Post on 04-Apr-2020
© Health Quality Council 2007
Process Mapping and Lean Principles to Enhance Care
Keith A. Willoughby, Ph.D.Senior Operations Research Specialist
Health Quality Council
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One-slide bio• Born and raised in Melfort, SK• B. Comm. (U of S)• M.Sc. (UBC)• Transportation analyst (Vancouver Regional Transit
System)• Ph.D. (U of Calgary)• Professor (U of S, 1997-1999; Bucknell University -
Pennsylvania, 1999-2005)• Senior Operations Research Specialist, HQC for
the past 2½ years
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Outline of Presentation • Lean 101… in 38 slides!
– History, principles, tools
• The role of process mapping
• Saskatchewan Lean health care examples
• The contributions of operations research (OR)
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What I hope to accomplish• Acquaint you with the concepts of Lean
• Introduce some of the language
• Answer the questions, “Why Lean? Why now?”
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Pop Quiz• Who started this whole notion of Lean
principles, and when did they do this?
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Answer A?• Institute for Healthcare
Improvement
• 2005: Published the seminal white paper “Going Lean in Health Care”
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How about… Answer B?• Virginia Mason
Medical Center
• Seattle, WA
• Began Lean journey in 2002
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It might be… Answer C?• Jim Womack (1990)
• 5-year, $5 million study of global vehicle production – International Motor Vehicle
Program
• Co-authored “The Machine That Changed the World”with Dan Jones and Dan Roos
• Coined the term “Lean”
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Is it…Answer D?• Taiichi Ohno (1912-1990)
• 1950’s: Toyota Production System
– Continuous Flow Production– Just-in-Time (JIT)– Eliminate defects– Top management commitment– Employee participation
• 1969: Established the Operations Management Consulting Group
– “Trainers” commissioned to promote Lean thinking within Toyota and the firms in its supplier group
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Or, how about… Answer E?• C.R. Dooley
• Helped to develop the “Training Within Industry” program (1940s)
• Infiltrated into Japanese industry by the Allied forces after World War II
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Could it be…Answer F?• Henry Ford, 1920s
• Continuous Flow Assembly
• Reduce wasted time– 1913-1914: doubled
production with no increase in workforce
– 1920-1926: Cycle time from 21 days to 2 days
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But maybe it is…Answer G?• Eli Whitney (1700’s)
• Quick production of high-quality muskets – Standard
interchangeable parts– Minimal product
variation– Ordered and integrated
workflow
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Another choice…Answer H?• The Venetian arsenal
• Republic of Venice, early 16th century
• Could produce nearly one ship each day– Standardized parts – Production-line basis
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What does this show us? • “(Lean ideas) are
not new.”
• John R. Black– Director, Lean
Manufacturing R&D (Boeing, Seattle)
– Virginia-Mason “Sensei”
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The $64,000 question• If these ideas are not new, why all the
buzz today?– 2005: IHI white paper
– June 25-26, 2007: UK hosted First Global Lean Healthcare summit
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Does Lean apply to healthcare?“Toyota” Production System Healthcare
Production processes (thousands, complex) (thousands, complex)
Quality
Safety
Customer satisfaction
Staff satisfaction
Cost effectiveness
Failures may cause fatality
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What is “Lean”? • Providing value with less waste
• Making common sense common practice
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Lean definitions• A set of quality improvement tools and philosophy
designed to eliminate the sources of waste in a system
• “The least wasteful way to provide better, safer healthcare to patients – with no delays”– Going Lean in the NHS (2007)
• Providing exactly what the patient needs, safely, when needed, in precisely the right quantity, and without waste
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The 8 sources of wasteCorrection (defects) Waiting
Overproduction Inventory
Motion Overprocessing
Material movement (transportation)
Underutilized human talent
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What Lean is NOT• Layoffs
• Patients = widgets
• Making people work faster
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Lean principles• 1. What is value from the customer’s
perspective? • 2. Understand your process• 3. Smooth the flow• 4. Shift from “push” to “pull”• 5. Continue to attack waste
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The principle of “Pull”• “Supplier doesn’t
produce until the customer signals a need”
• Is there smooth communication between process steps?
• Represents a fundamental paradigm shift
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Pull systems in practice
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Lean tools: A quick survey• Poka-Yokes
– Eliminates the opportunities for mistakes– Poka: Inadvertent errors– Yokeru: To avoid
• Check John Grout's PokaYoke Page on www.mistakeproofing.com
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Vehicles• Arrow to indicate
location of fuel tanks (driver/ passenger side) – Great for rental
vehicles
• Gas cap tether does not allow the motorist to drive off without the cap
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European streets• Tourists used to
right-hand side driving need some help in London
• Instructions are printed right on the asphalt
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At the airport • If your bag fits in
the size-wise unit it will fit in the overhead compartment
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Here’s one from my old neck of the woods!
