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Using Lean Principles for Clinical Quality Improvement

Nancy West, MPH, RN, CPHQ Clinical Consultant Qualis Health

01/23/2008

What is Lean?
A "set of concepts, principles and tools used to create and deliver the most Value from the Customers perspective while consuming the fewest resources.

Lean Enterprise Institute Available at: http:www.lean.org

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Lean Principles
1. 2. 3. 4. 5.

Listen to the voice of the customer. Map the processes. Identify the waste. Create a pull system. Produce and use Standard work.
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What is Value? Who is the Customer?


Value is inherent worth, determined by customer desire/ willing to pay for Ultimate Customer = The patient

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Why Lean in Healthcare?


Allegheny

General Hospital in Pittsburgh: 90% in the # of infections, which saved about $500,000/yr in intensive-care-unit costs1 Virginia Mason in Seattle: Created one standard instrument tray for 12 MDs performing laparoscopic gallbladder surgery, which reduced the cost of procedure by $9502 ThedaCare in Wisconsin: saved $154,00 in the Catheterization lab supply procurement processes3
1. 2. 3.

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Wysocki, B. To fix Health Care, Hospitals Take Tips From Factory Floor. The Wall Street Journal. April 9, 2004. Connolly C. Toyota Assembly Line Inspires Improvements at Hospital. Washington Post. June 3, 2005. GoingLean in Health Care. Inistitute for Healthcare Improvement. 2005

Key Lean Concept


The elimination of wasteful processes and waste within processes.

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Types of Waste
Overproduction Waiting Unnecessary Transport Overprocessing Excess Inventory Defects Under-utilized people

Liker JK. The Toyota Way: 14 Management Principles From The World's Greatest Manufacturer. McGraw-Hill; 2004:28-29.

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Consequences of Waste
Underutilized

employees Wait times for patients and employees Inefficient transfer of information Ineffective response to errors Missing or incomplete information Missed or untimely appointments

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Some Washington Healthcare Organizations applying Lean


Harborview

Medical Center Garfield County Hospital Overlake Hospital Swedish Medical Center University of Washington Medical Center Virginia Mason
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Local Hospital Example


Before 25 Steps 4 Value-Added Steps 70 min. Total Time 9% 17% % Value-Added Time 11 Queues 132 Orders in Process 10 Handoffs 4 Inspection Steps High Variation in High 01/23/200801/23/20082002 Corporate Strategies and Development, LLC Methods 2002 Joan Wellman and Associates, Inc. After 9 4 20 min. 32 - 42% 3 39 5 2 Low Low
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Eliminating Waste
Waiting
Solution: Process mapping and re-engineering Simplify and standardize processes Identify and eliminate work arounds, loop-backs Total Steps Rearrange Steps Combine Steps Total Handoffs Total Checks Total Forks

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Eliminating Waste
Errors

Solution: Poka-yoke; error-proofing Focus on prevention, not detection Ensure quality at the source Consider human factors science Use forcing functions Eliminate the root cause of error (the 5 whys)
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Eliminating Waste
Errors
If

you ask why five times, you will get to the root of a problem Five is not really a magic number, but its a good rule of thumb

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What is a Process?
A series of steps

Carried out in sequence Creates value Provides Service Makes Product

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Eliminating Waste
Excess Inventory

One hospital prepared a days worth of case carts the day before surgery. The new process is a pull system; carts are called for and assembled just in time for the next surgery. Assembly lead time from 20 hours to 10 minutes and problems with surgery schedule changes (and storage) are eliminated.
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Process Mapping Benefits


Clear pictorial definition of current work process Common understanding of work Focus on the process not the people Rapidly illuminates improvement opportunities

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Clarifies unnecessary work Ah Ha!

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Benefits of Future State


Future

State Maps Provide visual model


Help maintain improvement Support standard operating procedures (SOP) Increased efficiency Enhanced effectiveness Saves resources, time, and money
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Four Common Types of Maps

Simple

chart) Complex Process Map (Swim Lanes) Value Stream Map Spaghetti/Layout Diagram
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Process Map (also known as flow

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Process Examples
Patient

admission and check-in Patient transfer to room Tests performed

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Simple Process Map

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Complex Process Map

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Value Stream Map

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Spaghetti/Layout Diagram

Legend
MA Provider Patient

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Symbols Tell the Story


Patient arrives in ER YES Triage RN sees patient Chest pain ? NO Back to waiting room Called to exam room

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Steps to Creating a Process Map


1. Define

the process 2. Assemble the Right Team 3. Walk the Process 4. Discuss and map the current process 5. Validate with Colleagues/peers

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Pearls of Wisdom
Include all staff who touch the process Map is complete when all members agree that it captures: all steps in current sequence, beginning to end! Maintain mapping energy Celebrate successes

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Key Elements for Sustainability


Establish and document standard processes Create graphics to communicate and share progress Continue data collection/measurement Assign ownership and transfer ownership with turnover

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Acknowledgments Qualis Health would like to thank the Lean Expert Panel, a group of six QIO representatives who have been studying and applying lean principles. The members of this panel included the following:

Patricia Baker, RN, MS,CPHQ Jane Brock, MD, MSPH Donna Daniel, PhD Scott Endsley, MD, MSc Naomi Maxey, MPH Sarah Pavelka Patrick Toomey Kevin Warren
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MPRO Colorado Foundation for Medical Care Qualis Health Health Services Advisory Group Qualis Health Iowa Foundation for Medical Care Virginia Health Quality Center TMF Health Quality Institute
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Nancy West Clinical Consultant Qualis Health 206 364-9700 ext 2007 nancyw@qualishealth.org

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