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Lean Thinking in Health Care. Creating the Michigan Quality System. Jack Billi, M.D. jbilli@umich.edu Michigan Quality System: med.umich.edu/mqs. Michigan Quality System : Quality Safety Efficiency Appropriateness Service. Michigan Quality System & Lean References . 1/11/10.

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creating the michigan quality system

Lean Thinking in Health Care

Creating the Michigan Quality System

Jack Billi, M.D.

jbilli@umich.edu

Michigan Quality System:

med.umich.edu/mqs

  • Michigan Quality System:
  • Quality
  • Safety
  • Efficiency
  • Appropriateness
  • Service
michigan quality system lean references
Michigan Quality System & Lean References

1/11/10

Books:

  • Womack, Jones. Lean Thinking. (An overview)
  • Liker. Toyota Way. Liker, Meier. Toyota Way Fieldbook. Liker, Hoseus. Toyota Culture.
  • Shook. Managing to Learn. (Best book on leadership in a lean organization and A3 use)
  • Sobek, Smalley. Understanding A3 Thinking. (Problem solving and A3 use)
  • Dennis. Getting the Right Things Done. (Strategy deployment or hoshin kanri)
  • Rother, Shook. Learning to See. (Value stream mapping)
  • Baker, Taylor. Making Hospitals Work (From Lean Enterprise Academy, UK)
  • Graban. Lean Hospitals. (Applies Lean principles to health examples)

Articles:

  • Kim, Spahlinger, Kin, Billi. Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med. 2006;1:191.
  • Kim, Hayman, Billi, Lash, Lawrence. The Application of Lean Thinking to the Care of Patients With Bone and Brain Metastasis With Radiation Therapy. J Oncology Practice. 2007;3:189.
  • Kim, Spahlinger, Kin, Coffey, Billi. Implementation of Lean Thinking: One Health System's Journey. Joint Commission J Quality and Safety 2009;35:406.
  • Bush. Reducing Waste in the US Healthcare System. JAMA 2007;297:871.
  • Spear. (all Harvard Business Review) Fixing Health Care from the Inside, Today (9/05); Learning to Lead at Toyota. (4/04); Decoding the DNA of Toyota Production System. (9/99)
  • IHI. Going Lean in Health Care www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare

Web:

  • Michigan Quality System at UMHS: med.umich.edu/mqs
  • Lean Enterprise Institute: www.lean.org webinars, books, meetings…
  • Lean Healthcare Value Leaders Network www.healthcarevalueleaders.org
  • Lean Enterprise Academy (UK): www.leanuk.org
  • Ideal Patient Care Experience at UMHS www.med.umich.edu/i/acs/ipe.htm
lean thinking in health care at umhs summary a3 j billi 2 15 10
Background

UM has problems in quality, safety, efficiency, service

Problems harm patients, raise costs, frustrate workers

Economy: short & long term

Current state

>20,000 faculty, staff, trainees

>100,000 processes, all have problems

Great workers trying to do a good job

Goals

Ideal Pt Care Experience

Ideal Clinician/Staff Experience

Ideal Research/Trainee Experience

Safest health system in US

Financial stability

Analysis

Workers/mgrs: +/- trained in problem solving; little std work

Problems complex, cross units; work often invisible

Unclear responsibility for problems

Unclear priorities

Time, cost pressures: stress

Strategies

Spread a consistent QI model across UMHS

-Build on our CQI base

-Study lessons from Lean Thinking

20,000 problem solvers

Michigan Quality System

Plan: (UMHS workers help build it)

Lean Thinking in Health Care at UMHSSummary A3 J Billi 2/15/10
umhs in a slide
UMHS in a Slide

Integrated Academic Health System,

within major public research university:

  • UM Hospitals and Health Centers
    • 1000 beds
    • 1.6 million outpatient visits
  • UM Medical School
    • 1600 faculty physicians
    • 1000 resident physicians
    • 690 medical students
  • Total: >20,000 employees
gaps at umhs and most health systems
Gaps at UMHS (and most health systems):
  • Quality:Not all coronary patients get statin, aspirin
  • Safety:
    • Medication errors (10x infusion pump dose)
    • Labs labeled with wrong patient name
    • Results sent to wrong clinician
  • Efficiency:
    • Nurse, doctor searching for equipment, forms, pts…
    • Weeks waiting for appointment to the right physician
    • Higher LOS: fewer admissions, less $$, lay-offs
  • Appropriateness:
    • Antibiotics for resp. infection; MRI for low back pain
  • Service:Patients lost, staff look too busy to help
gaps at umhs and most health systems7
Gaps at UMHS(and most health systems):

A different perspective using lean thinking:

  • Waste: waiting, motion, errors -Muda
  • Uneven workload, variability -Mura

- Busy Monday, light Friday

- ORs, inpatient beds

  • Stress of overburden -Muri- Physicians, nurses, clerks, managers running faster- Nurse and physician shortage
where do we want to go
Where Do We Want to Go?

