When The Big Ten Meets The Big Three, The Successes Add Up.

When The Big Ten Meets The Big Three, The Successes Add Up

Agenda

• GM Perspective

• UM Perspective

Agenda

• GM Perspective– GM’s Lean History– Challenges Within GM – Applying GMS In The Supply Chain– Lessons Learned– Results

• UM Perspective

Lean History

• GM and Toyota negotiate

• NUMMI joint venture– Toyota Production System– Manufacturing in the United States

Lean History

• Years of learning– Hundreds of plant tours– Executive development programs– Short term and two year assignments

• Multiple interpretation

• Localized implementation

““All GM plants are a part of the same All GM plants are a part of the same company and must operate with one company and must operate with one production system with common production system with common elements”elements” Run Common and Run LeanRun Common and Run Lean

Jack Smithformer

GM Chairman

Lean History

EisenachEisenach

Lean History

• GM Global Manufacturing System

• General Motors’ interpretation and application of Lean best practices

• Deliver improved business performance

J.D. Power and AssociatesJ.D. Power and Associates2006 Initial Quality Study 2006 Initial Quality Study ResultsResults

2006 Top 15 North/South America 2006 Top 15 North/South America PlantsPlants

7 of Top 15

PP100PP100

PPH Based on Defect/MalfunctionNorth/South

America Plant Average 65

North/South America Plant

Average 65

WinsWins

Oshawa 2 received the Gold North/South American plant Oshawa 2 received the Gold North/South American plant award for the 2award for the 2ndnd consecutive year consecutive year

– 55thth consecutive year that a GM plant has won this award consecutive year that a GM plant has won this award

Magna Steyr’s Graz, Austria plant, which builds the Saab 9-Magna Steyr’s Graz, Austria plant, which builds the Saab 9-3 convertible, received the Gold European Plant Award3 convertible, received the Gold European Plant Award

2 segment winners – Grand Prix and Silverado Light Duty 2 segment winners – Grand Prix and Silverado Light Duty PickupPickup

11 segment leaders (top 3)11 segment leaders (top 3)

Swept the Large Pickup segmentSwept the Large Pickup segment

Corvette among top 10 models in industryCorvette among top 10 models in industry

Seven of the top 15 plants in North/South America, more Seven of the top 15 plants in North/South America, more than any other manufacturerthan any other manufacturer

© 2006 Harbour Consulting. All Rights Reserved

Top Ten Vehicle Assembly Plants - HPV

Sable, Taurus

Allure, Grand Prix, Lacrosse

Malibu

Grand Am, Malibu

Monte Carlo, Impala

Camry, Solara

Frontier

ION

Altima

Altima

A Leaner GM

• GM then:– 600,000 employees around the world– 460,000 in the United States– Sold 5.2 million cars and trucks globally

• GM now:– 327,000 employees worldwide– 140,000 employees in the United States– Sold 9.2 million cars and trucks globally

Challenges…

• Increase in competition

• $5.3 billion for health care in 2005

• Largest private purchaser of health care– 1.1 million employees, retirees and

dependents

Initial Collaboration Efforts

• Continuous improvement workshops– Traditional supply base and health care

• Area of focus – Quality improvement– Productivity increase– Inventory reduction– Lead time reduction

Lean History

• Five Lean Principles: People Involvement Standardization Built-in Quality Short Lead Time Continuous Improvement

Standardization

PeopleInvolvement

ContinuousImprovement

ShortLead Time Built-in Quality

GMS

Goal…

• Building Value and Eliminating Waste

Application Of GMS

19961996Global Manufacturing SystemGlobal Manufacturing System

• Assembly Plants

• Metal Fabrication Plants

• Powertrain

• Engineering

• Sales and Marketing

• HR

• Finance

• Purchasing…


Administrative EnvironmentAdministrative EnvironmentAdministrative EnvironmentAdministrative Environment

• EnginEngineeringeering

• SalesSales/Marketing/Marketing

• HR, FiHR, Financenance

• PurchasinPurchasingg

• HealthHealth CarCaree

Operations Operations EnvironmentEnvironmentOperations Operations EnvironmentEnvironment

• Mfg. PlanMfg. Plantsts

• Service CService Centersenters

• Parts WarehParts Warehousesouses

• Mock-Up/ProtMock-Up/Prototypeotype

• Suppliers’ OpSuppliers’ Operationserations……

Global Application


Supplier GMS (S-GMS)

• Improve QUALITY through a Shop Floor Management Process

• Teach, Coach, Mentor Leadership behavior

• Engage Team Members

• Develop Leaders as Teachers

• Apply the “What – How – Why – Thinking”

