Post on 25-Dec-2015
World-Class Performance
Lean in Healthcare Operations
“A Lean Guy Goes to the Hospital”Presented Aug 4, 2006
Mark Graban, LFM ‘99Senior Consultant, ValuMetrix® ServicesOrtho-Clinical Diagnostics, Inc.
Business Confidential, © Ortho-Clinical Diagnostics 2006
Agenda
• The Crisis of Waste in Healthcare
• Lean Thinking Principles in Healthcare
• Benefits for:– Patients
– Employees
– Hospitals
Business Confidential, © Ortho-Clinical Diagnostics 2006
Mark’s Spaghetti Chart
Business Confidential, © Ortho-Clinical Diagnostics 2006
Who Do I Work For?
• ValuMetrix Services (Ortho-Clinical Diagnostics)– Started in 2001 running Lean and Six Sigma pilots in labs
– Launched as a fee-for-service consulting business in 2003• Not “internal consultants”
– 100% dedicated to healthcare projects• Hospitals, Laboratory Companies
• U.S., Canada, Europe, China
– Application of the J&J “Process Excellence” Model
– Project-based approach, lean coaching, “train the trainer”• Goal is to help build a lean enterprise, not to do “kaizen events”
Business Confidential, © Ortho-Clinical Diagnostics 2006
In the News Almost Daily…
Business Confidential, © Ortho-Clinical Diagnostics 2006
Hospitals Are Dangerous…
CDC 1998:
90,000 killed and 2,000,000
injured from hospital-caused
drug errors & infections
Business Confidential, © Ortho-Clinical Diagnostics 2006
Preventable Errors Abound…
“… 3 to 5% of specimens taken
each year are defective… blood that isn’t drawn
correctly… mix-up with another
patient’s sample”
Business Confidential, © Ortho-Clinical Diagnostics 2006
Preventable Errors Abound…
Business Confidential, © Ortho-Clinical Diagnostics 2006
Preventable Errors Abound…
Business Confidential, © Ortho-Clinical Diagnostics 2006
Mass Production or Healthcare?
• Large batches
• Sub-optimizing one resource
• Lack of employee input
• One-person / One-machine
• Quality through inspection
• Automation is the answer
• Lack of standard processes
• Not communicating metrics
• Lack of leadership
• Constant fire fighting
Business Confidential, © Ortho-Clinical Diagnostics 2006
Non-Lean, Current Thinking
1. Specify value in the eyes of the provider (or the payer)
2. Identify your department and sub-optimize it
3. Make patients wait for the convenience of the system
4. Ignore some employees and devalue others
5. Continuously fight the same fires in the pursuit of surviving the day
Business Confidential, © Ortho-Clinical Diagnostics 2006
Applications of Lean in Healthcare
• Laboratories– Reducing Turn Around Times and Errors
• Emergency Departments– Reducing diversions, improving flow
• Outpatient Cancer Treatment– Reducing patient delays, increasing capacity
• Operating Rooms– Reducing changeover times, increasing utilization
• Pharmacies– Reducing errors, improving response
• Food Service– Reducing wasted food, improving quality
Business Confidential, © Ortho-Clinical Diagnostics 2006
Why LEAN Works in Healthcare
• LEAN is not a list of tools that applies only to factories
• LEAN is a philosophy of management that applies to any system
• LEAN rallies people around goals we can all agree on:– Patients and Employees
Business Confidential, © Ortho-Clinical Diagnostics 2006
Not About Cutting Heads
• Shortages of skilled employees– 51% of hospital med techs greater than 45 years of age,
vacancy rate at 11%
– Shortfall of 265,000 nurses expected by 2010
• Do more…
– With the same
– Eventually, with less
Business Confidential, © Ortho-Clinical Diagnostics 2006
Not Only About Cutting Costs
• Hospitals are using lean as a Business Strategy– Improving quality
– Improving service
– Improving employee satisfaction
– Growth strategies
– “Un-outsourcing” testing work
Business Confidential, © Ortho-Clinical Diagnostics 2006
Source: LEAN Thinking, Womack and Jones 1996
Principles of LEAN Thinking
1. Specify value in the eyes of the customer.
– The customer must be willing to pay for the activity
– The activity must change the form, fit or function of the product
– The activity must be done right the first time
– Who are the “customers?”
