LEANing Diagnostic Services - The Basics Everyone Should Kno€¦ · Four Key Principles to Lean...

©2010 Chi Solutions, Inc. Proprietary and Confidential.

LEANing Diagnostic Services - The Basics Everyone Should Know

Inquisit Audio ConferencePresenter: Anne T. Daley, MS, CSSBB, CMQOE

September 22, 2010

2 ©2010 Chi Solutions, Inc. Proprietary and Confidential.

Competition

Every morning in Africa, a gazelle wakes up; it knows it

must run faster than the fastest lion or it will not survive.

Every morning in Africa, a lion wakes up; it knows it must outrun the slowest gazelle or it will starve.

It doesn’t matter whether you are a lion or a gazelle: When the sun comes up,

you had better be running!

SeriousCompetition!


Welcome and What’s in This for Me?


Learning Objectives

At the end of the session, participants will be able to:

Explain basic Lean concepts and tools.

Explain a simple, organized, and systematic approach to LEANing a process.

Apply a few basic Lean tools to their own operations to drive process improvement.


Outline of Topics Lean Lingo and Tidbits

Basic Lean Concepts and Tools

Open Discussion/Q&A

Closing Thoughts


Lean Lingo and Tidbits


Philosophy: Quality vs. ValueQuality is “a state in which the customer and provider realize value entitlement in every aspect of the business relationship.” Mikel Harry, PhD

CustomerNeed

ProviderService

ValueExchange

Cost

Defects

Time

Price

Quality

Delivery

Product

Service

Capacity

Capability

“We are not in the business of quality,we are focused on the quality of our business.”

Creation of VALUE is Key


Why is Lean Important to My Operation?Lean is the elimination of waste or anything not absolutely required to deliver a quality product or service, on time, to our customers.

The Benefits of Lean:

Increases productivity by producing or servicing MORE with the same or less resources.

Improves quality.

Reduces inventory.

Reduces cycle time.

Improves on-time performance.

Increases capability by using freed-up resources.

Increases capacity to increase volumes and expand products or services.


What is Lean?

Step 1 Step 2 Step 3 Step 4Inputs Outputs

Reduction of wasted activity within a process

Lean: The application of principles whoseobjective is to eliminate WASTE while

improving process flow to achieve speed and agility at lower cost.


Four Key Principles to Lean Six Sigma

The Four Keys:

1. Delight Customers

2. Improve Processes

3. Teamwork

4. Data-based Decisions

Lean SixSigma

Variation &

Defects

Process Flow

ImproveProcesses

Quality

Speed

DelightCustomers

Data and Facts

Team-Work

Source: What is Lean Six Sigma, George, Rowlands, and Kastle, McGraw-Hill, 2003.


Five-step Process Improvement MethodologySix Sigma’s DMAIC Process


Simplified DMAIC Approach

Step 5: Process Control

Monitor the Process and Celebrate Success(Control Methods, Keep it Alive!)

Step 3: Process Analysis

Understand Relationship of Input and Output Variables

(Cause and Effect Analysis, Fishbone Diagram)

Step 2: Process Measurement

Understand the Current Process Flow(Process Mapping, Value Analysis)

Step 4: Process Improvement

Step 1: Project Definition

Select and Define Opportunity for Improvement

(Balanced Scorecard, Project Charter, VOC, SIPOC)

KaizenEvent

Understand Waste and Variation within Process

(Waste Reduction, Spaghetti Diagram, Continuous Flow, Push vs. Pull, Kanban, Standard Work, Statistical Analysis )

Identify, Prioritize, and Implement Solutions for Improvement

(Visual Workplace, 5S, Water Spider, Poka-Yoke, XY Decision Matrix, Implementation Plan, Leading Change)


Common Tools Used to Lean the Patient Experience


Step 1: Define MAICKey Concepts and Tools:

Balanced ScorecardProject Charter

Voice of the Customer


If a man knows not what harbor he seeks, any wind is the right wind. -Seneca


Balanced Scorecard: Radiology MeasurementsQuality Performance Improved patient flow through pre-

and post-procedure processes

Improved flow of information in tech/admin processes

Improved performance via standardization of processes and implementation of best practices

Customer Service Improved process cycle time

Reduction in overall throughput time

Improved customer satisfaction

Financial Performance Reduction in cost associated with

non-value-added activities

Improved capture of revenue via process improvement

Improved operating margins

Work Culture Improved employee satisfaction

Reduction in turnover and improved retention

Improved ability to attract new employees


Define: Project Charters

1. It increases the confidence of the leader and the supporting team.

2. There is more “buy-in” and support when people understand the problem (Problem Statement) and can sense the benefit (Objective Statement).

