Lean Guide
Transcript of Lean Guide
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Lean in Healthcare
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Lean Methods
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Lean Methods
Definition of Lean
Types of wasteKaizen
Value stream mapping
Tools
Takt time, throughput time, five Ss, spaghetti diagrams,kaizen events, standardized work, jidoka, andon, kanban,
SMED, flow and pull, heijunka, advanced access
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What Is Lean?
Elimination of waste
Toyota Production System (TPS)Philosophy
Produce only what is needed, when it is needed, with no
wasteMethodology
Determination of value added in the process
Tools
Five Ss, kaizen event, standardized work, etc.
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Lean Organization Inverted Pyramid
CEO
Senior
Administration
Directors & Managers
Front-line Staff
Support
Guidance
Implementation
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Types of Waste (Muda)
Overproduction
WaitingTransportation
Inventory
Motion
Overprocessing
Defects
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Seven Wastes of Healthcare
Overproduction
Producing more than
the customer needsright now
Working ahead ratherthan waiting
Justin
case thinking
Mixing drugs inanticipation of patient
needs Forcing admit to Critical
Care when not needed
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2. Transportation
Movement of productthat does not addvalue
Moving patients fortesting or treatment
Centralized storage
Transporting labspecimens
Transportingmedication andsupplies
Seven Wastes of Healthcare
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3. Motion
Movement of people that
does not add value
Searching for charts
Gathering supplies
Cross ward Nursing care
Seven Wastes of Healthcare
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4. Waiting
Idle time created when
material, information,people, or equipment is notready
Waiting for lab result Waiting for a bed
assignment
Waiting for discharge Waiting for treatment
Waiting for doctor, nurse
Seven Wastes of Healthcare
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5. Over Processing
Effort that adds no value fromthe patients viewpoint
Excessive paperwork
Redundant processes Unnecessary tests
Multiple bed moves
Requiring approval of surethings
Seven Wastes of Healthcare
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6. Inventory
More materials,
medications, or goods onhand than needed to servepatients right now
Lab specimen awaitinganalysis,
ED patients waiting forbed,
Excess pharmacy stock
Excess supplies
Seven Wastes of Healthcare
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7. Defects
Work that contains errors,
rework, mistakes or lackssomething necessary
Medication errors
Wrong patient wrongprocedure
Improper labeling of specimen
Multiple puncture for blooddraw
Failure to provide antibiotics in
time
Seven Wastes of Healthcare
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Kaizen Philosophy
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Kaizen Philosophy
Employeeled continuous improvement
Five steps Specify value
Map and improve the value stream
Flow
Pull
PerfectionEven if it isnt broken, it can be improved.
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Kaizen
Masaaki Imai coined the term in his book Kaizen : The key toJapans Competitive Success (1986)
Mindset in which all employees are responsible for makingcontinuous incremental improvements to the functions theyperform
The aggregate effect is the costeffective and practicalimprovements that have instant buyin by those who use
them
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Kaizen Blitz or Event
1. Determine and define theobjectives
2. Determine the current state of the
process
3. Determine the requirements of theprocess
4. Create a plan for implementation
5. Implement the improvements
6. Check the effectiveness of the
improvements7. Document and standardize the
improved process
8. Continue the cycle
Performed by
a team for
short periodof time
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Kaizen Blitz or Event
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Case Study Same day Surgery
Problem Statement
SameDay Surgery staff at this 230bed, forprofit hospital struggled toprocess patient information in a timely, organized fashion. Physicians
orders, preadmission test results, and patients medical histories were
often missing or incorrectly filed, leading to high patient wait timesand numerous procedure cancellations per week. These delays andcancellations caused increasing frustration among both patients andstaff.
Tools: Kaizen, Standardized work procedures, and Poka Yoke
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Case Study Same day Surgery
Issues
the team lacked of standardization for collecting, reviewing, anddistributing information.
there was no central repository for patients presurgery data, andstaff had lacked protocol for tracking patients who had been admitted.
staff were admitting patients with missing information such asphysicians orders, health and physical workups, or anesthesia reviews.
The Outcome
The hospital realized:
$75,000 annual tangible savings in payroll costs associated with stafftime spent searching for information
57% reduction in SameDay Surgery patient wait times resulting inimproved patient satisfaction.
Elimination of loose sheets of patient information, improveddocumentation accuracy and increased physician satisfaction.
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Case Study - Results of 175 Rapid Process Improvement
Weeks at Virginia Mason Medical Center
Source: Womack, J. P., A. P. Byrne, O. J. Fiume, G. S. Kaplan, and J.Toussaint. 2005. "Going Lean in Healthcare."
Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Online information available at:
http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm.
lV l S M i
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Value Stream MappingValue Stream Mapping
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Value Stream Mapping
Process map of the value stream
Includes information processing and transformationalprocessing
Valueadded steps: Would the patient and family be willing topay for this activity?
Nonvalueadded steps
Necessary
Unnecessary
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Value Stream Mapping Symbols
Supplier Database Sequence Kanban
Information InventoryImprovement
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VSM Exercise OPD Lab tests
Doctors
Office
Reception
Database
Laboratory
Reception
Takt time = 270 sec
Cycle Time = 240 sec
# of People = 2
Phlebotomy
Takt time = 270 sec
Cycle Time = 180 sec
# of People = 1
Test Orders
Test Orders
Test Orders
Patient Info
Specimen
Label
0-15 0-20
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VSM Exercise OPD Lab tests
Doctors
Office
Reception
Database
Laboratory
Reception
Takt time = 270 sec
Cycle Time = 240 sec
# of People = 2
Phlebotomy
Takt time = 270 sec
Cycle Time = 180 sec
# of People = 1
Test Orders
Test Orders
Patient Info
Specimen
Label
0-15 0-20
SpecimenDelivered 2 Hourly
Report
DispatchReport Delivered
1X daily
Test Orders
Report Delivered
1X daily
Test Results
Test Results
Doctors
Office
90 15 10 05 120 300 Next Day
320 /
Next Day
Process Efficiency Percent
(22%) =
Value Added Time (320)
Lead Time (1440)
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Value Stream Mapping
Radiology Lab
House-
keeping PharmacySupplies
Anesthes-
iology
Social
Services
Porter
Stabilize
Incorrect
patient forms
Roomsunavailable
Long wait after
cleared to discharge
Education
late
Slow
turnaround
Patients
30-90 min
Admitting
1-3 hr
Triage
1-60 hr
Labor
and
Delivery
20-80 hr
Post
Partum
3 hr
Discharge
0-2 hr 1-3 hr 1-8 hr 1-5 hr
LOS
Rooms
not available
Nurses time spent on
non-patient care
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Lean Tools
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Tools
Takt time
Throughput time
Five Ss
Spaghetti diagram
Kaizen blitz or event
Jidoka
Andon
Standardized work
Kanban
Single minute exchange of die(SMED)
FlowPull
Heijunka
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Takt time
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Takt Time
The speed with which customers
must be served to satisfy demand for the service.
Cycle time is the time to accomplish a task in the system.
System cycle time is equal to the longest task cycle time in the
systemthe rate at which customers or products exit thesystem, or drip time.
demand/dayCustomer
/daywork timeAvailableTakt time =
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Calculating Takt Time
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Calculating Manning Levels
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Throughput Time
Time for an item to complete the entire process, whichincludes:
Waiting time
Transport time
Actual processing time
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Example - The OPD Clinic
Cycle, Throughput, and Takt Time
Move to examining room
2 minutes
Patient check-in
3 minutes
Nurse does
preliminary exam5 minutes
Physician exam
and consultation20 minutes
Visit complete
Wait 15
minutes
Wait 15
minutes
Wait 10
minutes
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Patient checkin cycle time = 3 minutes.
System cycle time = cycle time for longest task = physicianexam and consultation = 20 minutes.
Throughput time = 3 + 15 + 2 + 15 + 5 + 10 + 20 = 70 minutes.
tient.minutes/paphysician24
enthours/patiphysician0.4aypatients/d100
hours/day5physicians8Takt time
=
=
=
Example - The OPD Clinic
Cycle, Throughput, and Takt Time
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Valuedadded tasks:
Nurse preliminary exam
Physician exam and consultation
Nonvalueadded steps, necessary:
Patient checkin
Valueadded time = 5 minutes (nurse preliminary exam) + 20minutes (physician exam and consultation) = 25 minutes.
Percentage valueadded time = 25 minutes/70 minutes = 35percent.
Example - The OPD Clinic
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Case Study Central OPD Scheduling
Problem: This 180bed, notforprofit medical center faced thedaunting task of building efficient outpatient scheduling
procedures from the ground up. Although the center haddedicated significant resources to a new centralizedscheduling department, patients still faced a high number ofpostponed and cancelled procedures due to delayed, lost, or
mismatched paperwork.
Tools: Process mapping, Visual controls, Pull systems, Poka
Yoke, Spaghetti diagrams and Standardized work procedures
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Case Study Central OPD Scheduling
Issues Identified
Wide variances in the amount of time different employees took to
complete the same task Poor execution of critical tasks such as obtaining physicians orders or
scheduling imminent procedures.
