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Leveraging Lean in Outpatient Clinics
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Table of Contents

Introduction to Lean
The Need for Change
National and Global Competition
Challenges for the Healthcare Worker
Lean and Layoffs
Traditional Healthcare Model
Introduction - So What is Lean?
Lean and Hospitals
What Results can you Expect?
The CEO and Lean
Typical Lean Metrics and Outcomes
Potential Lean Returns by Department
Typical Results/Return on Investments (ROI) and Implementing Lean
Lean and Systems Thinking
Boiled Frog Syndrome
Systems Thinking Principles
Viewing the Hospital with Systems Thinking
What is a Lean Business Delivery System?
Lean Business Delivery System Vision
Understanding the Value of the Lean Business Delivery System
Just In Time: The First Pillar of the Toyota Production System Model
An Example of One of the Rocks-Short-Staffed
Jidoka-The Second Pillar of the Toyota Production System
Jidoka Means: Never Pass on a Bad Part or Patient
Applying Jidoka to Healthcare
The Top of the Toyota House-Respect for Humanity
Lean is a Journey

Batching vs. Lean Thinking and Flow
Batching vs. Lean Thinking and Flow
Batching vs. Flow in a Healthcare Environment
Bathing Examples
Process Definition
Batching Systems
Why People Love to Batch?
One-Piece/Patient Flow
One-Piece Flow Example
Group Technology
Productivity - Definition
Batching The Domino Effect
Peak Demand
Examples of Batching in Healthcare
Chart Preparation
Application of One-Piece Flow to Healthcare
Flow-One-Piece Flow or Small Lot

Lean and Change Management
Implementing Lean is about Balance
Lean Culture Change
Paradigms
Change Equation
C Compelling Need to Change
Why Change?
V Vision
N Next Steps
Change and What's In It For Me
Lean and Change Management
Lean and Organizational Change - "Right Seat on the Right Bus"
Resistance to Change
Changes... Highs and Lows
Rule of Unintended Consequences and Bumps in the Road
Change is a Funny Thing
We are all Interconnected but not Typically Measured that Way
Horse Analogy
Comparison to Where We are Today
Employee Suggestion Systems
Barriers to Change
Most Loved Words
Does Your Organization have Sacred Cows?
Leadership and Organizational Changes
Communication, Change and Lean
Summary

Lean Foundation
Lean Foundation Baseline in the Basics Model
Think-See-Act Lean
System Lean Implementation Approach Utilizing the Basics Model
A Customer Service Story
Baseline Metrics
Data, Revenue, and Hospitals
The Impact of Data on Lean - Process Focused Metrics
Customer Satisfaction
Voice of the Customer Surveys
The VIP Visit
Easy to Do Business With
Centralized = Batching
What Does All This Have to Do with Hospitals?
Customer Value-Added Proposition
Customer Quality Index
Baseline the Process
Value Stream Map (VSM) the Process
Value Stream Discussion
Value Stream Mapping and Healthcare
Value Streams Objectives
Traditional Hospital Systems - SILOS
Lean Goals
Parts of a Value Stream Map
Value Stream Map Icons
Value Stream Map Definitions
Day 1
Day 2
Day 3
Day 4
Day 5
Current State Value Stream Mapping
Ideal State
Future State Value Stream Mapping
Value Stream Map Project Lists, Prioritization Matrix, and Tracking
Value Stream Layout Maps (sometimes referred to as Skitumi maps)
Baselining the Process-Data Collection and Analysis-Current State
Takt Time/Production Smoothing
Available Time
Customer Demand
Peak Demand
Cycle Time
Cycle Time and Takt Time-What's The Difference?
Designing Cycle Time to Takt Time
Length of Stay (LOS)
Length of Stay (LOS)
Length of Stay is Directly Correlated to Inventory
Length of Stay-A Key Metric
Reducing Length of Stay
Number of Staff Required
Total Labor Time
Quiz
Weighted Average
Financial Metrics
Measuring Inventory and Cash Flow
Work in Process Inventory
Sales of Reimbursement per Employee
Contribution Margin
Cost Per Case
Data and What People Think
Sustainability and Accountability
Process Owners Do Not Always have the Skill Sets Necessary to Manage in a Lean Environment
Notes