Business Confidential, © Ortho-Clinical Diagnostics 2006
Principles of LEAN Thinking
1. Specify value in the eyes of the customer.
2. Identify the value stream and eliminate waste.
13% of hospital costs are due to controllable waste.Source: Zuckerman, Hadley, and Iezzoni, 1994
Business Confidential, © Ortho-Clinical Diagnostics 2006
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Typical Organization is Silo-ed
Business Confidential, © Ortho-Clinical Diagnostics 2006
Value Stream – Anatomic Pathology
Pathologist
SpecimenCollection
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Business Confidential, © Ortho-Clinical Diagnostics 2006
Was this an “ER Problem?”
• “…empty beds are available in the hospital, but there aren’t enough nurses to staff them.”
• This is a Value Stream problem!
Business Confidential, © Ortho-Clinical Diagnostics 2006
Types of Waste – Lab Examples
• Defects
• Overproduction
• Transportation
• Waiting Time
• Inventory
• Motion
• Processing
• Human Potential
• Label on the wrong tube
• Drawing all blood at 4 AM
• Long walks, multiple handoffs
• Tube waiting on centrifuge to fill
• 50 weeks of supply
• Tech walking 80 ft to the printer
• Time/Date stamps added, not used
• Administration not listening to Med Techs or RN’s ideas for improvement
Business Confidential, © Ortho-Clinical Diagnostics 2006
Are We Tolerating Waste?
• Healthcare = Workarounds– Professor Steven Spear
• “Decoding the DNA of the Toyota Production System” (HBR)
• “Fixing Healthcare Today From the Inside” (HBR)
• Case Example: – 10-20% of MD orders are missing EVERY DAY
• Call and get the order – done?
• Tomorrow, we’ll do the same
• Problems need to be seen as opportunities
Business Confidential, © Ortho-Clinical Diagnostics 2006
Laboratory Layouts Drive Waste
Layout is driven bydepartments
Benches interfere withstraight-line walking, encourage batches
Business Confidential, © Ortho-Clinical Diagnostics 2006
Clinical Laboratory Product Flow
Business Confidential, © Ortho-Clinical Diagnostics 2006
Clinical Laboratory Timeline
Total CT = 5.44 hours
Business Confidential, © Ortho-Clinical Diagnostics 2006
Med Tech Walk Pattern
Pharmacist Walk Pattern
Layouts Drive Waste of Motion
Cancer RN Walk Pattern
Miles per Day!
Business Confidential, © Ortho-Clinical Diagnostics 2006
Typical 5S Baseline
Unorganized Workbenches Product Flow not Obvious Time wasted looking for things Hoarding of supplies
Poor Utilization of Space General Clutter Supply Shortages and
“Hidden” Inventories
Business Confidential, © Ortho-Clinical Diagnostics 2006
5S Improvement Examples
Business Confidential, © Ortho-Clinical Diagnostics 2006
Principles of LEAN Thinking
1. Specify value in the eyes of the customer.
2. Identify the value stream and eliminate waste.
3. Make value flow at the pull of the customer.
Business Confidential, © Ortho-Clinical Diagnostics 2006
• Mass Production Thinking Utilization– Keep expensive assets heavily utilized
• Machines Doctors
– The tradeoff is waiting time• Cars Patients
• Lean Thinking Flow– Focus on reducing Patient Waiting time
Reducing Patient Wait Times
Business Confidential, © Ortho-Clinical Diagnostics 2006
B
A
PATIENT
ARRIVAL TO TREATMENT
(HOURS)
LATENESS FOR TREATMENT
(HOURS)A 2.5 0.42B 3.5 1.08
AVG 3.0 0.75
• Blood drawn• MD consult• Needle into Port
• Check In / Check Out• Moving from room to room
• Waiting for Check In• Waiting for MD• Waiting for Treatment
Value Added
NVA But Required
NVA, “Pure Waste”
Outpatient Oncology Patient “Flow”
Business Confidential, © Ortho-Clinical Diagnostics 2006
Re-Work Loops Cause Delays
Business Confidential, © Ortho-Clinical Diagnostics 2006
Batching Prevents Flow
Business Confidential, © Ortho-Clinical Diagnostics 2006
Batching Hurts Quality
• Lack of “standard work” and opportunity for “error proofing” – Anatomic Pathology
Batch of slides made, 3 patients, risk of mixup? 2nd histotech labels one
slide at a time
Business Confidential, © Ortho-Clinical Diagnostics 2006
Batching Hurts Quality
• Lack of “standard work” and opportunity for “error proofing” – Pharmacy
Business Confidential, © Ortho-Clinical Diagnostics 2006
Flow and Heijunka
• You can’t have flow without some amount of “leveling” in the system
• “Leveled Production:– You won’t be Happy without it”