The Outcome
With the solution in place, scheduling efficiency and effectivenessincreased dramatically.
Total work time for the scheduling process decreased 56%,Total work time for the scheduling process decreased 56%, accompanied
by a noticeable drop in the number of postponed or cancelled patientprocedures.
With backup staff assigned to scheduling, the department is able tomaintain this level of excellence even during peak workload hours.
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5S
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5S Principles
Elimination of wasteElimination of waste
Every body is involved, CoEvery body is involved, Co--operative effortoperative effort
Attack root causeAttack root cause
Human being is notHuman being is not infalliableinfalliable
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Objectives
Improve housekeepingImprove housekeeping
Make every individual responsible forMake every individual responsible forhousekeepinghousekeeping
Beautify by simple meansBeautify by simple meansProductivity improvement by saving time,Productivity improvement by saving time,
space etc.space etc.
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5Ss
SeiriSeiri -- SortingSorting
SeitonSeiton -- Systematic arrangementSystematic arrangement
SeisoSeiso -- CleaningCleaningInspection while cleaningInspection while cleaning
SeiketsuSeiketsu -- StandardizationStandardization
ShitsukeShitsuke -- Self DisciplineSelf Discipline
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5S
If we do not do 5S, we cant do anyother work efficiently.
They are features which are common to
all places and are the indicators of howwell an organization is functioning.
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Activity Establish a criteria for eliminating unwanted
items. Eliminate unwanted items either by disposingthem or by relocating them.
Success Area saved or percentage of space available
Indicator
Meaning Distinguish between necessary andunnecessary items and eliminate the unnecessary items
SEIRI = Sorting
SEIRI S tiSEIRI S ti
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SEIRI = SortingSEIRI = Sorting
Japanese Meaning : The Japanese meaning of Seiriis to straighten and contain. Get rid of waste and put it
in order according to rules
OTHER JAPANESE MEANINGS - farmland cultivation,
Make an orderly system and straighten
Wh t i
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Item is not needed
Item is needed however quantity in stock is more
than what is needed for consumption in near future
Contingency Parts
Critically decide the quantity of contingency parts to
be retained and criteria for such parts
What is unnecessary
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Frequency of use Storage Method
*Things you have not used
in the past one year
Throw them out
*Things you have used once
in the last 6-12 months
Store at distance OR
Keep in store
LOW
*Things you have used onlyonce in the last 2-6 months
Store it in central placein your zone
*Things used more than once
a month
Store it in central place
in your zone
AVERAGE
HIGH *Things used once a week Store near the workplace
*Things used daily or hourly Store near the workplace
Organization
Id tif i
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Identifying unnecessary
1. Parts & Work in Process (WIP)
Things fallen back behind the machine or rolled under it
Broken items inside the machine Things under the racks/ platform
Extra WIP
Stock of rejected items Items accumulated over period for rework
Material awaiting disposal decision
Material brought for some trial, still lying even after trial
Small qty of material no longer in use
Identifyin unnecessary
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Identifying unnecessary
2. Tools, Toolings, Measuring devices
Old jigs, tools not in use are lying
Modified tools, tooling for trial, are lying after trial Worn out items like bushes, liners, toggles etc. lying
Broken tools, bits, etc. may be lying
Measuring equipment not required for the operationbeing performed, is lying
3. Contingency Parts
Many times storage place for contingency parts become
a last refuge for broken parts, surplus items and things
nobody is likely to use
Identifying unnecessary
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Identifying unnecessary
4. Shelves and Lockers Shelves and lockers tends to collect things that nobody
ever uses, like surplus, broken items etc.
5. Passages and Corners Dust, material not required seem to gather in corner
6. Besides Pillars and under the stairs These places tends to collect junk, spittoon etc.
7. Walls and Bulletin Boards Old out dated notices which have lost their relevance Posters or bulletins on wall Dust, remains of torn notices, cell tape pieces
Identifying unnecessary
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Identifying unnecessary
8.Floor, Pits, Partitions
Defective parts
Protection caps, covers Packing material
Hardware items , small items
Even tools, toolingItems dropped on the floor are never picked
9.Computer Hard Disk Many unwanted, outdated, temporary files pile up
Improvement methods
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Improvement methods
1. Flow Process Chart (Procedural Analysis)
Drawing a process flow chart for the system
eg. How to make and use category wise grouping
2. Operational Analysis
Preparing the sequence of operations for systemeg. How to perform Seiri (sorting)
3. Check ListA check sheet is used to decide what sort of main system
and sub system are necessary.