3. The problem becomes more manageable when it is transformed into a project.

4. There is a beginning and an end–you know when you’re finished–instead of an incomplete effort.

5. Most projects have hard financial benefit and/or they improve work conditions, predictability, and customer satisfaction.

The probability of success for an improvement project is greatly improved when it is properly defined.

Why are we here?


Problem Statement Goal/Objective Scope Timeline Resources/Team

Members Communication

Strategy Signatures of

Accountability

Basic Project Charter Elements(Name of Initiative) Project Charter

PROBLEM STATEMENT:

A specific, quantifiable explanation of the effect or pain the problem is causing within the organization (what, when, where and to what extent). It should not imply a cause, attach blame or responsibility nor should it imply a solution. Include current key performance metric of process or “baseline performance”.

GOAL OR OBJECTIVE:

Defines the expected outcome or level of performance in measureable terms and is stated in a positive manner (target metric reduction). Include financial performance or return-on-investment expectations (target savings).

SCOPE:

In Scope: (define what is relevant and to be worked on, include process start and end point) Out of Scope: (define what is not to be worked on) Constraints: (possible limitations that will affect project outcomes)

TIMELINE:

Includes start date, expected completion date and general overview of initiative schedule. RESOURCES / TEAM MEMBERS:

Project Sponsor – Identifies management level key stakeholder who supports project and ensures resources are available. Eliminates complex or political barriers to ensure project moves forward

Process Owner – Identifies individual accountable for process of concern, owns implementation and control plans

Team Members – Identifies representatives from each primary group involved in the process to be included in the team. Caution to limit the number of management members, the most productive teams are comprised of those that work the process every day.

Key Stakeholders – Identifies main individuals or groups impacted by the process. COMMUNICATION STRATEGY:

Define what will be communicated (project progress) to whom (audience/stakeholders), when (frequency of communication) and how (tactics)

SIGNATURES OF ACCOUNTABILITY:

Dated signatures indicate agreement with Project Charter content and shared accountability in meeting the project goals and timelines. Include Project Sponsor, Process Owner, Project Facilitator and Team Members


Charter: Goal or Objective StatementDefines the expected outcome or level of performance in measureable terms and is stated in a positive manner (target metric reduction). Include financial performance or return-on-investment expectations (target savings).

Example: Reduce average “patient register to patient in room” response time for imaging outpatients from 45 minutes to 20 minutes, 95 percent of the time within 60 days. The benefit will be to improve patient satisfaction.

Include the following: Improve some METRIC from someBASELINE level to some GOAL, by some TIMEFRAME, to achieve some BENEFIT and improve upon some CORPORATE GOAL or OBJECTIVE.


Voice of the Customer (VOC)Critical to Quality (CTQ) Characteristics:

Represents the “Voice of the Customer”

Measurement related to how the customer evaluates the quality of a product or service

Key performance indicator of the process output or outcome

Examples of CTQ Indicators:

Patient Center Wait Time

Final Report Turnaround Time

Patient Demographics Accuracy Rate


Voice of the Customer (VOC) : Warm or Cold?

Which environment do you prefer?Adding color to an area provides instant “warmth.”

Breast Center

Hospital Outpatient Imaging Center


Step 2: D Measure AICKey Concepts and Tools:

Process MappingValue Analysis


There are usually three views of a process:

What it ACTUALLY is..

22 33What it SHOULD be..

Process Mapping

What you THINK it is..

11


Cost of Poor Quality and the Hidden Operation

Workarounds Quick Fixes

Inspections

Scrap

Rework

Extra Equipment

IncreasedInventory

Increased Cycle Time

FrustrationDefects

Customer Dissatisfaction

Cost Op i Op i + 1

Analysis ScrapOff-lineCorrection

Correctable?

Verified?

