HCM II

Virginia Mason Medical Center CEO (Seattle, WA)

Former President of Virginia Mason Medical Center

Author of book, and former employee of Boeing; now lean consultant.  Connection to Mike Rona to start applying Lean to healthcare.

• -based on Toyota Production System; Post-WWII, pioneered in Japan.
• -Kiichiro Toyoda & Taiichi Ohno.
• -Coined by John Krafcik (1991)

-Strategy focused on eliminating waste while continuously increasing percentage of value-added time.

• -"waste"
• -any activity, service, or supply that consumes time, money, and other resources.
• -Creates NO value.

-continuous incremental improvement.

• 1) Patients deserve better 
• 2) Employees deserve better
• 3) Nation deserves better

• -personal trainer with the mastery of a body of knowledge.
• -specialist in Lean production.

• 1) Just-in-Time production (JIT)
• 2) Jidoka

-consistently delivering only the healthcare service that is needed, in just the required amount, where it is needed, and when it is needed.

• -Intelligent use of both people & technology with the ability/obligation to stop any process at the first sign of an abnormality.
• -Stop the line.

• 1) Flow of pts           5) Flow of info
• 2) Flow of clinicians   6) Flow of equipment
• 3) Flow of meds        7) Flow of process eng.
• 4) Flow of supplies

• -system where parts, supplies, info, and services are pulled by internal and external customers exactly when they are needed.
• -when the pt/customer is ready to receive the next service.

• -Risk for pts
• -Increased costs
• -Decreased satisfaction

• 1) overproduction  2) Waiting (time on hand)
• 3) Transportation  4) Processing  
• 5) Inventory (stock on hand)
• 6) Movement
• 7) Defective Products

• -redundant activities
• -e.g. Park Nicollet Health Svcs (PNHS) - excessive printing reports; VMMC - repetitive questioning --> EMR.

-the specific activities required to provide a specific service to the pt.

• -waiting to see physician, early admissions for afternoon procedures, staff waiting for meetings.
• -e.g. VMMC - 20min wait time, improved; PNHS, decrease lead time from 2hrs to 9min.

-a prescribed repeatable sequence of steps/actions that balances people's work to takt time.

• -production time aligned with  the rate of demand.
• -time it should take to provide a service to one pt based on the overall rate of demand from all pts.

• -inventory that builds up and requires disposal; takes time and energy to remove/move.
• -e.g. PNHS, implement Kanban to supply items that were high cost, low use so as not to over-stock; VMMC, wasted time moving supplies form closet to POU -- only stock in room at POU.

• -a way of automatically signaling when new parts, supplies, or services are needed.
• -"sign," sign board, billboard, doorplate, poster, or card.

• -aka Kaizen event.
• -team of people who do the work, fully engaged in a rigorous and disciplined 5-day process, using the tools of Lean to achieve immediate results in the elimination of waste.

• -lg. part of budget of for wages (70%), thus time is valuable -- optimize use of employees' time.
• -mostly staff trying to find equipment, info or attending meetings farther from dept.
• -e.g. PNHS - Rad techs moving equipment; VMMC - decreased walk time for RNs and PCTs.

-time spent walking from one location to another.

work area (VMMC example)

• -errors in charting/documentation; VMMC implement PSAs (patient safety alerts).
• -e.g. PNHS - created pt. tracking system, for pre-op pts; andon utilization.

• -a visual control device, usually a light, that alerts supervisors to factory floor needs or problems.
• -green, yellow, red light system for example.

• -movement of supplies, files, equipment
• -e.g. PNHS - vans transferring mail, files, and films; upgraded EMR. VMMC - decreased automated shipment of files not needed (neurology clinic).

• -unnecessary tests, repeatedly logging the same data.
• -e.g. VMMC - eliminate MRIs for non-surgical back pain pts.  PNHS - eating d/o institute, meet with psych before entering EDI for further eval.

-a generic and graphic representation of the Toyota Production System (Lean).

