Members Talk

May 10, 2011

Lean is it generically applicable?
Lean in different industries
Lean in Healthcare in the U.S.

Create a picture of your perfect

factory

Excerpt from US New and World

Report
What Medicine Can Learn From Business (U.S. News & World Report, June 17, 2008)

During the visit, a team led by Virginia Mason's chief of medicine met with a
Toyota guru, a sensei who had absorbed the Toyota approach into his very marrow.
Examining a layout of the hospital, the sensei learned that there were waiting
rooms scattered across the campus.
"Who waits there?" the sensei asked.
"Patients," said the chief of medicine.
"What are they waiting for?"
"The doctor."
The sensei was told there might be a hundred or so such waiting rooms and that
patients wait about 45 minutes on average.
"You have a hundred waiting areas where patients wait an average of 45 minutes
for a doctor?" He paused and let the question hang in the air. "Aren't you
ashamed?

Create a picture of your perfect

factory

Why?

How do patients make Lean in

Healthcare different?

Lean in Healthcare

Types of Customer Waste

Defects

Re-sticks, redraws, med errors

Overproduction

Blood draws done early to accommodate lab

Inventory

Pts waiting for bed assignments

Lab samples batched
Dictation waiting for transcription

Movement

Looking for pts

Missing meds
Missing charts or equipment

Excessive Processing

Multiple bed moves

Retesting

Transportation

Excessive transporting pts for tests

Waiting

Inpts waiting in ED
Pts waiting for discharge
MDs waiting for test results

Under-utilization

Nurses transporting patients to X-ray

Lean in other
industries

Financial Services
Research from the Corporate Executive Board finds that financial firms leveraging Lean
techniques achieve 20 percent to 40 percent cost reduction in 12 to 18 months. Equally
remarkable are specific anecdotal results:
One of the worlds largest financial institutions headquartered in the U.S., increased credit card
activation by 10 percent in one year, achieving $2 million in additional revenue through
increased card utilization. A prominent national bank reduced its wholesale lockbox
(payment processing) unit cost by 58 percent while reducing associate handling
time by 48 percent and errors by more than 75 percent in only eight months.
By implementing the right Lean tools and practices at each level of the organization, they create a
continuous improvement mindset throughout the culture. For example, senior leadership may
leverage a value-stream vision session event as a methodology to support the continuous
improvement goal of communicating, translating and deploying a new retail mortgage strategy.
Middle managers may rely on Kaizen, Business Reviews, and War Rooms to drive weekly and
monthly execution to operating commitments. And first level managers and employees may use
MDI (Managing for Daily Improvement) tools, Performance Boards, and Point Kaizens for daily
continuous improvement of existing processes.
Ultimately, most executives who have experienced the transformative power of Lean note how it
provides a disciplined, repeatable way to engage every employee to see their business
from a customers perspective, identify areas for improvement and make changes rapidly. They
say the true power of Lean isnt just in the quick, dramatic results, but in its ability to create a
sustaining, continuous improvement mindset throughout an organization.

Examples
Cell manufacturing of CT scanners
Kanbans, Visual Instruction in factories
Factory lines synchronized to demand
Lean processing of payroll and benefits
Lean complaints processes
Early warning of equipment prior to break-down
Call centres using control charts to drive
proactive action rather than wasted time later

BUT
How do patients make Lean in
Healthcare different?

Lean in the US
Healthcare
System

Miami Childrens

http://www.youtube.com/watch?v=be1HsYhr82c&feature=youtube_gdata_pl

Virginia Mason Production

System
How VMPS Works

Virginia Mason's vision is to be the Quality Leader in health care. This vision requires adopting a
paradigm shift from expecting errors and defects, to believing that the perfect patient experience
is possible. Key to accomplishing this is understanding that staff who do the work know what the
problems are and have the best solutions. VMPS strategies range from small-scale ideas tested
and implemented immediately to long-range planning that redesigns new spaces and processes.
VM uses several continuous improvement activities, such as Rapid Process Improvement
Workshops (RPIWs) and kaizen events focused on incremental changes, as well as 3P workshops
intended to completely redesign a process. VM has held 850 continuous improvement activities
involving staff, patients and guests.
Benefits of
VMPS

Patients spend more value-added time with providers, and VMPS helps providers
deliver the best possible care.