Our future state vision: The Ideal Patient Care Experience

Based on Institute of Medicine Report

“Crossing the Quality Chasm”Care that is:

  • Safe
  • Effective
  • Patient-Centered
  • Timely
  • Efficient
  • Equitable
slide9

The Ideal Patient Care Experience

  • The IOM “Chasm” Report gives us a vision of where to go
  • Lean Thinking gives us the holistic approach and business system to get there
slide10

The Ideal Patient Care Experience

  • The IOM “Chasm” Report gives us a vision of where to go
  • Lean Thinking gives us the holistic approach and business system to get there
what is lean thinking several perspectives
What is Lean Thinking? Several perspectives…

“The endless transformation of waste into value from the customer’s perspective”.

---Womack and Jones,

Lean Thinking

womack s 5 steps of lean thinking applied to healthcare
Womack’s 5 Steps of Lean ThinkingApplied to Healthcare
  • Specify valuefrom customer’s perspective
  • Identify the value stream for each service, and remove the waste
  • Make value flow without interruptions from beginning to end
  • Let the customer pull value from our process
  • Pursue perfection - continuous improvement

- Do this every day in all our activities

Source: Womack & Jones: Lean Thinking

the customer s perspective your clinic appointment
The Customer’s Perspective:Your Clinic Appointment
  • Call the clinic, voice prompts, on hold, leave message.
  • Clerk calls back and sets a date next week.
  • Arrive for the visit, check in, sit in waiting room.
  • Called into the exam room, wait for doctor.
  • Doctor sees you, saying she’s been waiting for you.
  • Diagnoses a URI, and BP is worse.
  • Doctor prints antibiotic prescription, walks to the staffroom to get it. You are allergic to that drug.
  • Doctor says to return in a week for the BP.
  • At check out you ask the cost – clerk says they’ll bill you,
  • No appointment is available next week.
  • Pharmacist says your insurance prefers a different drug.
  • Is there a problem?
using the 5 step process in the clinic visit
Using the 5 Step Process in the Clinic Visit
  • Specify valuefrom customer’s perspective
    • A quick, effective clinic visit
  • Identify the value stream for this service
    • Request > appointment > arrival > seeing doctor > check-out

…and remove the waste

    • Time on hold, callbacks, walking, wrong drug, unneeded test
  • Make value flow without interruptions from beginning to end
    • Staff and patient move continuously from check-in to exit
    • Less waiting for patient and staff
    • Errors surface immediately
  • Let the customer/worker pull value from the process
    • Physician pulls next patient to exam room; patient pulls med refill when needed
  • Pursue perfection – continuous improvement
    • Every day, every clerk, doctor, nurse thinks about how to redesign work to improve value to the customer, and ease for us
medsport appointments
MedSport Appointments

Long term problem:

  • Long delays to get an appointment
  • Frustrated referring physicians, patients
  • Frustrated MedSport staff, physicians
  • Incomplete records, phone tag
  • Physician review records prior to scheduling
  • Lots of hidden processes, errors, rework

Project scope:

  • MedSport consult – from request to scheduling
using the 5 step process on medsport appointments
Using the 5 Step Processon MedSport Appointments

1. Specify valuefrom customer’s perspective

Patients, physicians and staff: quickly scheduled appointments

2. Identify the value streamfor the service

Request > review> schedule appointment

…and remove the waste

Errors, time on hold, callbacks, physician reviews

using the 5 step process on medsport consults
Using the 5 Step Processon MedSport Consults

3. Make valueflow without interruptions from beginning to end

Staff scheduling appointments on first phone call

Uniform intake process

No waiting for appointments

Errors surface immediately

using the 5 step process on medsport consults21
Using the 5 Step Processon MedSport Consults

4. Let the customer pull value from the process

Same day appointments

Open till 7PM

5. Pursue perfection – continuous improvement

Every day, every clerk, doctor, and nurse thinks about how to redesign work to improve value to the customer

medsport project results
MedSport Project Results
  • Goal: reduce time from request to scheduling
    • Pre project:
      • process time = 27 min of work
      • wait time = 23 days
    • Post project:
      • 89% of appointments made on first call in 2.5 min
    • Physicians, nurses, and clerks:
      • Own the process, continue improvements
      • Freed to create more value
        • Video www.med.umich.edu/mqs
value stream mapping workshop
Value Stream Mapping Workshop

