1
Lean Healthcare –
Overview and Applications
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Jody Crane, MD, MBA
ED Physician, Mary Washington Hospital
Adjunct Professor, UT College of Business
1
Overview
� Mary Washington Hospital Background
� Overview of Lean Concepts and Tools
� Applied Lean at Mary Washington Hospital
� Lean Operations Applied to ED Design – The
Stafford Hospital Center ED
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 2
2
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Background:
Mary Washington Hospital (MWH)
� Located in Fredericksburg, VA about 40 miles due south of Washington, DC
� 2001 Reached our limits in 25-bed ED which poorly accommodated 75,000 visits per year, averaging 6% walkouts per year
� Summer 2002 Opened a state-of-the-art 50-bed ED
� Staffing budget based on patient volume and as such, no increase allocated, “It will never fill up.”
� Filled up on first day
� No plan, no organization
� Actual drop in visits to 72,500 despite rapid population expansion
3
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Background: MWH ED
� 2003 volume rebounded to 83,000 � Summer brought long waits, onset of hospital crowding
and complaints
� 13 negative letters to the editor in local newspaper in 3 months
� Winter came and brought worse overcrowding� Inpatient beds saturated
� Walkouts climbed to 12%
� Volume dropped to 78,000 in 2004 the following year
4
3
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Volume 2001-2007
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
Jan-01
Apr-0
1
Jul-0
1
Oct-0
1
Jan-02
Apr-0
2
Jul-0
2
Oct-0
2
Jan-03
Apr-0
3
Jul-0
3
Oct-0
3
Jan-04
Apr-0
4
Jul-0
4
Oct-0
4
Jan-05
Apr-0
5
Jul-0
5
Oct-0
5
Jan-06
Apr-0
6
Jul-0
6
Oct-0
6
Jan-07
Apr-0
7
Jul-0
7
Month
Volume
Monthly
Patient
Volume
2002
73,819
2003
83,608
2001
74,265
2004
78,606
2005
85,720
2006
92,019
2007
? 100K
5
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Walkout Rate 2001-2007
0%
2%
4%
6%
8%
10%
12%
14%
Jan-01
Apr-0
1
Jul-0
1
Oct-0
1
Jan-02
Apr-0
2
Jul-0
2
Oct-0
2
Jan-03
Apr-0
3
Jul-0
3
Oct-0
3
Jan-04
Apr-0
4
Jul-0
4
Oct-0
4
Jan-05
Apr-0
5
Jul-0
5
Oct-0
5
Jan-06
Apr-0
6
Jul-0
6
Oct-0
6
Jan-07
Apr-0
7
Jul-0
7
Month
Monthly
Walkout
Rate
Target
2002
2003
2001
2004
2005 20062007
6
4
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
December Admission Holds
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Date (December)
ER Holds Total Admits ER Admits OR Admits Average Walkouts
Number of
Patients
7
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Background: MWH ED
� Changes in 2004
� 100-bed wing opened in February
� New ED nursing manager
� Began focusing on process improvement
� Hospital-wide Patient Flow Team Implemented
� First focus- the admitting process
� Attention then turned to the ED to begin working on treat and released
patient throughput
� In 2006 began to take Lean Operational Approach
8
5
Overview
� Mary Washington Hospital Background
� Overview of Lean Concepts and Tools
� Applied Lean at Mary Washington Hospital
� Lean Operations Applied to ED Design – The
Stafford Hospital Center ED
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 9
Lean Healthcare
� An operations and process management strategy
� Derived from the Toyota Production System
� Focuses on creating patient value, eliminating waste, promoting flow and continuous improvement
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 10
6
Key Principles
� Key Principles
� Focus on Processes that deliver Customer Value
� Eliminate waste
� Promote flow
� Continuously improve the processes
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 11
Key Principles
� Key Principles
� Focus on Processes that deliver Customer Value
� Eliminate waste
� Overproduction
� Movement
� Inventory
� Over-processing
� Waiting
� Correction
� Transportation
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 12
7
Key Principles
� Key Principles
� Focus on Processes that deliver Customer Value
� Eliminate waste
� Promote flow
� Continuously improve the processes
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 13
Key Principles
� Key Principles
� Focus on Processes that deliver Customer Value
� Eliminate waste
� Promote flow
� Establish clear signals and handoffs
� Reduce batching and variation