Patients benefit from greater safety, less delay in seeing physicians for care and more
timely results and treatments.

VM staff benefit by having less rework and greater opportunities to care for patients one of the primary reasons many choose health care as a profession.

The reduction of waste in administrative processes that support patient care but take
valuable resources ultimately benefits customers. As a nonprofit organziation, savings
are reinvested to support VM's mission to improve patient health and well-being.

Virginia Mason Continued

VMPS Success
Stories
We have had many successes with VMPS. Below are a few examples of how VMPS has improved the quality of patient care.
PSA System Improves Patient Safety
Virginia Mason used VMPS to develop a Patient Safety Alert (PSA) system requiring all staff who encounter a situation likely to
harm a patient to make an immediate report and cease any activity that could cause further harm. If the safety of a patient is
indeed at risk, an investigation is immediately launched to correct the problem. From the program's inception in 2002 through
2009, 14,604 PSAs were reported. Most reports are processed within 24 hours a significant improvement from when reports
took three to 18 months to resolve. Patient safety at VM has increased and professional liability claims have dropped.
One-Stop Care for Patients with Cancer
Using VMPS, the Floyd & Delores Jones Cancer Institute at Virginia Mason was redesigned with a laboratory and pharmacy inside,
elimininating the need for patients to travel throughout the hospital for chemotherapy. Now, all cancer services are brought
directly to the patient in his or her private treatment room. For one patient, this reduced the length ofa chemotherapy visit from
10 hours to two and saved about 500 feet of walking at each visit.
Getting Back to Nursing
In most hospitals, nurses spend about 35 percent of their time in direct patient care. With VMPS, VM nursing teams increased it to
90 percent. They used RPIWs to evaluate their work and make improvements. Instead of caring for patients throughout a unit,
nurses work as a team with a patient-care technician in "cells" (groups of rooms located near each other). The cell model allows
nurses to monitor patients and quickly attend to needs. Also, the most commonly used supplies for each unit were moved to
patient rooms so nurses reduced walking back and forth to get supplies. Steps walked per day fell from 10,000 to roughly 1,200.
Hyperbaric Center Increases Patient Capacity
When the VM Center for Hyperbaric Medicine could no longer accommodate all the patients needing treatment, many assumed
the solution was a new building to house larger chambers. Instead, VM used VMPS tools to design and build a new hyperbaric
center in existing hospital space, which saved $2 million in construction costs and increased capacity from two to three patients
at a time to as many as 20.
Express Treatment in the Emergency Department
Emergency departments (ED) are a major entry point for hospitals and can be a bottleneck. ED patient care is typically more
expensive and involves longer wait times. Using VMPS, the ED team at VM learned to predict appropriate staffing levels for times
of greatest demand. A "team sort" process using standard clinical assessment tools to quickly identify and sort patients' care
needs was implemented. Those requiring minimal services receive express treatment and are discharged without going to
patient-care beds. This creates capacity for patients who require more extensive services. This work helped VM decrease the
number of hours the ED was closed and unable to receive new patients by more than 90 percent over the past two years. In
2011, VM will move its ED into more efficient space and the team sort process will allow the team to care for more patients.
Faster Revenue Cycle
VMPS principles are used in all areas of the organization, not just in clinical settings. The Finance Department began using VMPS
to address outstanding revenue (revenue owed to the organization that had not been paid in a timely manner). The team
improved Days Revenue Outstanding (DRO) in the clinic from 52.3 in 2003 to 29.4 in 2009 and in the hospital from 66.5 in 2003
to 42.6 in 2009. Cash deposits improved from $471 million in 2003 to $794 million in 2009.
Primary Care Achieves Positive Net Margins
Primary care has long been a money-losing area of health care and often a good year means breaking even. Primary care teams
in VM's eight locations used VMPS to realign their work and improve the patient experience. Teams analyzed how supplies and
providers "flowed" through the day. By making key changes, such as doing non-direct patient care (reviewing lab results, calling
the pharmacy) in between patient visits and setting up each exam room identically with needed supplies, providers were able to
see more patients in shorter work days with better quality care. Doctors, who previously stayed until 8 or 9 p.m. doing
paperwork, now leave by 6 p.m. The turnaround time for lab results also improved from 25 days for normal results to two days or
fewer. Today, these clinics consistently achieve positive net margins and see more patients without sacrificing time spent with

