A Brief on LEAN Fundamentals for Healthcare

Transcription

1 A Brief on LEAN Fundamentals for Healthcare Jerry Green, PhD June 28, 2016

2 Housekeeping 1. Using the control panel - Use the control panel on the right side of your screen to minimize and expand this panel by clicking on the arrow in the upper right corner. 2. Ask Questions - You can submit questions using the Question section located near the bottom of the control panel. We will take time to answer as many questions as we can during Q&A at the end of the presentation. If your question was not answered, we will respond to you individually after the event. 3. After the webinar - We want your feedback! Please take the short survey at the completion of the webinar. Also, all registrants will receive a copy of the presentation, and the recording for on-demand replay.

3 First: What is LEAN? Cycle-time reduction through waste elimination When cycle-time is the problem Tools and techniques that focus eliminating nonvalue added activities (waste). A LEAN Organization produces what is needed, when it is needed, with the minimum possible amount of resources. A LEAN organization maximizes the ability of all employees to add value. LEAN is about employee empowerment LEAN will NOT work in Command and Control organization

4 Always LEAN first Use LEAN before deploying other methodologies or your organization will spend unnecessary time improving activities that should have been eliminated, automated, or significantly simplified. LEAN can be deployed within other frameworks such as PDCA/PDSA or traditional DMAIC.

5 Agenda Why is LEAN important to healthcare? The five LEAN Steps & Tools 1. Define Value 2. Map the Value Stream 3. Eliminate the Waste 4. Implement the Solution and Pull Value 5. Maintain the Gain and Pursue Perfection In Conclusion Q&A

6 Five Step LEAN Process 1. Define Value from the customer s perspective. 2. Map the Value Streams and identify issues and constraints. Things that impede what the customer wants. Within DMAIC PDCA Define Plan Measure 3. Eliminate the Waste and allow the customer to flow through the value stream without interruption. 4. Implement the Solution and let the customer Pull Value through the work flow. 5. Maintain the Gain and Pursue Perfection Plan Analyze Do Improve Check Control Act

7 WHY IS LEAN IMPORTANT TO HEALTHCARE?

8 The way we work is constantly changing Systems Tools Technology IBM WH EMR MIDAS Etc Processes Process Ways of Working Training & Experience People Knowledge, Skills, Abilities

9 An uninterrupted flow for the patient is the end goal All team members ebb and flow to keep patient moving through the work flow without waiting or interruption Patient is ready with Labs, Med list, etc Percentage of No Shows reduced with remind Team members collaborate in huddles to prepare for patient arrivals Patient is at the top of the clinical universe Downstream wait time is eliminated as workers and supplies are ready when the patient arrives Process flow optimized and aligned to the technology Upfront pre-visit planning eliminates downstream rework cycles Upfront pre-visit planning is most efficient at reducing care gaps. All other methods require getting the patient back in the office. They re already here! All team members work at the top of license (what is legally allowed] Example not meant to be read

10 Transparency is critical: Identifies the area to focus on Helps to create a sense of urgency and ensure that the project team focuses on the right areas of the value stream.

11 Client Feedback from LEAN Workshops Reduced the percentage of billing errors by 50% + Designed a virtual visit process for wellness exams Designed a process to track patients through the system using rfid Designed a discharge process to align to Transition Improved the cycle time for patients to get into chemo chair from 8.5 hrs to 2.5 hours Decreased hand-off issues occurring during shift changes for 2 discharge groups Decreased fall prevention percentage Decreased cycle time for OR equipment sterilization Decreased the # of incomplete orders for an entire healthcare system Improved ability to hit on elements of ACO commitments Improved the capacity of clinics in which Outreach was driving up demand Decreased the cycle time for hiring clinical staff impacting percentage accepting Reduced wheels in and wheels out cycle time (45 to 20 min) Streamlined specimen processing cycle time and standardized across all shifts Designed a Comprehensive Primary Care initiative to reduce A1C scores for a population Reduce the approval process cycle time for high priority projects in a healthcare system Reduced cycle time for patient diagnostic communication in oncology process

12 1. DEFINE VALUE FROM THE PATIENT S PERSPECTIVE.