» From Toyota publication
Business Confidential, © Ortho-Clinical Diagnostics 2006
39% of Samples Arrive in Just 3 Hours of the DayTAT expectations are constant
Typical Hospital Lab Not Level
Business Confidential, © Ortho-Clinical Diagnostics 2006
Shift ShiftShift
Leveling Reduces Peak Costs
Business Confidential, © Ortho-Clinical Diagnostics 2006
Principles of LEAN Thinking
1. Specify value in the eyes of the customer.
2. Identify the value stream and eliminate waste.
3. Make value flow at the pull of the customer.
4. Involve and Empower employees.
5. Continuously improve in the pursuit of perfection.
Business Confidential, © Ortho-Clinical Diagnostics 2006
Pre-Lean Med Tech Quote:
“With all of the automation, I feel like a robot.”
Business Confidential, © Ortho-Clinical Diagnostics 2006
The “Thinking Production System”
“Perhaps the greatest strength of the Toyota Production System is the way it develops people.
This is why the T actually stands for ‘Thinking’ as well as for ‘Toyota.’”
– Teruyuki Minoura, Toyota
Business Confidential, © Ortho-Clinical Diagnostics 2006
Source: USA TodayAugust 24, 2005
What Mistake-Proofing Means to Healthcare
The Global Goal: Reduce Medical Errors
“Human error is inevitable. We can never eliminate it.” …..
We can eliminate problems in the system that make it more likely to happen.”
Liam Donaldson
WHO World Health Alliance
for Patient safety
Business Confidential, © Ortho-Clinical Diagnostics 2006
• Traditional Approach:– “Naming, Shaming, and Blaming”
• Lean Approach:– Supports open reporting of mistakes
– Root cause problem solving process
– “Anyone can make mistakes”
Lean Requires a Cultural Shift
Business Confidential, © Ortho-Clinical Diagnostics 2006
Error Proofing Example
• Micrograms or Milligrams?
• A medical mistake waiting to happen when written by hand
Business Confidential, © Ortho-Clinical Diagnostics 2006
Error Proofing Example
Confusing
Unambiguous(Lean)
Business Confidential, © Ortho-Clinical Diagnostics 2006
MD Resistance to Standard Work
• “… some surgeons make a tiny, mole-sized mark on a patient instead of a big, bold "X”…. I call them passive-aggressive marks…”– USA Today, 4/18/06
Which isMore effective?
Business Confidential, © Ortho-Clinical Diagnostics 2006
Lab Benefits from Lean
• Productivity improvement >30%
• Space savings of >450 sq ft
• Standardized work practices
• Reduction in Errors and Error Potential
• Test Turnaround Time (CT) reduced by 50%
Business Confidential, © Ortho-Clinical Diagnostics 2006
Hospitals Avoiding Capital Costs
• From 60,000 sq ft to 40,000 sq ft for new lab– Cost avoidance of $800,000
• Blood bank in new lab w/o adding 2,500 sq ft– Cost avoidance of $400,000
• Hospital food service cancels new building– Cost avoidance of $7,200,000
Business Confidential, © Ortho-Clinical Diagnostics 2006
Improving Patient Satisfaction
October
2005
Hospital System ED
60% Overall Rating
62% Privacy
78% Wait Time for MD
61% Likelihood of Recommending
December 2005
96%
84%
96%
98%
PATIENT SATISFACTION SURVEY SCORES
Business Confidential, © Ortho-Clinical Diagnostics 2006
Reflections on a Year in Healthcare
• Lean is a powerful methodology
• People are people
• Healthcare people have incredible intrinsic motivation
• Humility and asking questions is better than being a know-it-all
• Coaching the team to “do lean & be lean” is the only sustainable route
Business Confidential, © Ortho-Clinical Diagnostics 2006
A Call To Action
• What can you do?– Talk to hospitals and doctors in your communities
– Get involved with hospital boards
– Encourage employer health plans to push lean
– Consider a career shift into healthcare
– Resources:• “Good News… How Hospitals Heal Themselves” (DVD/PBS)
• Hardwiring Excellence (by Quint Studer)
• www.ihi.org (Institute for Healthcare Improvement)
• www.prhi.org (Pittsburgh Regional Healthcare Initiative)
• www.leanblog.org (Mark’s lean blog)
World-Class Performance
Lean in Healthcare Operations
Mark Graban, LFM ‘99Senior Consultant, ValuMetrix® ServicesOrtho-Clinical Diagnostics, Inc.
mgraban@ocdus.jnj.comwww.valumetrixservices.com
mgraban@yahoo.com www.leanblog.org