Process capability

Sometimes 99% is just not good enough

Sigma

Patient
Personal
Items

Coding
Processin
g

Scheduling Time DPMO

% Yield

3,660 Patients
With Misplaced
Personal Items
Every Day

770 Coding Errors

Every Day
Require
Correction

257 Calls Each

Day Exceed The
Two Minute OnHold Time

66,800

93.32000%

340 Patients
With Misplaced
Personal Items
Every Day

72 Coding
Errors Every
Day Require
Correction

24 Calls Each
Day Exceed The
Two Minute OnHold Time

6,210

99.3490%

12 Patients
With Misplaced
Personal Items
Every Day

13 Coding Errors
Every Week
Require
Correction

5 Calls Each
Week Exceed The
Two Minute OnHold Time

230

99.97700%

6 Patients With
Misplaced
Personal Items
Every Month

During The Year,

Only 10 Coding
Errors Require
Correction

During The Year,

3 Calls Exceed The
Two Minute OnHold Time

3.4

99.99966%

Most Useful Tools for healthcare (in

my opinion)
Value Stream MappingPatient at the Centre
5 S culture
Spaghetti Diagram
Single Piece Flow versus Batching
Visual Management

Examples
Increase capacity utilization of CT scanners
Pharmacy workflow
Lab workflow
ED results signaling
Pre-Op assessment
Lean theatres late start and time between cases
Asset tagging
New hospital design

Pharmacy Project
source: isixsigma website

Pharmacy Example 5S, VSM

Pharmacy Area

IV Area

Lean OR process improvement OR Turn Around Time

Turn around Time flows
Eliminated Waste

Reduced total time to get

patient ready in OR 21%
Reduced clinician travel
distance to get patient
ready in OR by 54%
Reduced EVS time to clean
OR by 50%

Team

10 hospital team members

Lean OR process improvement

Case cart pick
Before

Eliminated Waste

Reduced technologist
travel distance by 70%
Reduced cycle time by 46%
Improved productivity by
119%

After

Team

9 hospital team members

Lean ED

Example: ED Value Stream Map

Triage
EKG, Draw
Blood, UA,
Order X-Ray,
administer
Pain med

Front
Desk

Express
Care

Registratio
n
If rooms
full may
reg pt
while
waiting.

2- RNs
1 Tech

X-Ray
In ED

Portable

CT

Team Area
ED
Waiting
Room

ED MD
calls
before
scheduli
ng

Patient
Flow

Phone Call
Patient Wait
Time

Call critical
values

MD
Tube/bloo
d
RT

Registratio
n

Discharge
d (home
or
elsewhere
)

CT Fax
written
report

MR

Treatment

People
Flow (RN,
MD, etc.)
E-Information
flow
Other Flow
(blood, etc.)

Fax written
report/ED
access via
PACS

For
collectionif have
White Dot
Call
Repor
t

Nursing
Unit

Lab

Order Entry,
Call, wait,
page
Respirator
y Therapy
Blood
Gases

RegHospital
PsychConsult

Thank you.