Using Lean in QualityImprovement

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01/23/200801/23/2008 11

Using Lean Principles for Using Lean Principles for

Clinical QualityClinical QualityImprovementImprovement

Nancy West, MPH, RN, CPHQNancy West, MPH, RN, CPHQ

Clinical ConsultantClinical ConsultantQualis HealthQualis Health



01/23/200801/23/2008 22

WhatWhat is Lean?is Lean?

A "set of concepts, principles and toolsA "set of concepts, principles and toolsused to create and deliver the mostused to create and deliver the most

ValueValue from thefrom the CustomersCustomers’’ perspective perspective while consuming thewhile consuming thefewest resources.fewest resources.””

Lean Enterprise Institute Available at: http:www.lean.org



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Lean PrinciplesLean Principles

1.1. Listen to the voice of the customer.Listen to the voice of the customer.

2.2. Map the processes.Map the processes.

3.3. Identify the waste.Identify the waste.

4.4. Create a pull system.Create a pull system.5.5. Produce and use Standard work.Produce and use Standard work.



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What is Value? Who is the Customer?What is Value? Who is the Customer?

Value is inherent worth, determined by customerValue is inherent worth, determined by customer

desire/ willing to pay fordesire/ willing to pay forUltimate Customer = The patientUltimate Customer = The patient



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Why Lean in Healthcare?Why Lean in Healthcare?

Allegheny General Hospital in Pittsburgh: 90%Allegheny General Hospital in Pittsburgh: 90% ↓↓in the # of infections, which saved aboutin the # of infections, which saved about$500,000/yr in intensive$500,000/yr in intensive--carecare--unit costsunit costs11

Virginia Mason in Seattle: Created one standardVirginia Mason in Seattle: Created one standardinstrument tray for 12 MDs performinginstrument tray for 12 MDs performinglaparoscopic gallbladder surgery, which reducedlaparoscopic gallbladder surgery, which reducedthe cost of procedure by $950the cost of procedure by $95022

ThedaCareThedaCare in Wisconsin: saved $154,00 in thein Wisconsin: saved $154,00 in theCatheterization lab supply procurementCatheterization lab supply procurementprocessesprocesses33

1. Wysocki, B. To fix Health Care, Hospitals Take Tips From Factory Floor. The Wall Street Journal. April 9, 2004.

2. Connolly C. Toyota Assembly Line Inspires Improvements at Hospital. Washington Post. June 3, 2005.

3. GoingLean in Health Care. Inistitute for Healthcare Improvement. 2005



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Key Lean ConceptKey Lean Concept

The elimination of wasteful processesThe elimination of wasteful processesand waste within processes.and waste within processes.



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Types of WasteTypes of Waste

OverproductionOverproductionWaitingWaiting

UnnecessaryUnnecessaryTransportTransport

Overprocessing

Excess InventoryDefects

Under-utilizedpeople

Overprocessing

Liker JK. The Toyota Way: 14 Management Principles From The World's Greatest Manufacturer. McGraw-Hill; 2004:28-29.



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ConsequencesConsequences of Wasteof Waste Underutilized employeesUnderutilized employees

Wait times for patients and employeesWait times for patients and employees

Inefficient transfer of informationInefficient transfer of information

Ineffective response to errorsIneffective response to errors

Missing or incomplete informationMissing or incomplete information

Missed or untimely appointmentsMissed or untimely appointments



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Some Washington Healthcare OrganizationsSome Washington Healthcare Organizationsapplying Leanapplying Lean

Harborview Medical CenterHarborview Medical Center

Garfield County HospitalGarfield County Hospital Overlake HospitalOverlake Hospital

Swedish Medical CenterSwedish Medical Center University of Washington Medical CenterUniversity of Washington Medical Center

Virginia MasonVirginia Mason



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Local Hospital ExampleLocal Hospital Example

BeforeBefore

2525

44

70 min.70 min.

9%9% --

17%17%

1111

132132

1010

44

HighHighHighHigh

StepsSteps

ValueValue--AddedAddedStepsSteps

Total TimeTotal Time

% Value% Value--AddedAddedTimeTime

QueuesQueues

Orders in ProcessOrders in Process

HandoffsHandoffs

Inspection StepsInspection Steps

Variation inVariation in

MethodsMethods

After

9

4

20 min.

32 - 42%

3

39

52

Low

Low

01/23/2008©2002 Corporate Strategies and Development, LLC

©2002 Joan Wellman and Associates, Inc.



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Eliminating WasteEliminating Waste

WaitingWaiting

Solution:Solution:

Process mapping and reProcess mapping and re--engineeringengineering

Simplify and standardize processesSimplify and standardize processes

Identify and eliminate workIdentify and eliminate work aroundsarounds, loop, loop--backsbacks

↓ Total StepsTotal Steps

Rearrange StepsRearrange Steps

Combine StepsCombine Steps

↓ Total HandoffsTotal Handoffs

↓ Total ChecksTotal Checks

↓↓ Total ForksTotal Forks



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ErrorsErrors

Solution:Solution:

PokaPoka--yoke; erroryoke; error--proofingproofing Focus on prevention, not detectionFocus on prevention, not detection

Ensure quality at the sourceEnsure quality at the sourceConsider human factors scienceConsider human factors science

Use forcing functionsUse forcing functions

Eliminate the root cause of error (theEliminate the root cause of error (the5 whys)5 whys)



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ErrorsErrors

If you ask why five times, you willIf you ask why five times, you will

get to the root of a problemget to the root of a problem” ” Five is not really a magic number,Five is not really a magic number,

but itbut it’ ’ s a good rule of thumbs a good rule of thumb



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What is a Process?What is a Process?

