Jennifer Wortham, Dr. PH

President, Society of Healthcare Improvement Professionals

1

Introduction to the Lean

Management System

Lean and the Toyota Production System

▫ “Lean” is a management philosophy derived mostly from the Toyota Production System (TPS). It is renowned for its focus on reduction of the original Toyota seven wastes to improve overall customer value.

▫ The Toyota Production System is a comprehensive management system that focuses on continuous improvement and innovation. Key elements include:

Management System that focuses management on achieving strategy by aligning strategic goals with management objectives.

Active Daily Management (focuses on the execution of strategy).

Focused improvements – large cross-functional teams focused on improving a specific process.

Incremental improvements – everyone is doing improvements everyday.

2

Why Lean

• Lean is a proven method that enables

organizations to improve service and quality,

reduce waste and free up resources.

• It accomplishes this through engaging

employees in continuous process improvement,

and sustaining gains through a systematic,

standardized approach to “process”

management.

Waste Categories & Healthcare Examples

4

Excess Motion Searching for materials, people, information; gathering supplies from multiple carts/closets, walking between workstation.

Waiting Waiting for others to complete tasks before work can begin on the next task; waiting for tests results; physician waiting for access to OR (between cases).

Overprocessing Using more supplies then required to perform the job; gathering more information then required; over utilization in clinical practice (tests, medications).

Inventory Overstocked meds or supplies; supplies not available when/where needed; expired supplies.

Unused creativity Variation in practices, confusion/lack of clarity,

Idle staff, staff not performing at their level of capability

Overproduction Auto-copies of reports; multiple forms w/ same information, left-over food at meetings

Rework Unclear orders; correcting mistakes/errors; redoing work; medication errors; incorrect billing

Transportation Moving patients, supplies, equipment from one location to another.

Causes of Waste

• No method to prevent/catch errors

• Ineffective design/layout of

facilities

• Fragmented, poorly designed

processes

• Equipment failures

• Unorganized workspace

• No standards, non-compliance

with standards

• Poor communication

• No visibility to performance

• Lack of integrated systems & poor

system functionality

• Unbalanced workloads

• Lack of flexible workforce

• Inadequate training (no training)

• Batch systems

• Push vs. Pull

• Overburden or unreasonable

demand

• Redundancy in process

• Lack of information

• Poor layout

• Just in case

• Regulatory constraints

5

Improvement Opportunities & Countermeasures

6

Eliminate excess motion, confusion and searching?

Reduce over-processing, & eliminate redundant and unnecessary steps?

Reduce / remove physical barriers to flow?

Ensure you have the supplies you need, when/where they are needed?

Perform more consistently?

Eliminate downtime due to equipment failures?

Eliminate mistakes?

The 5S System

Process Smoothing/Flow Design

Equipment, Office/Cube Layout

Kanban System

Standard Work

Overall Equipment Effectiveness

Visual Workplace/Error Proofing

Match resources to demand? Load Leveling

Reduce Wait-

times

Improve

Throughput

Improve

Quality

Enhance

Service

Making Improvements

• Lean improvements are managed through small tests of change using a Plan-Do-See-Act cycle.

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Do

See Act

Plan

1. What’s the problem, how

you know it’s a problem,

what causes it, what action

will address the cause?

2. Perform/test the action

that you think addresses the

causes

3. What was the result of the

test? Was an improvement

made?

4. If improvement made,

make the tested action the

standard. If not, what was

learned, what else needs to

be tried?

Lean Pathway for Large Improvement Projects

8

Identify The Value Stream Process Mapping

Gap Analysis

Elimination of Waste Set Up Reduction, 5 – S, Takt

Improve Value Stream Flow Kaikaku , Visual Management

Improve Stream Quality TQM, Poka Yoke

Pull System Kanban,. JIT, P.O.U.