NoYes


Process Mapping Basic Components

ProcessStep InspectFirst Step

Delay

ProcessStep

ProcessStep

ProcessStep

ProcessStep

ProcessStep Last Step

NO

YES


Exercise: Basic Process MappingBeginning steps to create a process map:1. Label the process start point and end point

using an oval shape.2. Label each process step with a separate square

shape.3. Label each decision step with a separate

diamond shape, adding sub-process steps and decisions.

4. Label each delay (queue) step with a separate triangle shape.

5. AVOID temptation to add arrows at this time. (It is the last step in developing the map; we will add more to the map later.)


Process Mapping Tips Use self-stick notes.

(Precut shapes in process step color are pure joy)

Tape multiple large sheets of paper on wall to hold work.(Flip chart paper and masking tape best)

If step is forgotten and needs to be added in, move the self-stick notes to accommodate.

Walk the process after completing to validate work. (Expect to discover changes)

Always label and date a process map.

As ideas are generated, capture in a “Parking Lot.”(Improvement ideas, assumptions, questions, additional observations, and out-of-scope issues and ideas)

Concentrate on the process, not the tools and symbols.

Discuss what metrics could be used to measure process effectiveness, efficiency, and customer satisfaction; take notes.

Source: The Lean Six Sigma Pocket Toolbook, George, Rowlands, Price, and Maxey, McGraw-Hill, 2005, pg. 40-41.


What is a Value Stream? All the actions and activities required by the current state of the process to meet the consumer demand.

What is a Value Stream Map? A process map that visually documents how materials and information flow through the process.

When do you apply Value Stream Mapping? Process cycle time is too high or wait times

are too long. Need to communicate data and process flow. Process crosses many functions and has

many handoffs. Buildup of inventory or work in progress.

Value Stream Mapping


Value Defined

Value: The worth of a product as judged by the patient (customer).

The key question of all Lean processes is:

Does the process add value to the delivery of the product or service?

Value-added has three characteristics:1. The customer recognizes the value and is

willing to pay for it,2. It changes the product, and 3. It is done right the first time.


Process activities can be categorized in two additional value groups:

Value enabling means things that are: Required by law, regulation, or contract. Necessary for health, safety, environmental,

or ethical considerations.Non-value-added is:

Considered pure waste. Everything not classified as value-added or

enabling.

Additional Value Categories


Case Study:Current State Patient Process Flow

Prepared by Chi Solutions, Inc.

Imaging Patient Process Flow (Current State)Bi

lling

Tech

nical

Proc

edur

eRe

gistra

tion

Imag

ing

Rece

ption

Pre-

Regis

tratio

nSc

hedu

ling Clinician orders

procedure Clinician office staff (90%) or patient (10%) contacts Scheduling

Patient is scheduled in Cerner Books based on

desired location, recording verbal orders

Screening Mammo?

Patient Pre-Registered

Patient instructed to contact Pre-Registration

Patient contacts Pre-Registration

Patient Pre-Registered in Star, verbal information

provided (80++ questions)

Urgent?

Search Cerner Books for each

site and room for 1st available

Procedure specific

questions? Patient asked

procedure specific questions

Patient instructed Imaging will contact with prep information

Patient instructed to report to Hospital Registration or

OutPatient Imaging Department

Imaging contacts patient with

procedure prep instructions

Patient reports to Imaging

Clinician faxes orders to Imaging (<10%)

Clinician orders

collected and reviewed

Orders available & complete?

Resolve issue (s) with Radiologist, Techs or

contact Clinician

Pre-Registered

?

Patient Registered

CoPay?

Transfer Patient to Changing

Room or Procedure

Room

Patient waits in waiting room for

procedure

CoPay?

Collect Copay

Patient either escorted to

Imaging or returns to waiting room

Patient in changing room or procedure

room

Procedure performed

Additional work

needed?

Radiologist Reviews

Patient Available?

Imaging contacts patient, schedules

procedure

Patient instructed to contact Pre-Registration

Patient Report Released

Patient bill drops within

4 days of service

Patient sent “Do Not Pay” Invoice within 10 days

of service

Friendly reminders sent periodically depending

on Payor; from 14 (Medicare) to 60

(Commercial) days

Did Insurance

pay?100% ?

Patient Account Complete

Patient balance billed

Did Patient pay? Patient account

transferred to collections

Prep Information Needed?