13 Always start with a Charter No Charter, No Project Releases approved resources A living document: progressively elaborated Helps control scope creep All Charters must at least identify a: Definition of problem to solve Champion to approve Project Leader Project Team (5-8 recommended) Scope (What is included and excluded) Boundaries for project team Example not meant to be read Goal(s): The Key Measure(s) and can be multiple

14 Define the Voice of your Customer (VoC) Who is our customer(s)? Internal VoB / external VoC What do they want? What do they care about? (willing to pay for) When does the customer need the output? Covered in Waste/Flow How often do they need what we re providing them? Overall, what value are we providing them? Don t forget the Voice of your Business (VOB) Identify these for your process, dept. or organization

15 First, brainstorm using the 5M & P method People Method Machine Material Measurement Mother Nature Physicians Nurses Analysts Patients Qlty Mgr Etc Processes Methods Check Lists Approaches Workflows Etc... Laptops Medical Eqp. SW Programs Vehicles Routers Etc Sponges Paper Glue Tile Desks Etc Thermometer Story Points Blood Pressure Lab Scores Coordinate Etc Temperature Rain/Wind Policies HIPAA NCQA Etc

16 From the 5M and P identify the Customers Primary entity needs must be met However, needs go well beyond that of the primary entity Keep these stakeholders at the front of mind as you go through the LEAN steps

17 The Kano Model Satisfaction If included, patients/customers will be satisfied If omitted, patients/customers will not be dissatisfied Wow: Delighters customers don t know exists Dysfunctional Wants that patients/customers may not think to ask for Items move down over time If included, patients/customers will NOT be satisfied If omitted, patients/customers will be dissatisfied Expected: Customer clearly ask for this Functional Basic Needs: Customers expect this without having to ask for it 2015 International Business Machines Corporation 24 Dissatisfaction

18 KANO What s important: Not to forget Basic Needs To reaffirm what the customers are asking for, the Expected Needs Not trading Basic Needs for Wows To ensure that all stakeholder needs are cared for in the new design (5M and P)

19 2. MAP THE VALUE STREAM AND IDENTIFY ISSUES AND CONSTRAINTS.

20 Use the 5M s & P to help identify what goes into the map Methods Processes Materials Supplies Mother Nature Policies, Weather Measurement System How things are measured Machines Equipment, HW & SW People Any person

21 A SIPOC can help when there is ambiguity about a process Suppliers Inputs Processes Outputs Customers S I P O C EMR System Medical Supply Companies BD Medical Syringes IBM Etc... Appointment Sign in Form Lab Results Patient Summary Etc Vital Signs Head Ears Nose Mouth Etc Diagnosis Orders Treatment Plan Supply Ordering Etc Patient Clinic Etc

22 Think Horizontally, NOT Vertically It is natural to think only about my own functional area Vertical Thinking Many defects occur during the handoff or downstream Vertical thinking will not show after handoff issues Horizontal Thinking Visualize the Entity flowing through the process end to end Start at the point the entity first enters the flow End at the point the entity is no longer touched by the process If a coffee shop had bad tasting coffee, the cause could be anywhere in the process, not just in the coffee pot. Identify the Value Stream for Coffee Field to Cup

23 What is a Process Map? Visual representation of a process flow Illustration of what actually happens Shows the flow of a process Demonstrates scope of a project Start and end; steps and decisions Action Step? Decision or Path

24 Standard Process Map Symbols Start Stop Process Step or Operation Decision A complex process step that could be broken out into it s own map or Transport of movement Storage, waiting time Delay 24

25 Always map the current state in detail Effective change agent Evokes an emotional response Becomes a common language Identifies sources of waste Start here Identifies the potential inputs, actions and decision points that may impact a process and its outputs and then it ends here Serves as the foundation for process improvement activities Visual and engaging! Easy to do!