• Route 220 in central Pennsylvania
• In theory… helps motorists to drive safely
• Is it followed?
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Poka-Yokes in health care • Error: Putting a tube into
a patient’s stomach which was intended for their lungs.
• Solution: Squeeze the plastic bulb and put it on the tube. If bulb inflates, the tube is in the lungs. If not, an error has occurred.
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Another medical example• The U.S. Consumer
Product Safety Commission has recorded 167 deaths due to wheelchair related accidents from 1997-1999. – Of these, 105 were
wheelchairs rolling away from the person for one reason or another.
(www.saferwheelchairs.com)
• The response? A mistake-proofing device that locks the wheelchair when no one is sitting in it.
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One more medical example• Medical gas outlets are
designed so that the proper valves will only fit in their corresponding outlets
• Note the pins for “Medical Air” at 12 o’clock and 4 o’clock positions
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Visual control systems• Labels, colour-coding to:
– make it easier to find items
– quicker ability to detect abnormal from normal
• Examples:– Surgical shadowboards– Diagonal stripe along
the fronts of binders
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Other visual control systems
• This one may not work so well!
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Exploring 5S• “A visually-oriented system
for organizing the workplace to minimize the waste of time” (IHI, 2005)
• “Clears the clouds”– Eliminates the waste of
motion/ looking for things
• Makes the abnormal visually obvious
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Does this look familiar?
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Some more on 5S• It is NOT simply cleaning
up!
• Following 5S principles helps provide the disciplined habits necessary for further phases of Lean implementation
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More on 5S • Stands for 5 Japanese words each beginning with
the letter “S”
• Translated into English as either:– Sort, Simplify, Sweep, Standardize, Self-Discipline
– Sort, Set, Shine, Standardize, Sustain
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5S in practice: Five Hills Health Region
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More from Five Hills
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Standard processes • Standard processes
represents best practices
• “Standardization is often confused with rigidity…creative, individual expression is stifled.”
• Dr. Jeffrey Liker, University of Michigan
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Standard processes• Standardization captures learning
• “The task of continuous improvement is then to improve upon this standard, and the improvements are then incorporated into the new standard.” (Liker)
• With no standardization, individuals can make great improvements in their own work, but no one learns from them
• Without standards, there can be no improvement” (Taiichi Ohno)
• Standard processes are a quality tool, not a productivity tool
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The role of process mapping• Pictorial representation of a process
• Uses basic flowcharting symbols– Start point– Activity/ task/ step– Decision point – Final output
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Process mapping • Make sure the process maps are:
– Large enough to “envelope” the process
– Small enough to understand
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Process mapping in practice
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Facilitating communication
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Benefits of process mapping• Obtain clearer understanding of how the
process currently operates
• Helps “learn to see” and “develop eyes for waste”– Redundant processing, unnecessary movement
or wait time
• Assist with identifying and planning improvements
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Value stream analysis• The natural extension of process mapping
• Examines every activity in a process map
• Measures the process in terms of time, work in process and so forth – Identifies sources of waste
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Current value stream map (Mayo Clinic)
*** Mayo Clinic article is available on www.lean.org(under Community | Archives | Success stories)
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Current value stream map (Mayo Clinic)
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Future value stream map (Mayo Clinic)
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Detection to Biopsy patient flow example
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Saskatchewan Lean health care examples
• Patient flow between Regina and four south SK health regions– Value stream mapping– Creating standard processes
• Five Hills health region– ER patient flow, Mental Health & Addictions client flow– 5S initiatives in Maintenance, OR, Lab services
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More Saskatchewan examples• Emergency Department patient flow
– Regina: Pull systems with patient streaming– Saskatoon: Visual cues, standard processes
• Breast cancer patient flow– Value stream mapping, standard processes
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The contribution of “OR”• “OR” (operations research) is the application
of analytical models to improve decision-making
• The “Science of Better”
• Can be used to address hospital congestion problems
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Using OR in process redesign • Developed simulation model to determine impact of
layout redesign for Regina patient streaming project
• Model showed potential benefit of using 10 chairs and 2 designated beds
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Simulation model screenshot
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References• Going Lean in Health Care (IHI), 2005
• Womack JP, Jones DT. Lean Thinking, 2003.
• Some valuable websites:– www.lean.org (Lean Enterprise Institute)– www.leanUK.org (Lean Enterprise Academy)
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One final thought• There are no quick fixes
• “Improving the ED is like trying to change your fan belt with the engine running”
• Dr. Les Vertesi, Associate Director of Health Research (Fraser Health Authority)
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My coordinates• Phone: (306) 668-8810, ext. 130
• E-mail: kwilloughby@hqc.sk.ca
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The End• Thank you for your interest
• Questions?