Basic Lean Concepts and Tools - Assessment and Analyze

Levels of Waste
Low-Hanging Fruit
Five S Wastes
The Seven (Eight) Wastes
How do you Find Waste?
30-30-30 Exercise
People
Equipment
Communication
Visual Controls
Leadership
Cost of Waste
Baseline Entitlement Benchmark
Five Why's
Example
Another Tool to Get Rid of Waste: The Five W's and Two H's
Root Cause Analysis-A3 Strategy
Fishbones and Lean
Problem-Solving Model
Problem Statements
Lean Tools - Analyze/Assessment
BASICS-Assess the Process
Step One: Understand and Assess the Overall Process
Value-Added
Non-Value-Added Activities/Work
Non-Value-Added but Necessary Work
Unnecessary Work
Idle Time
Warranted IDLE Time Exceptions
The Patient Physical Examination
Step 1: Process Flow Analysis (PFA)-Following the Product/Patient
Mapping the Process-Identifying Process Boxes
Product Process Flow Analysis Tool
The Four Components Of PFA - Tips Analysis
Basic Lean Tools Understanding Types of Storage
Raw Material Storage
Work in Process Storage
Finished Goods Storage
Further Delineating Storage-Types of Work in Process
Lot Delay
Potential Lean Solution Example #1
Potential Lean Solution Example #2
Between Process Delay
Within Process Delay
Why Break Down Types of Storage?
Total Throughput Time
Product Process Flow Worksheet
Product Flow Point-to-Point Diagrams
How to Do a Point-to-Point Diagram
Network of Process vs. Operations Defined
Group Technology Matrix-Stratification Analysis
Example: Group Technology Applied to a Surgical Services Unit
Step II: Assess the Process-Operator Analysis or Full Work Analysis
Why Make the Operator's (Staff Person's) Job Easier?
Total Labor Time
Workload Balancing
How To Balance The Work
Separate Worker from Machine
Machine Time vs. Labor Time
Diagrams: Spaghetti Diagramming-Operator Walk Patterns
How to Do a Spaghetti Diagram
Network of Process vs. Operations Defined
Motion Study-Just When You Thought You Were "There"
Time is a Shadow of Motion
100% Efficiency with Humans
Operator Resistance
Step III: Assess the Process-Changeover Analysis
Internal Vs External Time
Four Parts of a Setup/Changeover Process
Healthcare Setup Translation
Why Reduce Setups? Benefits of Smed/SMER (Single Minute Exchange of Rooms)
Summary

Putting It All Together
Understanding Demand and Resource Needs
Appropriate Resourcing Can Drive Metrics
True Bottlenecks
Cross-Training
How to Construct a Cross-Training Matrix
Heijunka-Sequencing Activities, Load Balancing
Standard Work
Story
Job Breakdown/Work Flow Analysis
Developing Standard Work
Standard Work Form
Work Standards
Eventually Standard Work Can Lead to Semi- or Complete Automation
Leader Standard Work
Capacity Analysis-Part Production Capacity Sheet
Layout Design
Master Layouts
Creativity Before Capital
Lean Layout Design-Configurations-Determining the New Flow for the Area
The "U-Shaped" Layout
Straight Line Layouts
Parallel Layouts
Other Layout Considerations
Guidelines to Layout Re-design-Non-Negotiable
How Do We Know When the Layout is Right?
Work Station Design
Stand Up vs. Sit Down Stations with Chart Flow
Work Station Design Summary
Master Layouts and Lean Design
Lean and Architects
Do We Really Need to Add More Rooms or Space?
Layouts Drive Waste in the Form of Increased Labor Costs-Consider Adjacencies
Some Practical Examples of Lean Designs
Nursing Floors
Other Design Considerations
Lean and Regulatory Environment
Rate Companies on the Ability to Sustain Continuous Improvement Plan for Every Part-Amount of Supplies/Inventory Needed
Labeling
Kanban
What Parts Do We Kanban?
Constant Time or Constant Quantity