•• A series of stepsA series of steps•• Carried out in sequenceCarried out in sequence

•• Creates valueCreates value•• Provides ServiceProvides Service

•• Makes ProductMakes Product



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ExcessExcess InventoryInventory

One hospital prepared a dayOne hospital prepared a day’ ’ s worth of s worth of

case carts the day before surgery.case carts the day before surgery.The new process is aThe new process is a “ “pullpull” ” system;system;

carts are called for and assembledcarts are called for and assembled

just in time for the next surgery. just in time for the next surgery.

Assembly lead timeAssembly lead time ↓↓ from 20 hoursfrom 20 hours

to 10 minutes and problems withto 10 minutes and problems withsurgery schedule changes (andsurgery schedule changes (and

storage) are eliminated.storage) are eliminated.



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Process Mapping BenefitsProcess Mapping Benefits

•• Clear pictorial definition of currentClear pictorial definition of currentwork processwork process

Common understanding of workCommon understanding of workFocus on the process not the peopleFocus on the process not the people

Rapidly illuminates improvementRapidly illuminates improvementopportunitiesopportunities–– Clarifies unnecessary workClarifies unnecessary work

–– Ah Ha!Ah Ha!



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Benefits of Future StateBenefits of Future State

Future State MapsFuture State MapsProvide visual modelProvide visual model

–– Help maintain improvementHelp maintain improvement–– Support standard operating procedures (SOP)Support standard operating procedures (SOP)

Increased efficiencyIncreased efficiency

Enhanced effectivenessEnhanced effectiveness

Saves resources, time, and moneySaves resources, time, and money



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Four CommonFour CommonTypes of MapsTypes of Maps

Simple Process Map (also known as flowSimple Process Map (also known as flowchart)chart)

Complex Process Map (Swim Lanes)Complex Process Map (Swim Lanes)Value Stream MapValue Stream Map

Spaghetti/Layout DiagramSpaghetti/Layout Diagram



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Process ExamplesProcess Examples

Patient admissionPatient admissionand checkand check--inin

Patient transfer toPatient transfer toroomroom

Tests performedTests performed



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Simple Process MapSimple Process Map



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Complex Process MapComplex Process Map



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Value Stream MapValue Stream Map



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Spaghetti/Layout DiagramSpaghetti/Layout Diagram

MA

Patient

Provider

Legend



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Patient

arrives in

ER

Triage RN

sees patientChest pain

?

NO

Called

to

exam room

YES

Symbols Tell the Story…

Back towaiting room



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Steps to Creating a Process MapSteps to Creating a Process Map

1.1. Define the processDefine the process

2.2. Assemble the Right TeamAssemble the Right Team3.3. Walk the ProcessWalk the Process

4.4. Discuss and map the current processDiscuss and map the current process5.5. Validate with Colleagues/peersValidate with Colleagues/peers



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Pearls of WisdomPearls of Wisdom Include all staff who touch the processInclude all staff who touch the process

Map is complete when all members agree thatMap is complete when all members agree thatit captures:it captures:

––all stepsall steps––in current sequence,in current sequence,

––beginning to end!beginning to end!

Maintain mapping energyMaintain mapping energy

Celebrate successesCelebrate successes



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Key Elements for SustainabilityKey Elements for Sustainability

Establish and document standard processesCreate graphics to communicate and shareprogressContinue data collection/measurementAssign ownership and transfer ownership

with turnover



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AcknowledgmentsAcknowledgmentsQualis Health would like to thank the Lean Expert Panel, a groupQualis Health would like to thank the Lean Expert Panel, a group ofofsix QIO representatives who have been studying and applying leansix QIO representatives who have been studying and applying lean

principles. The members of this panel included the following:principles. The members of this panel included the following:

Patricia Baker, RN, MS,CPHQ Patricia Baker, RN, MS,CPHQ Jane Brock, MD, MSPHJane Brock, MD, MSPH

Donna Daniel, PhDDonna Daniel, PhDScott Endsley, MD, MScScott Endsley, MD, MSc

Naomi Maxey, MPHNaomi Maxey, MPHSarah PavelkaSarah PavelkaPatrick ToomeyPatrick ToomeyKevin Warren

MPROMPROColorado Foundation for MedicalColorado Foundation for MedicalCareCareQualis HealthQualis HealthHealth Services Advisory GroupHealth Services Advisory Group

Qualis HealthQualis HealthIowa Foundation for Medical CareIowa Foundation for Medical CareVirginia Health Quality CenterVirginia Health Quality CenterTMF Health Quality InstituteTMF Health Quality InstituteKevin Warren



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Nancy WestNancy WestClinical ConsultantClinical Consultant

Qualis HealthQualis Health

206 364206 364--9700 ext 20079700 ext 2007

[email protected]@qualishealth.org

Using Lean in QualityImprovement

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