Class” Mean?
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
“World Class” Companies Excel in Five Areas
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
What Does “World Class” in Health Care Mean?
Safe
Effective
Patient Centered
Timely
Efficient
Equitable
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
The Importance of Going to Japan
Understanding the possibilities
Seeing with “new eyes”
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Learning from Manufacturing Companies in Japan
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Yamatake Corporation Isehara Plant Shonan Plant
Toyota Motor Corporation Kamigo Plant(Engine) Motomachi Plant(Assembly & Welding) Tsutsumi Plant(Assembly & Welding)
Toyota Boshoku Kariya Plant
Denso Takatana Plant
The Yokohama Rubber Co. Ltd. Hiratsuka Plant
Aisin Nishio Plant
Yamaha Motor Co. Ltd. Yamaha
Learning from Manufacturing Companies in Japan
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
The Infrastructure Must Be in Sync with the Improvement Plan
Improvement efforts must not get ahead of infrastructure
Model lines should be an inch wide and a mile deep
Taiichi Ohno’s Seven Wastes
MUDAMUDA
Time on Hand(Waiting)
Transportation
DefectiveProducts
Processing
Movement
Stock on Hand(Inventory)
Overproduction
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
The Seven Flows of Medicine
Flow of patients
Flow of clinicians
Flow of medication
Flow of supplies
Flow of information
Flow of equipment
Flow of process engineering
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Surgical Services Case Study
Background Approximately 17,000 surgeries performed at Methodist Hospital in
2006: Each surgery requires multiple instrument trays with potentially
hundreds of instruments/supplies Multiple surgeons means multiple instrument/supply preferences Techniques and instruments added over time, but many old
instruments remain unused in trays, demonstrating both reprocessing and inventory waste:
Range for unused instruments has been 22-50% Mean score for unused supplies is 25% (but as high as 88% for certain
procedures)
16 RPIWs done over 2-year period to reduce unused instruments/supplies across all surgical specialties.
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Surgical Services Case StudyRPIW Methodology
Standard Work
Standard Work
Each team included a circulatingnurse & a surgical scrub tech
Makeup of Teams
RPIW target:Reduction of unused instruments/Supplies across all surgical specialties
Baseline for change 5 weeks prior to RPIW:* Scope & procedure/case types
selected* Product quantity analysis (PQA)
data collected* Supply pick lists color-coded to
identify utilization* Instrument counts/tray compiled
During Prep Weeks:* Data collected on instruments
(used vs. nonused) by followingtrays after surgery
* Cycle times for tray processing& supply picks measured
* Surgeon-unique additionalinstrumentation evaluated
Surgeons used as contentexperts to RPIW teams
Surgeon meetings during RPIW week; discussed:* Display of new recommended trays & supplies
by procedure* Consensus on standardization
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Surgical Services Case Study
Results at End of 2006
% of Case Volume % of UnusedEvaluated Instruments Difference(2004-2006) (Pre- vs. Post-Standardization)
18% reduction in processed instruments (translates to 79,530 fewer instruments handled & processed per month)
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Follow-up/Implications:
Follow-up Audits
• 30/60/90/120 day audits in place to maintain gains.
• Each RPIW audits previous case cart standardizations. One instrument tray is evaluated for compliance with standard.
• Standard work is in place for surgeons to reintroduce an instrument. (To date, no surgeons have utilized this process.)
Time Savings
• Reduction of instruments significantly affects workload of scrub tech & instrument room staff
• 79,530 fewer instruments processed per month = 2,615 fewer instruments per day
• Time savings per day: 20,917 seconds (349 minutes, or 5 hours, 50 minutes)
* Assuming 3 staff members touch each instrument for 2 seconds (scrub tech touches them twice)
Surgical Services Case Study
Goal: A Model Line
Line ImprovementsLine ImprovementsLine
Line
Verticaldevelopment(Link processes to create a cell)
• Change production method from “Push” to• Plan for Leveling “Pull”• Develop Standard Operations• Quickly Solve Flow Problems• Practice “Visual Control”
Plane ImprovementsPlane Improvements
Plane
(Link cells to produce a product)
Goal: Spread Across Plane
15-20Years
15-20Years
Critical Transition from Point
to Line
5-10Years
5-10Years
Point
Point
Point
(Eliminate waste
at source - Just start
somewhere)
Point ImprovementsPoint Improvements
Goal: Flow vs. Batch
10-15
Years
10-15
Years
Height3rd Dimensional
(Link all elements from concept to
customer)
Goal: Raise to Other Planes
Spatial ImprovementsSpatial Improvements
Other processes
make point and line
improvements based on the model line
Where Does PN See Itself Now?