Determine the Value Stream to be improved

Value Stream Scope

Understanding how things currently operate. This is the foundation for the future state

Current State Drawing

Designing a lean flow through the application of lean principles

Future State Drawing

Standardize for later improvement

Developing a detailed plan of implementation to support objectives (what, who, when)

Implementation Plan

Implementation of Improved Plan

The goal of mapping! 30, 60, 90 day follow-up

From John Long

why draw maps to find problems we have to be able to see them
Why Draw Maps? To find problems, we have to be able to see them!
  • Ron Hirschl’s basement clean-up
    • If you make waste visible, it’s easier to remove
    • If you make problems visible, they’re easier to solve
  • In healthcare: process steps are often invisible
    • Hard to find the non-value added steps
  • We use Value Stream Mapping so we all can see the waste and find problems
    • How is work done now?
    • How could we make the job easier for workers and better for customers?
    • What experiment should we try first?
value stream mapping learning to see
Value Stream Mapping:Learning to See

Front-line workers:

  • Create the map as a team
  • Describe the way the work is actually done now
    • Not how we think it is, or how it should be…
  • Verify in the real workplace (“go and see”)

Managers support the effort

value stream mapping learning to see27
Value Stream Mapping:Learning to See
  • “Ah ha” moments:
    • I never knew this is how it worked!
    • I can’t believe what a mess this process is!
    • No wonder we’re frustrated!
    • It’s a miracle a patient ever gets through it!
improvements don t have to wait for workshops we all can
Improvements don’t have to wait for workshops…We all can:
  • Do our work every day in a standard way that we created
    • Not just the way the work evolved!
  • Be alert to things going wrong
    • They always do!
  • Fix the problem now
    • For this patient or co-worker
  • Find and fix the root causes of the problem
    • So it never happens again!

Modified after Spear; Billi

lean thinking how to get it right every time steven spear institute for healthcare improvement
Lean Thinking:How To Get It “Right Every Time”Steven Spear, Institute for Healthcare Improvement
  • Catheter-related sepsis – a lot of little things:
    • No sink, no soap, no doormat reminder or buzzer
    • Gloves missing, wrong size, on other side of patient, at bottom of kit
    • 92% of nurses faced with impediments constructed ad hoc workarounds

Steven Spear. Fixing Healthcare from the Inside, Today

lean thinking how to get it right every time steven spear institute for healthcare improvement30
Lean Thinking:How To Get It “Right Every Time”Steven Spear, Institute for Healthcare Improvement
  • Short on Time???
  • Can’t find time to fix the root cause???
  • Rather use a workaround every day for the rest of your career?
  • Just take 10 minutes a day to fix root cause of one problem
    • Frees up time, so next week it will be 20 min.
    • Then it will be 30 minutes…

Steven Spear. Fixing Healthcare from the Inside, Today

slide31
Lean is not about working harder or faster

Lean is about finding waste and transforming it into value our customers want.

how can we create liberate 20 000 problem solvers
How can we create (liberate)“20,000 problem solvers”?
  • Help each worker take initiative to find and fix causes of problems he/she faces daily
    • This means each of us has two jobs:
      • Do the work
      • Improve the work
  • Managers role:
    • Support improvement work (time, mentoring)
    • Align improvements so value flows to the customer

Modified from J Shook

20 000 problem solvers
“20,000 Problem Solvers”

Every worker

applying the scientific method

to every part of daily work.

Turn all daily work into an experiment and every worker into an investigator. -Steven Spear

lean thinking as the scientific method applied to daily work
Scientific Method

Observation

Hypothesis

Intervention

Results/reflection

Revise hypothesis

New intervention…

Structured abstract

Lean Thinking

Go see, ask why, respect

Plan P

Do D

Check/reflect C

Adjust A

Repeat PDCA cycle…

A3 report, Value Stream Map

Lean Thinking as the Scientific Method Applied to Daily Work
lean thinking an analogy to great medical care
Lean Thinking - An analogy to great medical care

Tackle work problems with the rigor and systematic thinking we use for patient problems.