Dealing with papers
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Dealing with papers
How to reduce papers on
your table ?
1. Make a single pile of papers2. Go through them and sort in
following categories
a) Immediate action
b) Low priority
c) Pending
d) Reading materiale) For information
Dealing with papers
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Dealing with papers
How to reduce papers on
your table ?
4 D Principle4 D Principle
DODELEGATE
DELAY
DUMP
SEITION S t ti A tSEITION S t ti A t
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Activity - Functional storage
- Creating place for everything and putting
everything in its place
Success - Time saved in searchingIndicator - Time saved in material handling
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
Meaning To determine type of storage and layout thatwill ensure easy accessibility for everyone .
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SEITION S stematic ArrangementSEITION = Systematic Arrangement
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How to achieve Systematic Arrangement ?
Decide where things belongDecide where things belong
Decide how things should be put awayDecide how things should be put away
Obey the Put away rulesObey the Put away rules
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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How to achieve Systematic Arrangement ?
Decide where things belong-- Standardize Nomenclature
- Determine an analytical method of storage
Decide how things should be put away-- Name & locations to everything. Label both item
and location
- Store material functionally- Prevent mistakes with coding by shapes & colour
contd..contd..
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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How to achieve Systematic Arrangement ?
Decide how things should be put away-- Follow first in first out rule
- If two identical items are to be located, then store
them separately, colour code them.
Obey the rules
-- Put the things back to their location aftertheir use
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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USE :USE :
1 ) Signboards1 ) Signboards
2)2) ColourColourcodescodes
3) Outline markings3) Outline markings
4) Labels4) Labels
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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FunctionalFunctional
StorageStorage
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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Category Same category of material may be
stored in one location.
Eg. Allen Screws, Oil Seals
Operation
Wise
All items required for an
operation may be stored in onelocation.
Eg. Allen key, spanner etc hand
tools required for setting m/c
Functional Storage
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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Outlining and Placement Marks
-- Mark boundaries of dept., aisles, Machines
- Follow straight line, right angle rule- Nothing shall be kept outside the boundaries
Stands and shelves-- Keep only required number of stands and shelves
- Standardize height, size
- Provide casters where necessary so that it can bemoved
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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Wires and Ducts
-- Colour code
- When there are multiple connections - bundle thewires, label them and make sure that they are in
straight line /right angle and firmly anchored
Machine-tools & Tools-- Put the tools in the order you need them
- Location of the tool should be such that it can be
put away with one hand- Try to eliminate some hand tools by permanently
attaching it to the bolt head
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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Blades, Dies, Other important consumables
-- Store them in the protected place
- Maintain these things regularly by applying rustpreventive, oiling etc.
WIP- Work In Process-- Designate a place for each component/part- Decide on how much quantity to be stored
- Ensure that there is no damage to good part
during transit, they do not get rusty and they are
not mislabeled
SEITION = Systematic ArrangementSEITION = Systematic Arrangement
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SEISO = CleaningSEISO = Cleaning
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Meaning Cleaning trash, filth, dust and otherforeign matter. Cleaning as a form ofInspection
Meaning Cleaning trash, filth, dust and otherforeign matter. Cleaning as a form ofInspection
Activity - Keep workplace spotlessly clean
- Inspection while cleaning
- Finding minor problems with cleaninginspection
Success - Reduction in machine down timeIndicator - Reduction in no. of accidents
SEISO = CleaningSEISO = Cleaning
SEISO = CleaningSEISO = Cleaning
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Japanese Meaning :
Dictionary meaning to clean up and getting rid of dirt
and unclean items
While cleaning potential defects such as abrasion,damage, loose parts, deformities, leaks temp., vibration,
abnormal sound etc. are revealed hence Seiso is
Inspection
SEISO = CleaningSEISO = Cleaning
SEISO = CleaningSEISO = Cleaning
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Here cleaning means more than just keepingHere cleaning means more than just keeping
things clean. Cleaning should be viewed as athings clean. Cleaning should be viewed as a
form of Visual Inspectionform of Visual Inspection
Preventive measures should be taken to tacklePreventive measures should be taken to tackleproblems of dust, grim, burrs, leakage etc.problems of dust, grim, burrs, leakage etc.