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Pat. Returns to Function
In Patient Hospital
TBD
Pre
-Op
Pre
pa
rati
on
Pre-visit L/T
Day of Clinic Visit L/T
Post-Visit L/T
Day of Surgery L/T
Pre-SurgeryL/T
Da
ily
Ma
na
ge
me
nt
Bo
ard
s
Ma
teri
als
Flo
w
Us
e o
f N
on
-Su
rge
on
Cli
nic
ian
s
Sta
gg
ere
d S
tart
s
OR
Sc
he
du
lin
g P
roc
es
s
Sta
gg
ere
d
Sta
rts
Ca
se
Ca
rts
: S
tan
da
rdiz
e,
Wa
ste
Sta
nd
ard
ize
Ro
om
s
Sta
ff C
ros
s T
rain
ing
Vis
ua
l C
on
tro
l
Pu
ll S
ign
als
Primary Care
14.8 days
Total Surgical Services Patient Lead Time
415.5 minutes15.1 daysTBD43.8 minutes
Ac
cu
rate
Su
rge
ry T
ime
s
Inte
rop
era
tiv
e S
tan
da
rd W
ork
fo
r M
Ds
Pre
-Op
Pre
pa
rati
on
De
fin
ing
Be
st
Pra
cti
ce
Gu
ide
lin
es
PICIS: Surgery Information System
Implemented Underway
Not Started
Ins
tru
me
nt
roo
m
Pre
-Op
Pa
tie
nt
Pre
p
Lo
ad
Le
ve
l D
uri
ng
Da
y
Lo
ad
le
ve
l b
y D
OW
Tu
rno
ve
r T
ime
Re
du
ce
d S
urg
./s
taff
NV
A T
ime
OR
21
Sta
nd
ard
Ro
om
ing
Me
d.
Re
c.
Nu
rse
Po
st-
op
Cli
nic
s
5 Year Block (Point): Surgical Specialties
Pat. Returns to Function
In Patient Hospital
TBD
Pre
-Op
Pre
pa
rati
on
Pre-visit L/T
Day of Clinic Visit L/T
Post-Visit L/T
Day of Surgery L/T
Pre-SurgeryL/T
Da
ily
Ma
na
ge
me
nt
Bo
ard
s
Ma
teri
als
Flo
w
Us
e o
f N
on
-Su
rge
on
Cli
nic
ian
s
Sta
gg
ere
d S
tart
s
OR
Sc
he
du
lin
g P
roc
es
s
Sta
gg
ere
d
Sta
rts
Ca
se
Ca
rts
: S
tan
da
rdiz
e,
Wa
ste
Sta
nd
ard
ize
Ro
om
s
Sta
ff C
ros
s T
rain
ing
Vis
ua
l C
on
tro
l
Pu
ll S
ign
als
Primary Care
7 days
Total Surgical Services Patient Lead Time
208 minutes8 daysTBD22 minutes
Ac
cu
rate
Su
rge
ry T
ime
s
Inte
rop
era
tiv
e S
tan
da
rd W
ork
fo
r M
Ds
Pre
-Op
Pre
pa
rati
on
De
fin
ing
Be
st
Pra
cti
ce
Gu
ide
lin
es
PICIS: Surgery Information System
Implemented Underway
Not Started
Ins
tru
me
nt
roo
m
Pre
-Op
Pa
tie
nt
Pre
p
Lo
ad
Le
ve
l D
uri
ng
Da
y
Lo
ad
le
ve
l b
y D
OW
Tu
rno
ve
r T
ime
Re
du
ce
d S
urg
./s
taff
NV
A T
ime
OR
21
Sta
nd
ard
Ro
om
ing
Me
d.
Re
c.
Nu
rse
Po
st-
op
Cli
nic
s
10 Year Block (Line): Surgical Specialties
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
Dramatic Improvement in Health Care is Possible Through Lean!
“It was exciting to see the chance for making changes, since there is no time in our typical day to make the changes we would like to make. Also, this process was good because we didn’t have to talk it to death. It was fun, and a good experience.” (Clinician, RPIW team participant)
“I was struck by the complexities of our systems, and how presumably small changes in a process can have such an important impact on the work of others in the system. It is a challenge to develop new procedures in a way that benefits all the participants on the clinical side, and keeps focus on the ultimate goal – doing what is best for the patients.” (Clinician)
“This was the best RPIW ever! I finally feel as though someone actually cares that I work at home until 12:30 many, many nights. This has changed my life! Please keep the DA!!!” (Clinician)
“The improvements will have a great impact to the amount of time saved preparing for a case. This saved time will be directly shifted to the patient, increasing the amount of time the RN will have for patient care.” (Clinician)
“I never felt like I was at a hospital, because having worked at the Marriott for over 20 years, I felt that the Park Nicollet staff totally embodied the service philosophy and took care of my father-in-law’s needs.” (Patient, RPIW team participant)
© 2008, Park Nicollet Health Systems & John Black and Associates LLC
QUESTIONS?QUESTIONS?
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