• Incorporate PDCA – Plan-Do-Check-Act

Collaboration

Commitment To Lean

People People focused on focused on improving improving processes processes using GM-using GM-

GMSGMS

Lean Leadership

Culture of Learning

Problems as Opportunities

Problem Solving

Plan-Do-Check-Act

Cross-functional Involvement

Commitment To Lean


GMSGMS

Lean Leadership

Culture of Learning

Problem Solving

Plan-Do-Check-Act



Lessons Learned

• The principles of GMS can achieve results in health care

• Leadership commitment is key

• Long term change and sustainability requires more than quick hit workshops

Results

Lean Leadership

Culture of Learning

Problem Solving

Plan-Do-Check-Act




GMSGMS

Agenda• GM Perspective

• UM Perspective– Who We Are– Where We Want to Go– Why We Need Lean to Get Us There– How GM Got Us on the Right Road– Where We Are Now

Who We Are

Integrated Academic Health System, within major public research university:• UM Hospitals and Health Centers

– 817 beds– 1.6 million outpatient visits– 10,000 employees

• UM Medical School– 1500 faculty physicians– 995 resident physicians– 690 medical students

• M-CARE Health Plan

http://www.usnews.com/usnews/nycu/health/hosptl/tophosp.htm

Mission Synergy

PatientCare

Research

Education

Good-to-Great in Health Care

“Greatness is not a function of circumstance. Greatness, it turns out, is largely a matter conscious choice and discipline”.

---Jim Collins, Author Good to Great

How an Academic Medical Center Adds Value

Produces ‘social goods’ of value effectively and efficiently:• Competent, compassionate physicians and

nurses• Medical knowledge, new treatments and better

models of care• Unique services not available elsewhere• Safety net services for the poor and uninsured


Delivers value as defined by multiple stakeholders:• Our patients have the ideal healthcare experience• Our students obtain a superb education• Our faculty have rewarding academic careers• Our staff satisfaction is high• Our research sponsors get more out of our work

and…


• Those who pay the bills for health care– General Motors, Blue Cross, Medicare, Medicaid, and

people like you

receive high quality, cost effective, patient- satisfying care

Why Health Care Needs Lean Thinking

Traditional Health Care (or, the way I was trained)• Episodic• Requires patient initiation• Not well coordinated (patients & doctors)• Sporadic communication among clinicians• Sporadic patient education• Variable process of care• Clinicians’ opinions drive decisions• Systems do not prevent errors• Outcomes not measured• Expensive

Where Do We Want to Go?

Our future state vision:Based on Institute of Medicine Report“Crossing the Quality Chasm”

Care that is:• Safe• Effective• Patient-Centered• Timely• Efficient• Equitable

Crossing the Quality Chasm

• The IOM “Chasm” Report gives us a vision of where to go

• Lean Thinking gives us tools and methods to get there

Burning Platform for Change?

Burning Platform for Change?

Gaps at UMHS:

• Quality: Not all diabetic patients on statins, aspirin

• Safety:- Wrong site surgery- Fatal medication errors- Preventable wound infections

• Efficiency: Days waiting for a CT scan

• Appropriateness: Generic drug rate around 55%

Burning Platform for Change?• Bottlenecks

– ORs– Inpatient beds

• Stress of overwork (muri):- Physicians, nurses, clerks running faster

- Nurse and physician shortage

• Financial pressures- Troubled State economy- Health care costs burden employers- The uninsured

New Way of Thinking

• Cultivate– Accountability– Collaboration– Teamwork

• Weed out– Silos– Tribalism– WASTE and unnecessary complexity

“Act your way to a new way of thinking”.

---John Shook, Ph.D.

Senior Advisor, Lean Enterprise Institute

Author, Learning to See

http://www.lean.org/WhoWeAre/LeanPerson.cfm?LeanPersonId=4

“Find it, Fix it”

“Cultivate a ‘Find it, Fix it’ mentality for overcoming challenges in your area”.

---G. Richard Wagoner, Jr. Chairman and CEO

How Did GM Get Us on the Right Road?