Root cause of the problem should be identifiedRoot cause of the problem should be identified
and it should be eliminatedand it should be eliminated
SEISO = CleaningSEISO = Cleaning
SEISO = CleaningSEISO = Cleaning
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Various Minor DefectsVarious Minor Defects= Trash = Dirt =Knocking
= Loose parts = Leaks =Scattering
=Skips =Curvature =Abrasion
=Rust =Scratches =Eccentricity
=Lurching =Abnormal =VibrationMovements
=Abnormal =Heat =AbnormalSounds & smells
=Faded colour =Hisses
SEISO = CleaningSEISO = Cleaning
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SEISO = CleaningSEISO = Cleaning
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CleaningCleaning--Inspection points for most equipmentInspection points for most equipment
SEISO = CleaningSEISO = Cleaning
TighteningLoose bolts, welding detachment,
loose parts, vibration or bumping
noise, friction
Heat Oil tanks, motors, heater, axles, control
panels, washing/ cleaning water,bearing, wiring etc.
SEISO = CleaningSEISO = Cleaning
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CleaningCleaning--Inspection points for most equipmentInspection points for most equipment
SEISO = CleaningSEISO = Cleaning
Breakage, cracks, dent on sliding
parts, handle has come off, broken
switches, wire joints come off, wiresare broken or crack, crack dial of
various pre. gauges, meters etc.
Breakage,
Cracks
SEISO = CleaningSEISO = Cleaning
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Function wise Cleaning check list of equipmentFunction wise Cleaning check list of equipment
Pneumatics
Hydraulics
Compressed Air lines, air valves,
connections, meters, filters,
reservoirs etc.
Hydraulic oil tank, oil valves,
filters, pumps, hoses, gauges,cylinders etc.
SEISO = CleaningSEISO Cleaning
SEISO = CleaningSEISO = Cleaning
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Function wise Cleaning check list of equipmentFunction wise Cleaning check list of equipment
Mech &
Power Train
Electrical
Motor fan, fan belt, couplings,
Joints, pulleys, chains, pump
bearings etc.
Control panel, lamps, light, switch,
sensors, wiring, ducts, fuses etc.
SEISO = CleaningSEISO Cleaning
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SEIKETSU = StandardizationSEIKETSU = Standardization
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Meaning Setting up standards / Norms for a neat,clean, workplace and details of how to
maintain the norm (Procedure)
Meaning Setting up standards / Norms for a neat,clean, workplace and details of how to
maintain the norm (Procedure)
Activity - Innovative visual management
- Colour coding- Early detection of problem and early action
Success Increase in 5S indicatorIndicator
SEIKETSU StandardizationSEIKETSU Standardization
SEIKETSU = StandardizationSEIKETSU = Standardization
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SEIKETSU StandardizationSEIKETSU Standardization
Japanese Meaning :
Dictionary meaning
unsoiled things, purity and cleanliness
Clean manners ,
Clean cloths, clean politician
It is the proof that 3 Ss are being faithfully carried out.
SEIKETSU = StandardizationSEIKETSU = Standardization
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SEIKETSU StandardizationSEIKETSU Standardization
Tools used for analysis :MTTR
MTBF
OEE
SEIKETSU = StandardizationSEIKETSU = Standardization
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Regularizing 5S activities so that abnormalitiesare revealed
Make it easy for everyone to identify the state of
normal or abnormal condition
For maintaining previous 3S, deploy visual
management
SEIKETSU StandardizationSEIKETSU Standardization
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SEIKETSU = StandardizationSEIKETSU = Standardization
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Some methods for visual communicationSome methods for visual communication
Colour coding Use of Labels
Danger alerts
Indication where things should be put
Directional arrows/ marks Transparent covers
Performance indicators
SEIKETSU StandardizationSEIKETSU Standardization
SEIKETSU = StandardizationSEIKETSU = Standardization
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Some methods for visual communicationSome methods for visual communication
LabelsLabels Precision management labels
Inspection labels
Temperature labels
Responsibility labels
SEIKETSU StandardizationS SU Sta da d at o
SEIKETSU = StandardizationSEIKETSU = Standardization
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Points to remember in making visual control toolsPoints to remember in making visual control tools
1. Make them easy to see from distance2. Put the display on the things
3. Everyone can tell what is right and what is wrong
4. Anybody can follow them and make necessary
corrections easily5. Work place should look brighter & orderly
SEIKETSU Standardization
SEIKETSU = StandardizationSEIKETSU = Standardization
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Some everyday visual management examplesSome everyday visual management examples
Traffic signal Zebra crossing
In car - Petrol indicator
- Speed indicator
Direction arrows
Electric danger sign etc.