Paperwork Signed & Insurance Card

Copied

Tech enters order in Cerner

N

Y N

Y

N

Y

N

Y

Y

N

Y

N

N

Y

N

Y

N

YN

Y

N

Y

N

NN

Y

Process Delay

Patient TransportKEY:

Re-work, additional work,

(checking)DecisionProcess

Step

Billing Info

Complete?

Y

Contact Patient

Contact Clinician

N N


Case Study:Common Observations - Strengths and ChallengesStrengths: Scheduling centralized for patient appointments.

Significant available capacity at all sites.

Challenges: Scheduling unable to easily determine first available appointment within

system locations.

Lack of standardized physician ordering requisition; information received rarely complete (lack ICD-9 code, pre-cert number, procedure type unclear).

Inconsistent handling of physician orders–information obtained is variable and generally not received until patient presents for procedure.Occasional faxing.

Registration follows hospital IP protocol; excessive patient questions.

Billing practices and pricing follows hospital inpatient protocol; not competitive with local competition.

Patient time spent in obtaining scan is significant compared to freestanding imaging center–one person stated, it is an “afternoon event”vs. “over the lunch hour.”


Benefits of Mapping the Value Stream Visualize flow

Identify sources of waste

Get to a common language

Make decisions about flow obvious

Establish the foundation for improvement activities

Links material flow to information flow

walk the process write it down…and most importantly…

Understand the process through facts and data!


Step 3: DM Analyze ICKey Concepts and Tools:

Cause and Effect DiagramWaste Reduction

Spaghetti Diagrams


Provides “pain point” discovery

Cause and Effect Diagram (Fishbone)


Case Study:Fishing for Patient Satisfaction

Findings: Primary “pain points” were process-related.

UnsatisfactoryPatient Experience

Management Process

Materials & Equipment Environment

People

Clinician orders unclear

Staff shortage,especially

during break times

Pre-registration information excessive

Registration not always located or

performed in Imaging

Requisition not standardizedamong system sites

Bills confusing

Procedure roomunavailable

Multiple bills

Patient prep not acceptable

ER patient delaysOutpatient

Supervisor not on-site

<10% orders faxedto dept before appt

Signage from parking to department unclear

Parking limited

Follow hospitalinpatient processBilling requirements

Equipment downHeavy workload

Difficult to determinefirst available appointment

RIS limited functionality, Site schedules not consolidated


Over-processing

Motion Waiting

Defects Over-production

Transporting

Inventory

6. Unnecessary Motion Extra steps and data entry Supplies spread out in work area

7. Overprocessing Handling paperwork not required Process steps that do not add value Data collection for information not used

8. Human Potential Failure to engage people Skill not matched to task

1. Defects Time doing something incorrectly Correcting errors, rework Inspecting for errors Miscommunication

2. Overproduction/Making Too MuchUnnecessary testing Doing more than needed Doing something sooner than needed

3. Transporting/Moving ThingsExtra steps in the process Hand-offs, sign-offs

4. Inventory/Unnecessary StockExcess supplies on hand Supplies not used before expiration date Instrumentation spare parts that are not critical

5. Waiting For other functions or disciplines Patients awaiting exams in hallways Unnecessary STATs

Types of Waste (MUDA)

Types ofWaste

Human Potential


Spaghetti DiagramsIllustrates the physical flow of a person, product, or information as it moves through multiple steps in a process.

Benefit: Identifies workflow inefficiencies and provides a method of modeling out potential improvements before making major (or minor) process changes.

Basic Cooking Steps:

1. Gather the tools.

2. Draw the basic work area or workstations.

3. Diagram the workflow.

4. Analyze the diagram.

5. Design and test an improved workflow.

6. Communicate and pilot the changes.

7. Evaluate effectiveness.


Spaghetti Diagram of Patient Waiting Room

Findings:Patient moved multiple times

during the registration

process, while Imaging

personnel had minimal

movement.

Solution:Cross-train

Imaging receptionists to

do patient registration.


Step 4: DMA Improve CKey Concepts and Tools:

Visual Workplace5S


Case Study:Common Top 7 Potential Opportunities Standardize physician order requisition across the system

for any non-hospital patient. Obtain copy of physician order at time of scheduling; scan

paperwork into a system that Pre-registration and Imaging can view.