26 Example of a Cross-Functional Value Stream Map Original Paper Map completed in our workshop Turned into a Cross-Functional Value Stream Electronic Map Examples not meant to be read in detail

27 Time the activities and identify the constraints Backlog or WIP NVA VA CAPACITY Registration w/exam Exam w/treatment Capacity: 40/day VA: 80% 50/day 20/day 50/day Treatment 40/day 0% 100% 0% 90% Removing all the NVA could improve patient satisfaction, but capacity for this workflow would not increase. The overall capacity of a process = the single largest constraint The exam would need to be mapped in detail to identify and DOWNTIME, then eliminate waste in the value added step

28 A Few Process Mapping Tips and Hints Use mapping paper and sticky notes to make changes easy Involve Subject Matter Experts or you may be remapping Be the entity flowing through and capture everything Even wait points and rework loops Start and Stop at extremes Only one activity per sticky Don t put swim lanes on the paper map Instead, write down the swim lane on the sticky note pad, put on the left For decisions, show the percentage that goes down each path (even if just estimated) Don t have naked lines ( is not an activity but a line, label it as such, driving, , meeting, face to face etc.) Transportations go on the lines, so show how it was transported to the next process step

29 Use the LEAN criteria to identify non-value add activities (NVA) in the value stream The LEAN criteria for a patient centered value stream 1. The patient must care about it AND 2. The activity must change the patient or knowledge about the patient AND 3. The activity must be done right the first time

30 To identify non-value added activities, it helps to think about the 8 LEAN Wastes in the Muda Wheel Muda Wheel Defects Motion Over - Production Waiting Waste muda Non Value Added Processing Transportation Inventory Unused Employee Talent Defects - Incorrect data entry, incomplete information, mistakes Overproduction - Preparing extra reports, making too much Waiting Batching work, downstream step is not ready unused Creativity - Not working at the Top of a License Transportation - Travel to/from facilities, walking to copy machine Inventory - Purchasing supplies in bulk and storing in cabinet Motion - Extra steps and movement during an exam Excess Processing - multiple sign-offs, most meetings, downstream inspections, rework, approvals

31 Conduct a Value Add Flow analysis: Red Dot/Green Dot Evaluate via VA Criteria Change Management Starts Now Red and Green dots were used to decide if an activity was a Value Add [Green] or Non-Value Add [Red] Activity does not meet the value add criteria 1. Customer cares about it 2. It transforms the entity 3. It is done right the first time

32 A Spaghetti Diagram Map is another good way to identify process flow issues, especially Transportation A Birds Eye view of the flow of a process Can identify areas in which Activities could be done in parallel Walking can be addressed via redesigning the work area U Shaped work areas could reduce walk time Moving supplies, equipment, files closer IMPLANT CHANGING HALLWAY ipads OXID, P- P+ BASE TEOS-NI-TEOS Etc EP EMITTER S-FIELD DC, PT SILICIDE 1ST METAL 3RD CONTACT ND METAL

33 3. ELIMINATE THE WASTE AND ALLOW THE PATIENT TO FLOW THROUGH THE VALUE STREAM WITHOUT INTERRUPTION.

34 Ensure continuous flow in your design so the entity (patient) never waits IDLE WORKERS VS IDLE PATIENT

35 5 Why Problem Statement: An item was missing in the Exam Room WHY? Why was an item missing from the exam room WHY? Someone forgot to re-stock WHY? The Kanban card was not pulled in time WHY? The key person went on vacation, no backup WHY? A new delegate was never appointed There may be more than one Why for each issue and each Why can have multiple paths

36 Using a Fishbone (Ishikawa Diagram) with the 5M s and P and the 5 Why can help identify root causes 1. The Problem statement is the Fish head 2. Use the 5Ms and P as the major bones 3. Use the 5 why process with each failure mode to move from symptoms and get to the root causes for each bone 4. Place the root causes on the diagram as smaller bones

37 Use the FMEA (Failure Modes and Effects Analysis) to calculate the Risk Priority (what to do first, second etc.) Process Step/Input What is the input? Potential Failure Mode What can go wrong with the input? Potential Failure Effects What is the effect on the outputs? S E V How bad? Potential Causes O C C Current Controls What are the causes? How often? How can these be found or prevented? D E T R P N How well? Actions Recommended What can be done? Risk Priority Number (RPN): Severity X Occurrence X Detect ability = RPN # Severity of Effect (1=Not Severe, 10=Very Severe) Occurrence of Cause (1=Not Often, 10=Very Often) Detection of Current Controls (1=Likely to Detect, 10=Never able to Detect)