• Provided GMS training– GM University (Pontiac, MI)– Lansing Grand River visit – Shared GMS materials, tools and templates

• Coached initial learning projects• Provided training for UMHS coaches• Introduced UMHS to

lean experts

Lansing Grand River Visit

GMS Exercise • Purpose: To Teach an overview of the Five

Principles of GMS and some of the Elements through an Interactive Exercise

UMHS Leadership Day 2005

GM-GMSGM-GMS

Continuous Continuous ImprovementImprovement StandardizationStandardization

Built-In-Built-In-QualityQuality

ShortShortLead TimeLead Time

People People InvolvementInvolvement

GMS ExerciseUMHS Leadership Day 2005

Learning Projects Coached by General Motors

• Vascular Access - “Right line at the right time”• Medication Management • Emergency Department - ideal patient flow• Faculty Appointment and Credentialing • Operating Rooms - “Decision to incision”• Discharge Planning

ClinicED Radiology OR Admitting DischargePICC

Patient Journey

Learning Projects

ClinicED Radiology OR Admitting DischargePICC

Orders Management Project

IdealPatientFlow

CT Scheduling and Reporting

OrthopaedicScheduling

ENTCases

Vascular Access:Order to LinePlacement

Patient Journey

Care Transition

Wound Care

Misdirected Results

Sched.

Admits

Learning Projects

Selected Project Results

• Vascular Access:Increased PICC lines placed within 12 hours by nurses from 35% to 71%; reduced by 46% cases needing to be place by interventional radiology.

VAS Supply Cart 5S

Drawer: Pre-5S

Drawer: Post- 5S


• OR ENT Cases:99% of history and physicals are now complete at pre-op visit compared to 75% prior to workshop.


• Radiation Oncology:

Now treating 61% of brain metastases patients on the first day of call.


• Results Reporting: Pre-workshop:– 125,000 misdirected/undeliverable radiology results – 310,000 misdirected/undeliverable pathology results

Post-workshop: – Standardized requisitions with labels– Upgraded electronic results reporting– Requisition imaging for radiology


• Orthopaedics Project:Reduced time to schedule MedSport appointment from 23 days to 2-1/2 minutes.

Where Are We Now? The Michigan Quality System

In Year 2 of our lean journey:• “Michigan Quality System” endorsed as uniform

approach to process improvement– Quality– Safety– Efficiency– Appropriateness

• “Growing our own” model for MQS– Adapted to health care– Adapted to unique culture of UMHS

Where Are We Now?The Michigan Quality System

• Developing lean leaders• Integrating existing QI units as MQS infrastructure • Mapping key Value Streams• Choosing projects strategically to improve

“Quality, Safety and Flow”• Coalescing cadre of 15 lean coaches as a

learning community• Planning for roll-out across units and missions

Lean Leadership at UMHS

“We must all embrace the concepts of lean manufacturing – The Michigan Quality System. We will use it to streamline every single process in our organization. We should be the academic leader in transformation to Lean Healthcare.”

---Allen S. Lichter, M.D Dean, UM Medical School

State of the School Address May 2006

Conventional Thinking vs. Lean Thinking in Health Care(Dean Lichter: State of School Address)

Conventional • Medical errors are

inevitable. We benchmark to an acceptable level of errors.

• We practice efficiently, with little room for improvement without adding substantial resources.

Lean• We strive to become a “defect

free” organization. We benchmark to zero errors. Our culture and our processes are designed and re-designed to eliminate the chance of error.

• We have waste and inefficiency in every activity in the organization. Identifying and removing the waste will allow us to be more productive without adding resources.

Lean Leadership at UMHS

“We’re trying to become the safest hospital in the United States”.

---Darrell “Skip” Campbell, M.D Chief of Staff UM Hospital

Detroit Free Press Interview

Where Are We Now?Mapping Key Value Streams

• High level inpatient current state map

Location

Radiology

Radiolgy Tech./MD

Radiology Dept.Location

Dischargeprocess

Bed, N.S.Location

Dischargeplanning

HO (PA/NP),Attng, RN, D/Cplanner, Patient& Family

Bed, N.S.Location

Miscellaneousservices

PICC - PICC RNRT - RTPT - PT ...

PICC - BedRT - BedPT - Dept. ...

Procedures(post

admission)

HO (PA/NP),Attng., ConsultHO/Fellow,Consult Attng,Cath Lab, ...

Bed, OR, MPU,Int. Radiol.,Cath Lab, ...

Nursing Station(NS)

Consults

Consult HO/Fellow/ConsultAttng

Bed

HO (PA/NP),Attng, RN, D/Cplanner, Patient& Family

C. Safe, Efficient Discharge

Patient andFamily

Billers,Regulators

Home

Home with VN

ECF

Other Hospital

Expired

Clinic Visit

D. Post Discharge Care

Anticipateddischarge

Delayeddischarge

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

5/26/06

UMHHCPrograms and Operations Analysis

6

Transition of CareCare coordination

team project

MQSCCT

MQSPICC

Sections:

A. No Avoidable AdmitsB. High Quality Input Journey: Safe and Efficient FlowC. Safe, Efficient dischargeD. Post Discharge CareE. Leveling

7 4

Delays - Lack ofneeded images/tests/procedures/consults

Any delay in timelycare is bad care

Notes:HO = House Officer FTQ = First Time QualityH & P = History and Physical MR = MRI = Magnetic Resonance ImagingAttng = Attending physician CT = CAT ScanP/T = Process Time Int. Radiol. = Interventional RadiologyL/T = Lead Time

~All Some Some Most All All

Next Steps:1. Revise model - Cook - DEF’s -Done, needs work2. Prioritization meeting (MV ask TAD regarding use at AHD meeting)3. Prioritize most critical initiative, charge team - MQS coach4. Present model to HSEG - FGP, SMT, ECCA ...