� Establish proper capacity
� Synchronize and “tighten” processes
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 14
8
Key Principles
� Key Principles
� Focus on Processes that deliver Customer Value
� Eliminate waste
� Promote flow
� Continuously improve the processes
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 15
Lean Tools
� Value Stream Mapping, Process Mapping
� Standard Work, Demand/Capacity Management
� 5S (Sort, Set in order, Shine, Standardize, Sustain)
� Inventory Management (Pull systems), visual controls
� Setup/changeover reduction (Rapid Changeover)
� Mistake proofing, root cause analysis
� Targeted flow improvements, Continuous flow cells
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 16
9
Lean Tools
� Value Stream Mapping, Process Mapping
� Standard Work, Demand/Capacity Management
� 5S (Sort, Set in order, Shine, Standardize, Sustain)
� Inventory Management (Pull systems), visual controls
� Setup/changeover reduction (Rapid Changeover)
� Mistake proofing, root cause analysis
� Targeted flow improvements, Continuous flow cells
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 17
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Process Mapping – “Low Tech”
18
10
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 19
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Value, Waste, and Tools –System Improvements
20
11
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 21
Lean Tools
� Value Stream Mapping, Process Mapping
� Standard Work, Demand/Capacity Management
� 5S (Sort, Set in order, Shine, Standardize, Sustain)
� Inventory Management (Pull systems), visual controls
� Setup/changeover reduction (Rapid Changeover)
� Mistake proofing, root cause analysis
� Targeted flow improvements, Continuous flow cells
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 22
12
Lean Tools
� Standard Work, Demand/Capacity Management
� Defining the current work sequence and making sure it
functions in accordance with patient demand
� Demand Analysis
� Quantitative analysis of arrival rates/patterns
� Calculating takt time
� Capacity Analysis
� Work sequencing
� Appropriate staffing
� Designed to meet takt time
� Demand Capacity Matching – Applying these principles in
complex service industries where demand varies over time
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 23
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
� Spaghetti Diagram of staff movement processing CT patients
� Total nursing and CT tech walking 4 hours per day
� Total annual cost $35,000
24
13
Stafford Hospital Volume (03/09)
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 25
Stafford ED MD Demand/Capacity no
PA (2.5 pts/hr)
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 26
14
Stafford ED MD Demand/Capacity
w/PA (2.5 pts/hr)
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 27
Lean Tools
� Value Stream Mapping, Process Mapping
� Standard Work, Demand/Capacity Management
� 5S (Sort, Set in order, Shine, Standardize, Sustain)
� Inventory Management (Pull systems), visual controls
� Setup/changeover reduction (Rapid Changeover)
� Mistake proofing, root cause analysis
� Targeted flow improvements, Continuous flow cells
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 28
15
Lean Tools
� 5S – A tool for redefining the organization and
performance of your workplace to better promote
effective patient care
� 5 phases of implementation
� Seri (sar-ree) Sort
� Seiton (say-tond) Simplify
� Seiso (say-so) Sweep
� Seiketsu (say-ket-soo) Standardize
� Shitsuki (she-soo-kay) Sustain
� “A place for everything, everything in it’s place”
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 29
Mainside Team at the Work Place
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 30
16
Main ED VSM –
Supply Location Modifications
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
MD encounter #1
Avg Time
Location
MD
1. H&P/charting:
Othoscope – tips (wrong
ones), bulbs (missing or
not plugged in), functions
improperly
2. Cart supplies:
Tongue depressors (not
there), culture swabs
(usually out of red), guiac
developer/cards/lube,
4x4 gauze (need non-
sterile), tissues
3. Techs (for assistance)
4. Dopplers
1. IV tubing/bags (pyxis)
2. Pumps (trauma room,
supply closet, if any).