Reduce amount of information obtained from patient during registration; consolidate forms.

Expand the initial process mapping of patient flow; educate staff on Lean workflow concepts and tools.

Continue review of billing practices (hospital vs. freestanding) to improve price competitiveness.

Obtain Voice of the Customer–provide each patient with a “how are we doing?” card.

Work with IT to develop first available appointment scheduling capability.


Case Study:Future State Patient Process Flow

Prepared by Chi Solutions, Inc.

Future State Imaging Patient Process Flow

Billi

ngTe

chni

cal

Pro

cedu

reIm

agin

g R

ecep

tion

& R

egis

tratio

nS

ched

ulin

g &

Pre

-Reg

istra

tion

Clinician orders procedure Clinician office staff

(90%) or patient (10%) contacts Scheduling

Patient is scheduled in Cerner Books based on

desired location, recording verbal orders

Patient asked procedure specific

questions

Patient instructed to report to Hospital Registration or

OutPatient Imaging Department

Patient reports to Imaging

Clinician faxes orders to Imaging (<10%)

Orders available & complete?

Resolve issue(s) with Radiologist, Techs or contact

Clinician

Pre-Registered

?

CoPay?

Transfer Patient to Changing

Room or Procedure

Room

Patient waits in waiting room for

procedure

Patient in changing room or procedure

room

Procedure performed

Additional work

needed?

Radiologist Reviews

Patient Available?

Imaging contacts patient, schedules

procedure

Patient Report Released

Patient bill drops within

4 days of service

Payment received?

Balance Bill

Patient?

Patient Account Complete

Patient balance billed

Did Patient pay?

Patient account transferred to collections

Tech enters

order in Cerner

Y Y N

N

YN

YN

YN

Y

Process Delay

Patient TransportKEY:

Re-work, additional work,

(checking)DecisionProcess

Step

Billing Info

Complete?

Contact Patient

Contact Clinician

Collect CoPay

Bill Patient or Insurance

Patient Pre-Registered

Clinician orders

collected and reviewed

Paperwork signed,

insurance card copied

Patient Registered

N Y

NN

Y

N

N


Principle: As you clean up a workplace you make the problems of that workplace visual!

Visual Control: Any communication device in the work environment that informs:

How work should be done.

Whether work is deviating from the standard.

Examples: Magnetic board for scheduling of patient rooms or

technical staff work assignments Graphs that show daily performance Supply storage shelf labeling

Visual Workplace


Visual Communication: Information EmpowersThe distinctive aspect of Visual Communication is it provides a group of workers timely information on process performance.

Visual Communication can be: A sign A label A photograph A display A trend chart A color scheme Whatever serves the purpose

A Visual Message is observed by everyone working in a given area, everyone who passes through the area, and everyone who comes into range of visibility.


Visual Management: Communication Boards

Communicating the Five Pillars of Performance:People, Quality, Service, Growth, and Finance

Breast Center

Hospital Imaging Department


SORT STRAIGHTEN STANDARDIZE SUSTAINSHINE

Exposes Problems

Safe Working Areas

Space Reduction

One-piece Flow

Discipline to Follow Standard Work

Foundation and Building Blocks

for All Other Activities

DrivesProductivity!

Workplace Organization: 5S

Sort Straighten

Shine Standardize

Sustain


5S Translation - Workplace Organization

Step Japanese Literal Translation English

Step 1: Seiri Clearing Up Sorting

Step 2: Seiton Organizing Straightening

Step 3: Seiso Cleaning Shining

Step 4: Seketsu Standardizing Standardizing

Step 5: Shitsuke Training and Discipline Sustaining

Focus on using the English words, much easier to remember.


Purpose: Practice using 5S concepts and tools Materials: Colored dots (red/yellow/green),

cluttered workstationExercise:

1. Sort: Attach colored dot to each item using the following description:

Green - Use daily or multiple times per weekYellow - Use weekly, or critical when neededRed - Rarely or never used, able to obtain

2.Straighten: Remove the red items from the workplace (store or discard) and relocate the yellow items to a “near” location

Applying Lean: 5S Dot Exercise


Applying 5S: Supply Room

Before

Sorted through supplies (discarding those expired and not used), set to order, and standardized remaining items

After


What is a Kanban?Kanban - A signaling system to manage and control the movement, production, or supply of material within aprocess. Kanbans have two primary functions:

Instruct processes to make products. Instruct material handlers to move products.