SEIKETSU Standardization
SEIKETSU = StandardizationSEIKETSU = Standardization
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Some visual communication signsSome visual communication signs
SHITSUKE = Self DisciplineSHITSUKE = Self Discipline
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Meaning Every one sticks to the rule and makes it
a habit
Meaning Every one sticks to the rule and makes it
a habit
Activity - Participation of everyone in developing
good habits
- Regular audits and aiming for higherlevel
Success High employee moraleIndicator Involvement of all people
S SU Se sc p ep
SHITSUKE = Self DisciplineSHITSUKE = Self Discipline
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Japanese Meaning :
Dictionary meaning is
learning of the manners
having manners, dressing neatly ORtraining children for good customs
Japanese Meaning :
Dictionary meaning is
learning of the manners
having manners, dressing neatly OR
training children for good customs
pp
SHITSUKE = Self DisciplineSHITSUKE = Self Discipline
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Activities :
5S Committee
5S Training
5S Competition / evaluation5S Month
Posters , Literature etc.
Activities :
5S Committee
5S Training
5S Competition / evaluation
5S Month
Posters , Literature etc.
pp
SHITSUKE = Self DisciplineSHITSUKE = Self Discipline
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We need everyone to maintain 5S guidelines.We need everyone to maintain 5S guidelines.
To maintain DISCIPLINE, we need to practice andTo maintain DISCIPLINE, we need to practice andrepeat until it becomes a way of life.repeat until it becomes a way of life.
Discipline is the Core of 5SDiscipline is the Core of 5S
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SHITSUKE = Self DisciplineSHITSUKE = Self Discipline
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Discipline means making a steady habit of properlyDiscipline means making a steady habit of properly
maintaining correct proceduremaintaining correct procedure.
Time and effort involved in establishing properTime and effort involved in establishing proper
arrangement and orderliness will be in vain if we doarrangement and orderliness will be in vain if we donot have discipline to maintain it.not have discipline to maintain it.
pp
SHITSUKE = Self DisciplineSHITSUKE = Self Discipline
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PledgePledge
It shall be my constant effort to maintain my workplaceIt shall be my constant effort to maintain my workplace
in good order byin good order by
Assigning a place for everything & keepingAssigning a place for everything & keeping
everything in its placeeverything in its place
Sorting out unwanted material periodically &Sorting out unwanted material periodically &
discarding themdiscarding them
Keeping my work area neat & clean everydayKeeping my work area neat & clean everyday
pp
Organization
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g
Departments into areas
Coordinators at department level
Coordinator at each area level
Training for all
Audit each area and make action check listImplement actions
Audit and evaluation on continuous basis
Five Ss
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Sort
Separate and remove clutter and items unneeded in theworkspace.
Extraneous items impede the flow of work.
Set in Order
Organize what is left to minimize movement and make things clear.
Shine (and inspect)
Clean area, storage, equipment, etc. and inspect for warning signsof breakdowns.
Standardize
Set up an area with 5
S supplies (cleaning supplies, labels, coloredtape, other organizational items) and schedule time andresponsibility for restoring work area to its proper conditionregularly.
Sustain
Audit area regularly, expand 5S to other areas.
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Spaghetti Diagrams
Spaghetti Diagram
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Medication
Call Bell &
Bedpan
Educating
Discharge
Process
Rounds
With
Doctor
BookingInvestigation
Instruction for Spaghetti Diagram
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1. Select the process to be mapped. It is generally goodto start with work processes that are executed
repeatedly and frequently. These processes will givethe best returns on time invested.
2. Follow a person through the current state workprocess. If desired, have the person wear a
pedometer to know distance traveled (this can also beapproximated if the floor layout is to scale). As youfollow, draw the person's motion on the floor layout(you should not lift your pencil off of the paper, itshould be 1 continuous line).
*Also note any safety or ergonomic hazards while you observe*
Instruction for Spaghetti Diagram (Continued)
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3. Discuss the current state.
Talk about the total distancetraveled and discuss ways that it could be reduced bymoving equipment, bringing materials closer to theworkplace, eliminating rework steps, or changing the order
of steps.4. Draw a map of the future state and implement. Draw a
map that anticipates the future state workflow based onthe brainstormed ideas. Develop an action plan toimplement the future state.
5. Verify the future state by following a person through it.Verify that the future state works as you expected. Makecorrections where necessary
6. Communicate and make permanent.
Communicate andtrain all users of the area on the new process. Show themthe current state and future state spaghetti maps. Changestandard work so that the new process becomes standard.Ask for feedback to continuously improve the process.
Case Study Nursing Team Redesign
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Problem Statement
The Nursing Staff at this 230 bed for profit (Point of Use) hospitalstruggled with processes and systems that impacted their ability to
spend time at the patients bed side. A study performed on onenursing unit revealed that approximately 32% of a nurses day wasdedicated to activities that were considered nonvalue added or waste.In total, 46% of nursing time was spent on tasks related to patient carewhile the remaining 54% was directed towards regulatory tasks and
waste.