Qty? Peds? Trigger for
requested more?
3. Oral contrast: juice
(fridge)
4. IM injections: needles,
syringes and meds (med
room)
5. Band-aids (cart)
6. NG tubes (pyxis)
7. Foleys (pyxis)
8. Poop detail: diapers,
spray (T4 pyxis), wipes
(by doc box)
9. Pelvic exams: carts
(set locations 1 per
team), speculum (pyxis)
10. Bladder scan (T2
secretary)
11. Port-a-cath (pyxis/
med room), Central line
(pyxis)
12. Restraints
13. GI Cocktail: need kits
14. Pharmacy
15. Clot box
RN intervention
Avg Time
Location
RN
1. Lac procedures:
Sutures (T3 pyxis),
suture tray (T3 pyxis &
trauma room), Lidocaine
(med room)-Would like
these in supply bundles
2. Lumbar puncture:
Trays (pyxis), mask,
needles (med room),
consent (forms drawer),
betadine, Mayo stand,
LP needles (other than in
kits)- Would like in supply
bundles
3. Intubations:
disorganized
4. Central Line: Kit
(pyxis), betadine,
consent (forms drawer),
saline flushes (med
room), mask/gloves.
5. Chest tube: Suction
(pyxis), CT tray (pyxis/
chest cart), lidocaine,
needles (med room),
betadine
MD Procedures
Avg Time
Location
MD
1 1
31
Spaghetti Diagramming
� Before event, nurses wore
pedometers for entire shift x
1 week
� 3 miles walking during a
shift
� Team mapped different
paths based on supplied
needed for a typical patient
� Eliminated 80% of supplies
� Reduced Staff Movement
� Improved satisfaction and
productivity
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 32
17
Pyxis Supplies to POUMost Patients
Description Cost Charge
IV start kit $1.58 $ 0
IV Catheter $1.68 $24
PRN Adaptor $3.25 $12
Maxidrip set $3.26 $15
1000ml NaCl $1.20 $36
Adult Nas Can$0.53 $2
Total/patient $11.50 $89
Few Patients
Description Cost Charge
Yankauer $0.39 $22
Suction Can unk. $16
Adult Ambu $7.52 $167
Peds Ambu $11.46 $48
Infant Ambu $18.89 $175
Peds pulse ox $11.70 $40
Proshield Cr. $7.60 $30
Pink Spray $2.15 $9
Total/patient $59.71 $507
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 33
Future Directions
� Eliminate ED supply room in
favor of point of use supplies
� Implementing innovative
POU supply management
system based on
scales, louvers and active
tracking to eliminate Pyxis
� Reduce Human work to 3
min per day
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 34
18
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Chest Tube Tray
Before After
35
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
MWH Implementation- 5S
Simplify/Standardize
36
19
Lean Tools
� Value Stream Mapping, Process Mapping
� Standard Work, Demand/Capacity Management
� 5S (Sort, Set in order, Shine, Standardize, Sustain)
� Inventory Management (Pull systems), visual controls
� Setup/changeover reduction (Rapid Changeover)
� Mistake proofing, root cause analysis
� Targeted flow improvements, Continuous flow cells
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 37
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
The Pelvic Cart
38
20
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Top DrawerSecond Drawer
Third Drawer
The Pelvic Cart
Fourth Drawer
39
Adaptor
welded by
engineering
dept
The Pelvic Cart
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 40
21
Lean Tools
� Value Stream Mapping, Process Mapping
� Standard Work, Demand/Capacity Management
� 5S (Sort, Set in order, Shine, Standardize, Sustain)
� Inventory Management (Pull systems), visual controls
� Setup/changeover reduction (Rapid Changeover)
� Mistake proofing, root cause analysis
� Targeted flow improvements, Continuous flow cells
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 41
Mistake-Proofing Examples
Bloodloc: Mistake-proof Transfusions Stick-proof IV Catheters
Right-site Surgery
Oxygen Delivery
Smart Bandage
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 42
22
Lean Tools
� Value Stream Mapping, Process Mapping
� Standard Work, Demand/Capacity Management
� 5S (Sort, Set in order, Shine, Standardize, Sustain)
� Inventory Management (Pull systems), visual controls
� Setup/changeover reduction (Rapid Changeover)
� Mistake proofing, root cause analysis
� Targeted flow improvements, Continuous flow cells
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 43
Overview