Implementing Lean in a Healthcare Environment
How to Implement Lean Methodology
The Lean System Implementation-Are You Ready for It?
What Type of Commitment is Required?
What is Kaikaku?
Kakushin
Importance of Lean Pilots
Keep the Ownership with the Line Organization
Lean Implementation Objections and Retail Sales Techniques
Objections are Good!
Types of Closing Questions
General Overarching Lean Implementation Tips
Team Charters
Guidelines for the Supervisor
Train the Staff in the New Process
Types of Training
Overview Training
On the Job Lean Training
Executive Training
The Lean Implementation Model
General Discussion of the Four Methods
Kaizen (Method 3) vs. the Traditional Point Kaizen (Method 2) Event Approach
Kaizen
Point Kaizen Events
Potential Pitfalls of the Traditional Point Kaizen Approach
Disadvantages of Point Kaizen Events Used for First Time Implementation
Advantages/Results of Kaizen Events
Visual Management System Components
Five S
Visual Displays
Visual Controls
Story
Visual Management System
Lean Goal is Zero Defects-Difference Between an Error and a Defect
Poka Yoke
Types of Control and Warning Devices
Examples of Cause and Effect
Total Productivity Maintenance
Total Productivity Maintenance Goals
Overall Equipment Effectiveness
New Maintenance Paradigm
Lean and Maintenance in Hospitals
Construction Challenges
Hospital and IT Systems
BASICS-Checking the New Process
BASICS-Sustaining the Process
Sustaining Tools
Sustain Plans/Control Plans
Leader Standard Work
Visual Management
Accountability
Discipline
Staff Involvement
You Get What You Expect; You Deserve What You Tolerate
Additional Sustaining Tools
Repeat the Cycle!
Lean Practitioners.
Lean Hospital Implementation (System Kaizen and Point Kaizen) Lessons Learned
Create the Leadership Road Map
Make Sure Your Organization is Ready
Create a Lean Steering Committee-But Make It the Senior Leadership Team
Lean Consultants Should Report to the CEO
Create a Lean Organizational Infrastructure
Communication Plan
Training Plan
Leadership Cannot Stay in Their Ivory Tower
Leadership Must Lead and Drive Lean Changes, Not Just Support Them
Leaders Must Participate in Lean. You Cannot "Get It" in a Two hour or Four Hour PowerPoint Pitch
Don't Let Lean Turn into Finance-Driven FTE Witch Hunts
Work to Establish the Lean Culture, Not Just the Tools
Insist On Updating Standard Work
Do Not Reward Work Arounds
Don't Encourage the Victim Syndrome
Physician Resistance to Lean
Get Everyone Involved in the Analysis Phase
Give Lean System Implementation Time to Work Before Trying to Change the Underpinnings
Dedicate Resources Up Front
Include a Strategy for Accountability and Sustaining as Part of the Continuous Improvement Road Map
Listen to Your Lean Consultants/Experts
Adopt and Integrate Standard Work and Create a Suggestion and Reward Systems
Don't Leave Managers in Place Who Aren't Going to Get It
Don't Lay People Off After Lean Implementation
Don't Shortcut the Tools
Encourage Lean Architectural Designs
Include a "Go Forward" Person on the Team
Train, Train, Train
Create an Escalation Process
Identify the Process Owner and the Team Leader Up Front
Change Reward System
It's Just a Bump in the Road
Multiple Site Rollout Strategies
Site/Area Selection
Trying to Implement Several Projects at Once without Sufficient Resources