Hospitaladmissionprocess

Locate bed Insurance

work Hospital

paperwork

Operator

Location

Nurseadmissionprocess

HO H & P Admission

note Orders Attng. note

Operator

Location

Location

Daily exam

HO (PA/NP),Attng, RN

Bed

Location

Labs

Lab Tech.

Bed

Location

Documen-tation

HO (PA/NP),Attng, RN,Consult (HO,Attng), Ancil.

Bed, N.S.

Location

Give meds

PharmacyDept., RN

Pharmacy,N.S., Bed

Nursing care

RN aids

Bed

Daily orders

HO (PA/NP),(Attng)

N.S.

OR?

High Level Inpatient Value Stream

ED

Clinic

ORPACU

Outsidehospitaltransfer

I

I

A. No AvoidableAdmits

B. High Quality Input Journey - Safe and Efficient Flow

E.

Leve

ling I

I

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

P/T= minL/T=FTQ=%

1-40° x 6°

4 - 6°

4 - 24°

48 - 96°

MQSED

A. Alternativeto admission:

Root causes Solutions

ORschedule

Transferscreen

P/T= 0.5 hoursL/T= 12 hoursFTQ= 30% ?

Essential InterventionsIntakeAdmission

MR/CTDelay

1098

5

43

? Scheduled v. Unscheduled? Surgery v. Medicine? Clinical condition, Transplant, CV, Cancer

Goals of MQS Theme for 2006: Quality, Safety, Flow Clinical Problems: Risk, Safety and Flow:Quality Safe - Inappropriate blood transfusions (OP)Safety Timely - Lack of DVT prophylaxis (C)Efficiency Effective - Infection from OR (SCVP) (C) -Tight Glucose controlAppropriateness Patient Centered - Cath related blood stream infection (C)

Efficient - Medication error (C)Equitable - Medication error (C)

- Falls (C)- Wounds, decubitus

Waste

All All All All All ~All

MQS CT

MQSWound

Leveling

Leveling

Where Are We Now?Mapping Key Value Streams

• Cardiovascular Center as “Model Line”

Where Are We Now?Learning from Our Early Projects

“Lessons Learned” from PDCA reviews:• Lack of alignment and clear priorities

– with strategic, operational, capital and IT plans– lean projects can’t just be “piled on”

• Unrealistic scoping • Fear of job change • Must have

- clear escalation protocol- time-efficient model for engaging busy clinicians

• Must plan for transition from project to line management• Need to further develop UMHS coach cadre

Where Are We Now?Learning from Experience of Others

• General Motors collaboration• Health care peers

e.g., Virginia Mason Medical Center, ThedaCare• Lean Thinkers Series• External lean consultants• UM College of Engineering • Lean Enterprise Institute

Where Are We Now?

Integration strategies:• Organizational learning plan • Institutional communications plan • Embedded coach model

Tactics:• Chair incentive goal• A3s on faculty satisfaction with clinic operations

Where Are We Now?Organizational Learning Plan

• JIT training for project teams• Overview courses• 5 day Lean Healthcare Certificate course

- collaboration with UM College of Engineering

• 4 day internal training course• Coach development track

Will UMHS Succeed in its Lean Journey?

Vision

Discipline and

Purposefulness Lean Tools

Leadership

With a little LOT OF help from our friends…

GM-GMSGM-GMS

Continuous Continuous ImprovementImprovement

StandardizationStandardization

Built-In-QualityBuilt-In-QualityShortShort

Lead TimeLead Time

People InvolvementPeople Involvement

Sincere Thanks

Past and Current General Motors andGMS Colleagues:• Sheila Hainsworth• Andrea Ebbitt• Nancy Walkup• Marsha Manning• Sandra McKenty• Darlene Dempsey• Jan Whitehouse• L.L. “Woody” Williams

Sincere Thanks

Our Lean Teachers:• John Shook, Ph.D.• (the late) John Long, M.D.

When The Big Ten Meets The Big Three, The Successes Add Up.

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