38 Example from our LEAN workshop: FMEA with paper and sticky notes

39 Waste elimination strategies Once Waste (NVA) is identified: 1.First Priority: Eliminate (do not improve an activity that should be eliminated) 2.Second Priority: Automate Poka Yoke Auto populate 3.Third Priority: Simplify Reduce handoffs Eliminate redundancy Co-locate and sequence tasks Reduce approvals Standardize Reduce motion Prioritize efforts Balance resources One piece flow 5S

40 Poka Yoke Ideas Reduce NVA by eliminating rework loops, auto populating data entry Drop down menus for data entry Color coding items that go together Manual processes automated (not manumated) Electronic sensors for danger areas Bar coding Collision detection systems Correct position setting tape so item is always placed in the correct location Barriers to electronic files Computerized Physician Ordering Systems Plug protections for children

41 5S Detail Steps 1. Sort: Keep only what is needed, discard everything else. Sort the remaining into categories 2. Store: A place for everything and everything in its place. Store and label all items in an area that is easily visible and accessible to the group. 3. Shine: Keep the workplace tidy and organized and labels obvious. 4. Standardize: All areas must be set up exactly the same way. 5. Sustain: Maintain, plan, schedule, train, track and audit all areas periodically.

42 Examples of 5S Set in Order Labels Styrofoam Inserts Clear Visuals Archived Obsolete Files

43 Finally: Map the to be process As-Is To-Be Map the To Be with all combined ideas and create an action item list to start implementing them!

44 4. IMPLEMENT THE SOLUTION AND LET THE PATIENT PULL VALUE THROUGH THE WORK FLOW. Up to this point, everything is still on paper

45 A Kanban can help with Pull Kanban is literally a signal that something needs to be ordered or that the next step in the process is now ready for the entity flowing through I m ready! Pull Step 1 Step 2 Step 3 Step 4 Step 5 No one from an upstream step moves the entity to the next step until the next step is ready for it Only reorder when signaled (the Kanban card is on top)

46 Now, it s all about Change Management Let the fun begin

47 It s now all about Change Management Change is individual not organizational The easy part is done Now, the real hard part begins

48 The Adoption Curve Settlers Will go along with the change once it has been proven safe for them This group is afraid of losing its value Dinosaurs Will never accept the change and will fight any efforts to get them on-board Majority This group, the majority, is watching to see what happens This group is already on board and will pull others to join Pioneers Will embrace and support the change early. Won t understand why it took so long 16% 68% 16% Laggards Get the Pioneers to help you pull up Settlers Early Adopters

49 Kotter s 8-Steps can help with change management Kotter s 8-Steps for Managing Change 1. Create a sense of urgency 2. Form a guiding coalition Those who can help move the project forward Up and down the organizational hierarchy 3. Create a vision of the future 4. Communicate the vision 5. Empower action 6. Create short term wins 7. Don t let up 8. Make change stick

50 5. MAINTAIN THE GAIN AND PURSUE PERFECTION.

51 Compare before and after measures Measure Before VS After and report on improvement Before After

52 Monitor and Close: Pursue Perfection Go back and review the Charter and patient values from the KANO Redefine new and tougher targets Find additional waste to remove using the LEAN Criteria It takes about 90 days for a change to stick Only the Champion can close the project Must insist on evidence that the project was successful and when doing more is not worth the cost to continue Monitoring and measuring the key measures must continue FOREVER

53 IN CONCLUSION

54 Processing Approvals Rework End to end

55 Why LEAN? To Optimize all three bubbles Systems Tools Technology IBM WH EMR PeopleSoft Etc Processes Process Ways of Working Training & Experience People Knowledge, Skills, Abilities

56 If you want more, we have our LEAN Fundamentals Workshop for Healthcare coming up in July For more information Or visit the LEAN Fundamentals Workshop website

57 Q&A

58 THANK YOU! The recording and handouts will be sent to you via within 2 business days