Continuous Improvement

Tra

inin

g &

Aw

are

ne

ss

Define the Problem

Analyze the Root Cause

Improve the Environment

Implement Error

Proofing

Control &

Standardize

Tra

inin

g &

Aw

are

ne

ss

Measure the Problem & Make it Visible

Improve the Process

Em

plo

yee E

ng

ag

em

en

t,

Tra

inin

g a

nd

Aw

are

ness

Eliminate Unnecessary Steps

5 S, Cell Design, Point of Service

Issue Analysis/Five Why’s

GEMBA / Data Collection/ Process Mapping

Problem and Issue Identification

Active Daily Management System (ADM) Strategic Goals / Focus Area

Sustain through ADM

Lean Six

Sigma

Process

Improvement

Methodology

Lean

Management

Practice

Continuous Flow

Work-loads

are balanced Redundant

work is eliminated

Just in Time

Right Service Right Time

Right Amount

Right Place

True North

Patient Focused

Built-in-Quality

Errors are prevented

We never pass along defects

The Lean Health Care Model

Lean Management System

Workplace Organization – 5S

Culture: Respectful - Responsive - Responsible

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Measure What

Matters

Focused

goals, data driven

decisions and regular

review of performance

Make It Visual

Display /

review performance

metrics

Standardize Work

Identify and spread best

practices

Continuous Improvement

Engage the front-line through huddles, posting

performance to standards & rounding

Lean Management

System

Sy

ste

ma

tic

Ma

na

ge

me

nt

Ac

tive

Da

ily M

an

ag

em

en

t

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Advantages of the

Lean Management System

• Establish clear quarterly goals for improvement, and

align unit-level work group activities with our supporting

commitment goals and priorities.

• Better communication of goals and expectations

• Help us achieve greater transparency

• Involving employees will promote teamwork

• Helps identify and solve problems instead of working

around them

• Provides a mechanism to measure on-going progress

How Lean Works

• Aligns and integrates work (add value, decrease activity)

• Articulates consistent expectations for the organizations

leaders

• Improves organizational results

• Builds stronger leaders

• Engages everyone in problem solving

• Greater transparency and faster response

• Removes waste and adds value for the customer

Objective Management Plan

Each department should have an objective management plan in place for their each of their areas of responsibility. The purpose of the objective management plan is to: • Provide an overview of the departments longer-term goals • Provide a summary of the departments current (monthly,

and YTD) goals and performance against those goals • Include plans to achieve the goals, including the specific

tasks and associated deliverables • Include analytics and drivers behind each gap in

performance • List issues and possible goals for the following quarter • Identify required resources, if any, to achieve goals • Include anticipated impediments and plans to remove

them

Monthly Management Operating Review & Objective Reporting Tool

Management performance reviews

should be conducted on a regular

basis:

• Directors meet with VP to

establish focus goals and report

on progress towards objectives

every month

• Directors meet with managers to

review progress with active daily

management objectives every

week

Director: VP:

Goal Actual Trend

Due % Com Status

Month / Year

Measure / Description Notes / Action Plan

Service Recovery

Visual Boards

Process flows / metrics

Objective

Act

ive

Dai

ly

Man

age

me

nt Daily Huddles (All shifts)

Peer Rounds

Purposeful Rounding

Evaluations Completed Timely

Employee Recognition

Turn-around times

Effi

cie

ncy

&

Re

sou

rce

Ste

war

dsh

ip

He

alin

g

Envi

ron

me

nt

Co

urt

esy

&

Car

ing

Par

tne

rsh

ipC

linic

al

Exce

llen

ce

HCAHPS

Budget

Department:

A3

's in

Pro

gre

ss

Core Measures

Next Steps

Ke

y In

itia

tive

s

Introducing Leader Standard Work

• Leader Standard Work is a critical

step in ensuring that our Lean

Culture prospers. But, Leader

Standard Work is dependent on a

few things. In what follows, I’ll

cover a few of those items and

provide an example of Leader

Standard Work.

Why Implement Leader Standard Work

• Leader standard work is a set of practices and key activities that bring

greater focus to process performance, helps identify opportunities for

improvement, and enables us to sustain improvement gains.

• Leader Standard work requires a change from traditional management

thinking.

▫ In a conventional world, experienced managers and supervisors

have learned how to patch up and work around problems, to get the

job done.

▫ In the Lean way of thinking, we identify problems, and then ask,

‘Why?’ The focus is on improvement, looking for clues, to

understand and improve.

▫ Visual charts reflect how processes are performing. Keeping these

charts current “leads to identifying problems as they occur, like

preserving evidence at the scene of the crime, where the process

stumbled or was out of “standard”.