� Mary Washington Hospital Background
� Overview of Lean Concepts and Tools
� Applied Lean at Mary Washington Hospital
� Lean Operations Applied to ED Design – The
Stafford Hospital Center ED
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 44
23
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 45
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
“Super
Track” � Fast Track
located in or near
triage for the purpose of promptly treating patients who require very low resource utilization
Treatment Room 1
Treatment Room 2
Procedure
Chair
Entrance/Exit
1 MD/PA1 Nurse1 Tech
Results Waiting
46
24
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
� Pre process-improvement seen in the “low acuity area” of the ED� ESI levels 4,5
� ESI Level 3’s sometimes spill over backlogging 4,5 patients
� 16 beds, 3 PAs, 3 RNs, 2 techs
� PA productivity 2.1 patients per hour with 5-6 beds each
� LOS 2.5 hours for low acuity patients
Before
Low Acuity
Area
Entrance/waiting area
Triage
47
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Rapid Cycle Testing / Implementation
� “Leaned” the process
� Procedure trays pre set-up to reduce set-up times
� Point of use supplies
� One Piece Flow
� Load Leveling
� Virtual Beds for patients getting ancillary testing
48
25
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
� Beds – 74%,
� Beds Closed
� PAs – 33%
� RNs – 33%
� Productivity (RN and PA)
75-100%
� LOS – 60-66%
� Patient Satisfaction-
Incredible!
After
Beds free to
see higher
acuity
patients
49
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Today….
50
26
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 51
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Consider a different scenario that
actually happened here at Mary
Washington Hospital
52
27
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
“Team Triage”*
� Team of providers utilizing an “intake team” mentality for promptly assessing, treating, and discharging level 3 patients
2 Providers (MD/PA),2 RN,1 Paramedic2 Scribes, 1PSR/HUC
Quick Look Quick Reg
Quick Triage
TreatmentArea
5 Rooms
Results Waiting
53
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
RATED Implementation
� “Leaned” the process� Visual Management
with color coding
� Point of use supplies
� Rapid Changeover
� Reduced Staff Movement
� Reduced Variation
� Designed to meet takt time
54
28
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Super Track
55
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Super Track
Intake, D/C
56
29
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Super Track
Intake, D/C
Intake, TX, D/C
57
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Super Track
Intake, D/C
Intake, TX, D/C
Main ED
58
30
0%
2%
4%
6%
8%
10%
12%
14%
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
Month
Volume vs. Walkouts 2001-2009
Volume Walkouts
MonthlyPatient Volume
MonthlyWalkout Rate
2002 20032001 2004 2005 2006 2007
Target
2008
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 59
6,000
6,500
7,000
7,500
8,000
8,500
9,000
2:09
2:24
2:38
2:52
3:07
3:21
3:36
3:50
4:04
Mo
nth
ly V
olu
me
Le
ng
th o
f S
tay
2004-2009 Volume vs. T&R LOS
Treat and Released LOS Volume
2005 20062007
2004
2008
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 60
31
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Creating Patient Value as Indicated by Press Ganey Scores
Jan 2004-Jun 2008
65
70
75
80
85
Jan-
04
Apr
-04
Jul-0
4
Oct-0
4
Jan-
05
Apr
-05
Jul-0
5
Oct-0
5
Jan-
06
Apr
-06
Jul-0
6
Oct-0
6
Jan-
07
Apr
-07
Jul-0
7
Oct-0
7
Jan-
08
Apr
-08
Month
Pre
ss G
an
ey A
bso
lute
Sco
re
61
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 62
32
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Top RATEDJuly 24, 2008 3:43 am
NOT THAT LONG AGO, most of the letters to the editor that landed here regarding the Mary Washington Hospital emergency room were complaints about the excruciatingly long time a patient had to wait to get treatment. Develop an after-hours high fever and you could count on camping out most of the night. Now, however, we're hearing how delighted readers are with the efficiency, friend-liness, and expertise of the MWH ER staff.