Tools: JIT, Spaghetti diagrams and Standardized work
procedures
Case Study Nursing Team Redesign
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Issues encountered
Reduce Waste in the Process
Improve Flow for Caregivers and Increase Patient Care
Decrease Wasted Motion Document Equipment/Maintenance Issues
Standardize Nursing Floor Processes
The Outcome
Standardized Patient Room Layout/Equipment
Patient Supplies Stocked at the Point of Use
43% Overall Waste Reduction
30% Increase in Care Related Activities
27% Increase in Bedside Time
12% Decrease in Wasted Motion (Steps)
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Standardized Work
Standardized Work
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Written documentation of the way in which each step in aprocess should be performed
Not a rigid system of compliance, but a means ofcommunicating and codifying current best practices
Apollo Gleneagles Hospitals care pathways
Standardized Work
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Standardized Work - Definition
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Standardized work is A TOOL FOR MAINTAINING
PRODUCTIVITY, QUALITY, AND SAFETY, at high levels
Standardized work is defined as work in which the
sequence of job elements has been efficiently organized,and is repeatedly followed by a team member
Standardized work is a process whose goal is kaizen. If
standardized work doesnt change, we are regressing
Why Standardized Work
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Provides a basis for employee training.
Establishes process stability.Reveals clear stop and start points for each process.
Assists audit and problem solving.
Creates baseline for kaizen.
Enables effective employee involvement and
pokayoke.
Maintains organizational knowledge
Elements of Standardized Work
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Takt Time and Cycle Time
1. Takt Time = Daily operating time / Required quantity per day
2. Cycle Time = Actual time for process
3. Goal is to synchronize takt time and cycle time
Work Sequence
1. The order in which the work is done in a given process.2. Can be a powerful tool to define safety and ergonomic issues
InProcess Stock
1. Minimum number of unfinished work pieces required for the
operator to complete the process
Implementing Standardized Work
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Implement new
standard work
Substantiate
and enumerate
improvements
Modify the
existing process
Identify areas of
opportunity
Evaluate the
current
situation
LeanTransformation
process
VSM Current state
Standard work sheet
Observation sheet
Combination sheet
Percent load charts
Implement standard work
Conduct training
Communicate changes
Share information
ID Constraints
Non Value Add
Muda
5S, Leveling, Quick
Changeover, Kanban,
Visual Controls, Andon,
Poka Yoke, DMAIC
Conduct Pilots
Money Saved
Enhanced Revenue
Floor Space & Time Savings
Human Resources
Misconceptions of Standardized Work
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Standardized work is sometimes mistaken to be a static work
process.
Workers may feel threatened that their jobs are at risk and
therefore may not participate fully in optimizing the
process.
Standardized work may not show immediate results due to
other factors:
worker attrition additional training requirement
improvement cycle just beginning
Tools of Standardized Work
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Tools of Standardized Work
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Tools of Standardized Work
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Case Study Operating Room Turnover
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Problem Statement
The O.R. staff of this 250 bed community not for profitmajor medical center wanted to reduce the changeoverand setup between surgical cases in this eleven O.R. suiteinpatient surgery department. The staff recognized thatimproved overall efficiency in this process would result inimproved patient care, improved physician satisfaction andgreater O.R. capacity without increasing staff.
Tools: SMED, Kaizen, Value Stream Mapping, and Poka Yoke
Case Study Operating Room Turnover
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Outcomes
The O.R. staff realized an initial reduction of 46% of timededicated to the O.R. turnover process. Since inception of
lean management, efficiency has grown to a 60% reductionof time needed in the O.R. changeover process.
Case Study Operating Room Turnover
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Case Study Operating Room Turnover
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Jidoka and Andon
Jidoka and Andon
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Jidoka is the ability to stop the process in the eventof a problem.
Prevents defects from passing from one stepin the system to the next
Enables swift detection and correction of
errors
Andon is a visual or audible signalingdevice used to indicate there is a problem
in the process.
What is Jidoka?
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Automation with a human touch
Practice of stopping a manual line or process whensomething goes amiss
Also known as Autonomation
Healthcare example Detection of drug drug interaction
and medication error through software
What is Jidoka?
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Quality builtin to the process
First used by Sakichi Toyoda at the beginning of the 20thcentury
A pillar of the Toyota Production System
Healthcare example 30 degree Head Elevation as a primarytool for prevention of Ventilator Associated Pneumonia
Role of Jidoka
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Autonomation is an important component of LeanManufacturing Strategy for highproduction, low varietyoperations, particularly where product life cycles aremeasured in years or decades.