Help every worker become a skilled clinician.

lean thinking is like great medical care for daily work
Lean Thinking is Like Great Medical Care for Daily Work
  • Great Medical Care
  • Collect data personally, systematically, at the bedside (H&P)
  • Impression and plans
  • Tests and treatments
  • Assess results & reflect
  • Revise impression & plan
  • Std write-up, presentation
  • Lean Thinking
  • Go see, ask why, respect
  • Plan P
  • Do D
  • Check/reflect C
  • Adjust A
  • Value Stream Map, A3
the goal of analysis to implement a plan
The Goal of Analysis: To Implement a Plan

Determine the Value Stream to be improved

Value Stream Scope

Understanding how things currently operate. This is the foundation for the future state

Current State Drawing

Designing a lean flow through the application of lean principles

Future State Drawing

Standardize for later improvement

Developing a detailed plan of implementation to support objectives (what, who, when)

Implementation Plan

Implementation of Improved Plan

The goal of mapping! 30, 60, 90 day follow-up

From John Long

slide38
We know half the plan is wrong, we don’t know which half. We have to watch it unfold, find what’s not working right now, and fix it.
  • Traditional companies think of a plan

- as a prediction of what will happen.

  • Lean companies think of a plan

- as an experiment to be conducted

- to tell us what we didn’t know about the work

        • Paraphrase of Steven Spear , Fixing Healthcare… HBR’05

Plans are useless, planning is essential. (Eisenhower)

slide39

Can You Find Waste in Your Area? How Do They Build On Each Other?

Waste? (muda)

  • Overproduction and Production of Unwanted Products:
  • Material Movement:
  • Worker Motion:
  • Waiting:
  • Over-processing:
  • Inventory:
  • Correction of defects:
  • Wasted creativity of employees:

Variable Workload?

(mura)

Overburden?

(muri)

slide40

Not All Waste Is Equal

  • Production of Goods, Services Not of Value to the Customer
    • Most important form of waste
    • Worsens all the others
  • Appropriateness – key to quality health care!
    • Eliminate tests, treatments, steps, processes that do not add value
  • Better to eliminate work than to improve how it’s done
    • Hard to beat the efficiency or safety of a cardiac cath that’s not done because it wasn’t needed!
    • If its not worth doing, its not worth doing well.
          • -Donald O. Hebb
role of the leader in a lean organization
Role of the Leader in a Lean Organization

Standardized Problem Solving

  • Go and see
  • Ask “why?” 5 times
  • Respect people

- Fujio Cho, Chair of Toyota

Leader’s role is to mentor by asking questions

- John Shook, LEI

slide42

“But we don’t have the right culture to do this…”

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

---John Shook, Ph.D.

Author, Learning to See

and Managing to Learn

Lean system empowers by cascading responsibility:

  • Standard work created by workers
  • Stop the line (andon cord) for abnormalities
  • Standard workplace to do the job every time (5S)
  • Systems to replenish what’s needed (kanban)
  • Value stream mapping to see complex processes
  • Structured problem solving and idea presentation (A3)
why umhs chose lean thinking
Why UMHS Chose Lean Thinking?

…to improve quality and efficiency,

to reduce errors and stress

  • It is a learning approach
    • Empowers workers to redesign their work
    • Uses “Work as Learning”
  • It is the scientific method applied to all we do
    • Uses “Work as Discovery” of new knowledge
is lean thinking just cqi tqm in a new coat of paint
Is Lean Thinking just CQI/TQM in a new coat of paint?

Builds on Traditional CQI:

  • Frontline workers redesign the work
  • Analyzes root causes of problems (5 whys)

Expands on CQI:

  • Starts with value defined by the customer
  • Each step to produce only what is needed by the next one: Just-In-Time
  • Uses “one piece flow” to surface problems now
  • Focuses on overburden & uneven workload, not just waste and errors
  • Value stream maps are very useful for invisible work of health care
mqs learning projects
MQS Learning Projects
  • Why use them? To Learn!
  • Goal of “Projects”:
    • Teach managers and workers that they can design their work to solve problems
  • Why not train all managers and workers first?
    • We Learn Lean Thinking By Doing
    • “Learn-do-reflect-discuss” cycle of a learning organization
mqs learning project results
MQS Learning Project Results

Radiation Oncology(over 70 faculty & staff)

  • Patients referred for brain metastases required 3 visits over 5 days (consult, simulation, treatment)
  • After mapping the process, the team redesigned the process, removing unnecessary steps
  • Now 95% of patients have all 3 parts within 24 hours
  • Billing process first-time-quality increased0% to >95%
        • Video www.med.umich.edu/mqs
mqs learning project results47
MQS Learning Project Results

Results Reporting~ 13% lab results had no ordering physician, radiology requisitions lost, extensive rework

  • Preprinted labels (12/06)
  • Imaged requisitions increased by 880% (from 957 to 9380)
  • Labs without ordering physician fell from 13% to 2%
internal results reporting
Goal