The change stems from a program called RATED ER. The experimental patient-flow process invented by the MWH staff is so effective it's getting national attention. Already called "quite possibly brilliant" by the journal Emergency Medicine News, RATED ER is also slated to get some coverage in TIME.
The innovation's acronym stands for "Rapid Assessment, Triage, and Efficient Disposition of Patients in the Emergency Room." Essentially, it streamlines the process of diagnosis and treatment, focusing particularly on "semi-urgent" patients--those complaining of abdominal pain or nonspecific chest pains who may or may not need admission, depending on test results. More expeditiously treating this large group moves everyone through the ER faster.
It isn't as though MWH was the only hospital where ER visits dragged: The American Medical Association says 90 percent of the nation's emergency rooms are at or above capacity. A 2007 report by Press Ganey found that emergency departments that saw more than 40,000 patients a year (MWH will see more than 110,000 in 2008) had average door-to-door times exceeding 4.4 hours. The MWH average sometimes reached 6 hours.
Now, using RATED ER, that number has fallen to 3 hours, and the number of walk-outs (patients who tire of waiting and leave) is below 2 percent—down from 12 percent.
The emergency room will never be able to provide patients with instant service, but the situation is much better than it used to be. MWH should be proud. Someday, its innovation may help ERs all across the country provide more efficient care--and letters-to-the-editor writers will have to direct their fury elsewhere.
Cable providers, anyone?
63
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D.
Key Points� Patient Value Streams can provide valuable
insight and can add value when focusing on
healthcare improvement
� You should focus on eliminating waste from
the patient’s perspective
� Patient waiting
� Set up times for common procedures
� Overproduction (Doing more than the patient
needs or wants)
� Over-processing (redundant information
gathering, steps)
� Patient and staff transportation/movement
64
33
Overview
� Mary Washington Hospital Background
� Overview of Lean Concepts and Tools
� Applied Lean at Mary Washington Hospital
� Lean Operations Applied to ED Design – The
Stafford Hospital Center ED
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 65
© 2009, Jody Crane, MD, MBA
Stafford
Medical
Center ED(Opening Feb 2009)
Entrance
Walk-in
Squad
Entrance
34
© 2009, Jody Crane, MD, MBA
Stafford
Medical
Center ED(Opening Feb 2009)
Rec/
Quick
Security
Waiting
Area
Waiting
Area
Peds
Waiting
Triage
(4)
Intake
RW
Area
Main ED
14 beds 1 Trauma bay
Treat
Bays
(4)
Lab
Rad/
CT
Area
Entrance
Walk-in
Squad
Entrance
© 2009, Jody Crane, MD, MBA
EntranceRec/
Quick
Triage
(4)
Intake
RW
Area
Treat
Bays
(4)
ESI 4,5
ESI 2,3
ESI 1,2
Admit
DischargeESI 2-5
Stafford
Medical
Center ED(Opening Feb 2009)
35
Summary
� Lean is promising and has tremendous
implications for the future of ED operations and
design
� It is critical to have the operational framework in
place or at least very well conceptualized prior to
a new ED or existing ED redesign
� As patient demographics change, so must ED
flow and design elements to accommodate a
growing lower acuity patient population
© 2009, Jody Crane, MD, MBA, Charles E. Noon, Ph.D. 69
Top Related