How Organization Can Benefit From Jidoka
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Jidoka helps to detect aproblem earlier
Jidoka avoids the spread of
bad practices
A level of human intelligence
is transferred intoautomated machinery
Kanban
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Task 1
Workstation
1
Task 2
Workstation
2
FullKanban
Customer
Order
FullKanban
Empty
Kanban
Empty
Kanban
Kanban
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Single Minute Exchange of Die (SMED)
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Used to reduce changeover or setup time, which is the timeneeded between the completion of one procedure andthe start of the next procedure
Pioneered by Shigeo Shingo
Steps
1. Identify and classify internal and external activities2. Separate internal activities from external activities
3. Convert internal setup activities to external activities
4. Apply changes to convert remaining internal activitiesto external activities
5. Streamline all setup activities
Single Minute Exchange of Die (SMED)
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Healthcare examples
1. The changeover times in Operation Theaters, i.e.,
the time between the surgeries typically accountfor high valued OT utilization time. These alsoaccount for variations in OT scheduling effectingoverall utilization, increasing cancellation and
reducing revenue generation
2. The higher room arrangement and bedmakingturn around times account for increased waiting
times for the patients waiting for admission
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Advanced Access
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Patients are unable to obtain timely primary careappointments.
Advanced access scheduling reduces the time betweenscheduling an appointment for care and the actualappointment.
The goal is swift, even patient flow through the system.
Advanced Access - Advantages
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Decreases noshow rates
Improves patient satisfaction
Improves staff satisfaction
Increases revenue
Higher patient volumes Increased staff and clinician productivity
Promotes greater continuity of care
Increased quality of care
More positive outcomes for patients
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Lean Templates
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Lean Templates
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Lean Templates
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Lean Templates
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Lean Templates
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Lean Templates
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Lean Templates
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Lean Templates
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Mistake Proofing
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One description divides the process into two distinct steps:
determining the intent of the action, and
executing the action based on that intention.
Failure in either step can cause an error.
Mistakes are errors resulting from deliberations that lead to
the wrong intention. Slips occur when the intent is correct,but the execution of the action does not occur as intended.
Generally, mistakeproofing requires that the correct
intention be known well before the action actually occurs.
Mistake Proofing Approaches
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The approaches to error reduction are diverse and evolving.More innovative approaches will evolve, and more categorieswill follow as more organizations and individuals thinkcarefully about mistake
proofing their processes.
Tsuda lists four approaches to mistakeproofing:
Mistake prevention in the work environment. Mistake detection (Shingo's informative inspection).
Mistake prevention (Shingo's source inspection).
Preventing the influence of mistakes.
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Mistake Detection
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Mistake detection identifies process errors found byinspecting the process after actions have been taken.Immediate notification that a mistake has occurred is
sufficient to allow remedial actions to be taken in order toavoid harm.
Shingo called this type of inspection informative inspection.The outcome or effect of the problem is inspected after an
incorrect action or an omission has occurred.
Informative inspection can also be used to reduce theoccurrence of incorrect actions. This can be accomplished byusing data acquired from the inspection to control theprocess and inform mistake prevention efforts.
Statistical Process Control (SPC) is a set of methods that usesstatistical tools to detect if the observed process is being
adequately controlled.
Mistake Detection
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Mistake detection identifies process errors found byinspecting the process after actions have been taken.Immediate notification that a mistake has occurred is
sufficient to allow remedial actions to be taken in order toavoid harm.
Shingo called this type of inspection informative inspection.
The outcome or effect of the problem is inspected after anincorrect action or an omission has occurred.
Informative inspections are
Statistical Process Control statistical tool to assess the processcontrol
Successive Checks inspections of previous steps
Self Checks devices to allow the users to assess their own quality
Mistake Detection Setting functions
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A setting function is the mechanism for determining that an error is aboutto occur (prevention) or has occurred (detection).
It differentiates between safe, accurate conditions and unsafe, inaccurateones.
Determines and ensures that informationrequired in the process is available at the correct timeand place and that it stands out against a noisy
background.
Information enhancement
Facilitates checking that matched sets ofresources are available when needed or that the correct
number of repetitions has occurred.
Grouping or counting
(Shingo's fixed value methods)
Checks the precedence relationship of theprocess to ensure that steps are conducted in thecorrect order.
Sequencing(Shingo's motion step)
Checks to ensure the physical attributes of theproduct or process are correct and errorfree.
Physical
(Shingo's contact)
DescriptionSetting Function
Mistake Detection Control functions
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Mistake Detection
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Mistake Detection Fall from Wheelchair
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