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Key Lean Management System Tools

• Systematic Management

▫ People and strategy alignment

Focus on the “True North Goals”

▫ Objective reporting (dashboards/metrics)

▫ Leader standard work

• “Active Daily Management” for continuous process

improvement

GEMBA (Go see) “Rounding” and coaching in the

moment

Standard work reinforced through a visual workplace

Team Huddles focused on continuous improvement –

PDSA/Lean projects – with visibility to performance

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Rounding

• Rounding

• Provides the manager an

opportunity to see work as it is

performed

• Observe critical to quality

metrics

• Observe and coach

standard work

• Round with a checklist and

tracking tool

• Post results on the huddle

board

1

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M T W Th F M T W Th F M T W Th F M T W Th F

All Staff 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am 6am

Team Leader

MD of the Day

AN II

Liza Caabay9am 7am 9am 7am 9am 7am 9am 7am

Operations Manager

Erick Ascencio11am 7am 11am 7am 11am 7am 11am 7am

Manager, Non-Invasive

Robert Yang7am 7am 7am

Manager

Lisa Gorski7am

Director

Johanna Bruner7am 7am 7am 7am 7am 7am 7am 7am 7am 7am 7am 7am

Director of Operations

Dr. Mahajan7am 7am 7am 7am

Executive Director

Shannon O'Kelley7am 7am

Medical Directors

Dr. Shivkumar and Dr. Tobis 7am

Pediatric Team

Drs. Alejos, Patel, Aboulhosn,

Levi, Schwarzenberger

7am

Key

AM Huddle

AM Coordination Rounds

CICARE Rounds

Management Rounds

*Quarterly Rounds

RRUMC Cardiovascular Linked Check-ins

Week 1 Week 2 Week 3 Week 4

Month

Visual Management

Visual Management

• Visual Queues – signs, visible standards, and posted instructions.

• Performance board and huddle boards in each unit.

• Performance Board: departmental-level metrics, goals, and tactics

• Huddle (two-way Communication) board: includes measures that are relevant to staff, updated daily with daily stats and trended where indicated. Staff can write on the board or use sticky notes to share their ideas for improvement. Display feedback from patients (i.e., staff recognition, and/or complaints, etc.).

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Service

Financial

Quality

Growth

People

Key

Drivers of Performance

A3’s In Progress &

Completed

Audit of Compliance with

Standard Work

History

Performance Over Time

x x x x

Example:

Daily data

Department/Division Performance Board

Example Departmental Visual Wall

• Department and unit-level goals and performance metrics (include

process/task level metrics)

• Updated daily with daily stats and trended where indicated.

• Improvement opportunities / A3’s

• Displays feedback from patients (i.e., staff recognition, and/or

complaints, etc.).

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Daily Stat On Cycle Time % for Stats

Staff-level Measure

A3’s Improvement Projects

Audit of Compliance with Standard Work

Building a Department /

Division Performance Board Goal & History of

Departments Performance Over Time

Key Drivers of Performance

A3’s Improvements /

Standard Work

Audit of Compliance with

Standard Work

Example

Department/Units History of

Performance Over Time

Key

Drivers of Performance

Tests and

treatments

are

thoroughly

explained

Plan of Care

Not Explained

in Clear

Terms

Standard

Process for

Communicating

Plan of Care

Observation of

Staff

Communicating

Plan of Care

Customer Service

This is the metric you should include in the Staff Huddle Board

Unit Level Huddle / Communication Board

Summary

Your Performance Board should:

• Communicate about the things that matter to your department.

• Create transparency – staff need to understand how they are performing

• Instill and reinforce standard work

• Communicate improvements being made – so everyone can support the change effort

The Daily Huddle

Team Communication - Daily Huddles

• Daily Huddles provide an excellent

means for two-way communication

with staff

• Daily huddle message

• Review critical to quality metrics

• Review trended dashboard metrics

• Engage staff in the process of

improvement

• Provide valuable and timely coaching

• Read patient comments and customer

feedback

• Update staff on process or method

changes

Running the Huddle

1. Manager, supervisors, leads and staff gather at the huddle board.

2. Conduct shift updates (staffing situation, special requests/events, patient hand-off’s, etc.)

3. Start by reviewing improvement work in progress. 4. Briefly review your A3’s. If the status indicator is

green move on, if red take a moment to discuss. 5. Prioritize opportunities to determine improvements

that will be implemented and those that will be tabled.

6. Assign resources to new improvement actions. 7. Take a moment to acknowledge a staff person for job

well done.

Examples

• http://www.youtube.com/watch?v=uaQ8GGXCxjM

• Everett Clinic

• http://www.youtube.com/watch?v=dJrORZEiXpo

• Intermountain

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Develop Your Huddle Strategy

Question Your Strategy

Where should the huddle board be located in your department?

How often should you have huddles (list time of day / day of week, etc.)?

Who should participate in the huddle?

Who will lead the huddle?

What are the key objectives of your huddle?

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Questions