Executives and Lean
Introduction
Been There, Done That
More than just a Competitive Advantage
Board of Directors Training
Differences Between Lean and Six Sigma
Define Reality for the Lean Initiative
Resources and Accountability
Lean Should Be Where the Action Is
Removing Barriers
Measurements to Drive Outcomes
Who is to Blame?
You are What You Measure
Control or Sustain Process
Lean and Audits
"Project-itis"
Human Error Factor
Fair and Just Culture
Communication, Communication, and more Communication
Gemba - Where the Truth Can Be Found
What Questions Should You Ask When Doing a Gemba Walk?
Meetings
Paying for Suggestions
Physician Engagement
The Cog in the Chain of Command
Value Stream Managers in the Lean Organization
Role of the External Consultant
Summary
Punch List of Considerations/Ideas for the Executive Leader

Roles and Responsibilities of Managers and Supervisors
Setting the Stage: Role of Managers and Supervisors
Do You Really Want to Know What I See? Do You Really Want to Know
What I Think
Key Responsibilities and Tools for Managers and Supervisors
Communication
Identify and Provide Resources
Time Management and the "Fires"
Standard Work and Healthcare
Following Standard Work Does Not Mean We Stop Thinking
Implementation
Problems with Behaviors
Understanding Employee Satisfaction
Management and Supervisor Performance
Delegation
The Journey of a Lean Sensei with a Star Wars Analogy
On-Line Lean Training

What It Means to Have a Lean Culture
Organizational Dissemination of Lean
Understanding what a Lean Culture Looks Like-"the People Piece"
Importance of the 50% People Piece
People vs. Task-We Need a Balance
Vision
Organizational Value Systems
Pearls of Advice
Managing Resistance to a Lean Culture Change
Lean Culture Assessment
Assessment Issues and Discussion
Motivation and Continuous Improvement
High-Level Steps to Implementing a Lean Culture
Step 1: Utilize Skip Levels to See What Your Employees are Thinking
Step 2: Education and Training
Step 3: Create a Pull for Lean
Step 4: Create a Lean Implementation Plan
Step 5: Create a Lean Steering Committee
Step 6: Baseline Metrics
Step 7: Implement a Pilot-Utilize the BASICS Model
Step 8: Gemba Walks
Step 9: Sustain-Hoshin and Suggestion System
Step 10: Continuous Improvement
Barriers to Continuous Improvement
Effort to Overcome Each Barrier Types
Work to Sustain and Improve with Lean
How Do You Get the CEO on Board?
Story...Lean in County Government
Committing the Right Resources to Sustain
Human Resources and Lean
Sustaining the Continuous Improvement Culture

Lean in the Outpatient Clinic Setting
Primary Care Clinics
Overview
Access to the Clinic
Standardize Appointment Lengths
Emergency Visits
Arrival to Physician
Health Insurance Portability and Accountability Act and Lean
Staffing
Calculating Staffing
Results Achieved
Gastrointestinal Outpatient Clinic
Process Flow Analysis
Hospital "X" Outpatient Gastrointestinal Clinic
The Lean Gemba Assessment Walk
Lean Capacity Analysis (Peeling Back the Onion)
Registration
Pre-Op
Consult Room
Recovery
Length of Stay Considerations
The Rest of the Story
Staffing
Summary
Root Cause
Staffing
Other Considerations
Comparison
Before
Proposed After
Final Result
Pre-Testing Clinic-The Path to Patient Readiness
Typical Pre-Testing "Patient Readiness for Surgery" Projects
The Pre-Testing Clinic Model
Traditional Pre-Testing Process
Need for Standard Orders
Standard Pre-Testing and Pre-Op Order Sets
Lean Solution
How to: The Procedure to Create Standard Orders for "Medical Clearance for Surgery"
Key Considerations
Standard Orders Rollout-General Lean Project System Implementation Considerations
Physician Acceptance and Adoption
How to Implement the Physician Office Component
Physician Office Education
Selection of Pilot Offices
Necessity for Pre-Testing
Necessity to Schedule Pre-Testing at least 3-10 days (whenever possible) Prior to the Surgery Date
Lean Pre-Testing Model
Pre-Testing Infrastructure
Traditional Process Flow and Issues of the "Readiness for Surgery Process"
Pre-Testing Phone Call Process
Pre-Testing Patient Interview
The Pre-Testing Model-Patient Visit
Problems Typically Encountered
Hospital X Lean Results in Pre-Testing are Proven
Level Loading the Schedule
Hospital B-Standard Work-Thoughts and Discussions Surrounding the Introduction of Standard Work to Staff in a Pre-Testing Clinic
Step 1-Grab the charts
Step 2-Introduce yourself to the patient
Step 3-Take vitals
Lessons Learned and Ideas Implemented from Various Lean Pre-Testing Initiatives
Results
Pre-Testing Model Calculations
Conclusion