Benefits: Promotes visual management. Provides pickup or transport information. Prevents overproduction and excessive transportation. Controls the amount of WIP in the system. Serves as a visual work order. Exposes waste and forces a root cause solution.


Visual Management: Kanban Supply System

Kanban - A signaling system to manage and control the movement, production, or supply of material within a process. Kanbans have two primary functions:

Instruct processes to make products. Instruct material handlers to move products.


Visual Management: Kanban Supply System


5S Assessment Deployment

Assessing the level of 5S in a work space: Sort

Only items currently used remain in work space

StraightenEverything has a place and everything is in its place

ShineItems are maintained, marked off; areas clean

StandardizeProcesses identified, documented, and consistent

SustainSelf-triggered activities on a daily basis to maintain


Step 5: DMAI Control

Key Concepts and Tools:Control Methods


Outcome: Reduced Outreach Imaging Center Patient Wait Time

Maintain the Gains

Monitoring performance will increase the ability to sustain or continue to improve over time.

“Leaned” Patient Registration Process

Major Patient Dissatisfaction

“Leaned” Physician Order Process


Keep it Alive! Communicate success:

Storyboards/bulletin boards

Showcase of excellence event

Article in organizational newsletter

Monitor ongoing performance:

Balanced scorecard

Quality metrics–establish limits of performance that trigger review

Integrate into individual performance expectations


Next Steps


Moving to the Future: Kaizen Events

“Kaizen Blitz” events move the organization from its current state to the future state

using Lean Six Sigma principles in a rapid manner.

KaizenEvent


Overview of Kaizen Approach1. Construct project charter to clarify scope, goal,

key stakeholders, timeline, and deliverables (Define)

2. Collect performance data on process to be improved (Measure)

3. Facilitate team meetings: First: Define and Measure Second: Analyze and Improve Third: Analyze and Improve Fourth: Analyze and Improve (if needed) Fifth: Control and Celebrate


Summary of Process Improvement Process

Step 5: Process Control

Monitor the Process and Celebrate Success(Control Methods, Keep it Alive!)

Step 3: Process Analysis

Understand Relationship of Input and Output Variables

(Cause and Effect Analysis, Fishbone Diagram)

Step 2: Process Measurement

Understand the Current Process Flow(Process Mapping, Value Analysis)

Step 4: Process Improvement

Step 1: Project Definition

Select and Define Opportunity for Improvement (Balanced Scorecard, Project Charter, VOC, SIPOC)

KaizenEvent

Understand Waste and Variation within Process

(Waste Reduction, Spaghetti Diagram, Continuous Flow, Push vs. Pull, Standard Work, Statistical Analysis )

Identify, Prioritize and Implement Solutions for Improvement

(Visual Workplace, 5S, Kanban, Water Spider, Poka-Yoke, XY Decision Matrix, Implementation Plan, Leading Change)


Lean Application Examples Patient Scheduling/Registration: A frequent

opportunity target in many diagnostic services.

Staffing vs. Workload: Helps to break away from “historical staffing patterns” to “workload-based staffing.”

Billing Process Improvement: The majority of outreach programs do not effectively manage revenue.

Spatial Design: Application of Lean thinking regarding process improvement before design is finalized leads to effective use of space and reduced construction cost.


Open Discussion/Q&A


Why Use Lean?

Improve Patient Safety

Improve Physician Satisfaction

Enhance Customer Value

Increase Company Value

Improve Employee Satisfaction

60% Process Time Improvement

50% Improvement in Throughput

30% Improvement in Quality Levels

40% Cost Reduction

20% Floor Space Reduction

Speed

Customer’s Perception of Value and Safety

Operational Excellence Top Quality Service

Lean Business

Processes


For additional information and Lean tool templates visit: www.chisolutionsinc.com

To navigate the website:Knowledge Center/Presentations/LEANing Diagnostic Services - The Basics Everyone Should Know

Presenter Contact Information: Anne T. DaleySenior ConsultantChi Solutions, Inc.(800) 860-5454 [email protected]

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