• -Foundation = goal of lean (eliminate muda).
• -Floor = leveled production (heijunka).
• -Columns supporting roof = JIT production & Jidoka.
• -Columns within house = Left (people, materials, & machines), Middle (standard work, kanban, & andon), Right (takt time, one-piece flow, & pull production).

• LEFT = Necessary resources
• MIDDLE = Lean Methods
• RIGHT = Outputs

-scheduling products and services in such a way as to eliminate bottlenecks and maximize throughput.

-where any staff member can stop any process or procedure if that staff member believes proceeding would adversely affect pt safety or negatively impact efficient operations.

• 1) Takt-time-paced Production.
• 2) One-piece Flow
• 3) Pull Production

• -providing services/products at the overall rate of demand from the pts. 
• -e.g. total hrs/mins in a work day for a # of pts.

• -all equipment, other supplies, and information are physically grouped together to enable one person to perform all the steps necessary to complete a process or action.
• -opposite of batching work.

-system where parts, supplies, info, and services are pulled by internal and external customers exactly when they are needed.-when the pt/customer is ready to receive the next service.

• 1) people
• 2) materials
• 3) machines

• Method: standard work; prescribed, repeatable sequence of steps/actions.
• Principal output: take-time production.

• Method: standard work-in-process (SWIP) and kanban.
• Principal output: work with takt-time management to enable one-piece flow.

• Method: operational availability/andon.
• Principal output: pull production.

-the availability of healthcare equipment when needed.

-the amount of work-in-process inventory on the floor to provide pt care for the day.

• -a document identifying the steps necessary to complete a task, who should perform each step, and the reasonable (repeatable) amount of time to complete each step.
• -e.g. PNHS & blood pressure work sheet.

Made up of standard work, takt time, and standard work-in-process.

• 1) Sort - the unnecessary
• 2) Simplify - organize
• 3) Sweep - identify unsafe conditions
• 4) Standardize - define and communicate
• 5) Self-discipline - hold everyone to same standard

-a pictorial representation of the steps in a value system, either as a current or future (desired) state.

• 1) get rid of competing strategies
• 2) Find outside Sensei
• 3) No shorter than 5 yr contract
• 4) Develop a sense of urgency

• 1) Identify your business & its scope.
• 2) Est. a Kaizen Promotion Office & Kaizen Operations Team.
• 3) Begin with a model line an inch wide and a mile deep.
• 4) Implement your waste-elimination strategy via workplace Kaizen events & Kaikaku.
• 5) Map value streams/disrupt organization.
• 6) Focus on cutting lead time/cycle time.
• 7) Reorganize by service lines & value streams, flatten the organization.
• 8) Develop internal leaders.
• 9) Deal with excess people at outset.
• 10) Implement world-class management system.
• 11) Link pay to value creation and elimination of defects.

• -combination of Lean and budgeting ideas from Jeremy Hope & Robin Fraser.
• -based on key performance indicators.
• -e.g. PNHS - cost per unit of svc, and units of svc per full-time equivalent.

• -develop lean action plan.
• -work with managers & CEO on day-to-day basis.
• -edu/development of Lean leaders.
• -2-5% of work force.

• -for each major svc. line.
• -PHNS, each ran by Lean leader having completed 18mo. training in lean/kaizen.

- production preparation process.

- a new facility or process.

- an established facility or process.

- The amount of time it takes to complete a task or process.

• 1) Daily management, management by policy (MBP), determine improvement priorities.
• 2) MBP - opposite of management by objective.  How goals are determined, plans made to achieve goals, and ensure progress.  
• 3) Cross functional management - major management system for implementing breakthrough improvements across organizational lines.

• -a catch-ball process.  Meaning where goals are proposed and discussed by people all the way down and up the chain of command.
• -aka hoshin kanri

• QCDSM
• -quality, cost, delivery, safety and morale.

-where the work gets done, e.g. the factory floor or hospital floor.