Appendix: Glossary

Index

About the Author

W. Protzman, III, MBA, CPM is a Shingo Prize-winning author and internationally renowned Lean consultant with over 31 years' experience in materials and operations management. He spent more than 13 years with AlliedSignal, now Honeywell, where he was an aerospace strategic operations manager and the first AlliedSignal Lean Master. He has received numerous special recognition and cost-reduction awards. Charles was an external consultant for DBED's World Class Maryland Consortium while he was with AlliedSignal. He had input into the resulting World Class Criteria document and assisted in the first three initial DBED World Class Company Assessments. Charles has taught students in Lean principles and Total Quality from all over the world. In November of 1997, Charles Protzman formed Business Improvement Group, LLC (B.I.G.). B.I.G. is located in Baltimore, Maryland and specializes in implementing Lean Thinking. Charles has spent the last 18 years implementing successful Lean product line conversions, kaizen events, and administrative business system improvements (transactional Lean) across the globe. Charles participated in numerous benchmarking and site visits including a two-week trip to Japan in June 1996 where he worked with Hitachi in a kaizen event. He is a Master facilitator and trainer in TQM, total quality speed, facilitation, career development, change management, benchmarking, leadership, systems thinking, high performance work teams, team building, Myers Briggs Styles Indicator, Lean thinking and supply chain management. He also participated in Baldridge Examiner and Six Sigma management courses. He was an assistant program manager during Desert Storm for the Patriot missile-to-missile fuse development and production program. Joyce Kerpchar, PA is a Shingo Prize-winning author and health care expert, with over 30 years of healthcare industry experience and currently serves as a director at Florida Hospital Orlando, which is part of the Adventist Health System, an acute-care, tertiary hospital caring for more than 1.5 million patients a year. She joined Florida Hospital in 2001, and has held a variety of roles, as interim director of strategic for surgical services, director of the Institute for Surgical Advancement, a senior consultant implementing Lean across the eight campuses in a variety of clinical departments, is a Six Sigma Black Belt and is a certified MBTI instructor, product and project manager roles developing and implementing software applications. She began her career as a board certified physician's assistant in cardiovascular and thoracic surgery and primary care medicine. Prior to joining Florida Hospital, she held a variety of administrative positions in healthcare-related industries, which included managed care operations and contracting for a PruCare/Prudential Healthcare who served 200,000 members in nine counties in Central Florida, Product Management for Avio Corporation, a provider of information technology for ambulatory healthcare organization, and was a partner in a consulting firm which specialized in business and market entry strategy for high tech start-ups. Ms. Kerpchar is passionate about leveraging Lean in healthcare processes, to eliminate waste and reduce errors, to improve the overall quality and reduce the cost of providing healthcare. Dr. George Mayzell, MD, MBA, FACP is the senior chief medical officer and chief clinical integration officer for Adventist Midwest Health. He joined the organization in January 2013 after serving as CEO of Health Choice and senior vice president of Methodist Le Bonheur Healthcare in Memphis, Tenn. Dr. Mayzell has more than 30 years of experience in medicine and is a board certified internist and geriatrician. He received his medical degree from the University of Medicine and Dentistry of New Jersey and his MBA from Jacksonville University. He previously served as senior medical director of managed care for University of Florida and Shands Hospital. He spent more than 10 years with Blue Cross Blue Shield of Florida, working as regional medical director for care and quality and corporate managing medical director for pharmacy and care. Additionally, he has more than 10 years of practice experience. Mayzell has co-authored two books, Leveraging Lean in Healthcare and Physician Alignment: Constructing Viable Roadmaps for the Future.

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