Improve delivery of test results

Accomplishments

Enhanced & implemented Results Inbox

Reduced lab requisitions with no ordering provider from 13% to 2%

Internal Results Reporting
mqs learning project results49
MQS Learning Project Results

Emergency Dept. and CPU

  • Acute coronary syndrome:
    • Goal is “Door to Balloon” within 90 min.
    • Go and see, mapping: time spent on EKG, serial paging
    • Redesign patient flow, parallel paging
    • Within 90 min. – Increased from 75% to 85%
  • Time to ED discharge decreased 10 minute

Before, nurses prioritized sickest, never got to discharges.

mqs learning project results50
MQS Learning Project Results

Care Transitions: MFH discharge from 5B

  • Timely appointments in hand at discharge
  • Management until the first follow-up visit
  • Mapped the discharge process, MLine pilot
  • Pilot results:
    • Decreased 14 day readmissions by 33%
    • Decreased visits to ED within 72 h. by 81%
mqs learning project results51
MQS Learning Project Results

Cardiovascular Center

32 projects and analyses over 3 years

  • Non-value-added time during device clinic visit reduced from 100 to 10 minutes
    • Tech & nurse visits simultaneously
  • Time for new medication delivery decreased from 90 to 41 minutes with implementation of “cart-less” system
  • Standardized bedside stocking in ICU reduced extra supply runs from 4.5/bed/month to 1.7/bed/month
mqs learning project results52
MQS Learning Project Results

CT scheduling and throughput

  • In by 9, out by 5 for inpatients; no longer a weekend bottleneck

Vascular Access

  • Doubled PICC lines placed within 12 hours by nurses from 35% to 71%; reduced by 46% cases needing interventional radiology
  • Nurses standardized their cart, saved 1 hour/day
additional materials
Additional Materials
  • Michigan Quality System “House”
  • MQS Project Selection Process/Criteria
  • Waste Examples in Health Care
  • The Ideal Patient Care Experience statements for UMHS
slide60

MQS

Michigan Quality System

Just-In-Time

Built-in Quality

UMHS Values: Respect, Compassion, Trust, Integrity, Collaboration, Leadership

Overview/MQS Philosophy (All Missions) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, Park-Nicollet /jmk 04.09.07

slide61

MQS

Michigan Quality System

Quality – Safety – Efficiency – Appropriateness – Service

Built-in-Quality

Just-in-Time

Error-Free

Don’t Make,

Accept, or

Send on

an Error

Using the fewest resources to consistently deliver

exactly

what the customer needs

Customer Defines Value

LeveledWorkload

Continuous Improvement (P-D-C-A) and Learning

Standardized Work

Make Value Flow by Eliminating Errors and Waste

MQS House – Master version (All Missions) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, J. Womack, Park-Nicollet /jmk 04.09.07

slide62

MQS

Michigan Quality SystemSafe - Effective - Efficient - Patient-Centered - Timely - Equitable Health Care

Built-in-Quality

Just-in-Time

Error-Free

Don’t Make,

Accept, or

Send on

an Error!

Using the fewest resources to consistently deliver appropriate careRight Care,

Right Time,

Right Setting

IdealPatient Care Experience

LeveledWorkload

Continuous Improvement (P-D-C-A) and Learning

Standardized Work

Make Value Flow by Eliminating Errors and Waste

MQS House (Clinical Mission) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, J. Womack, Park-Nicollet /jmk04.09.07

slide63

MQS

Michigan Quality System

Quality – Safety – Efficiency – Appropriateness – Service

Just-in-Time

Built-in-Quality

QUANTITY

QUALITY

  • Pacing by Demand
  • Continuous Flow
  • Pull Systems
  • Error Proof
  • Surface Problems
  • Stop and Respond to Abnormalities
  • Solve Problems at Root Cause

Customer Defines Value

STABILITY

LeveledWorkload

Continuous Improvement(P-D-C-A) and Learning

StandardizedWork

  • Methods
  • Robust Processes
  • Organized Workplace (5S)
  • Visual Control
  • Technology and Equipment
  • Reliable, Tested
  • Serve People and Processes
  • Preventive Maintenance -TPM
  • Work Force
  • - Skilled, Capable, Flexible
  • Engaged, Motivated- Design Work, Solve Problems
  • Materials
  • Materials Readiness
  • Supplier involvement

Make Value Flow By Eliminating Errors and Waste

MQS Methods (All Mission) Sources: J. Shook, J. Billi, J. Liker, S. Hoeft, Park-Nicollet /jmk 04.09..07

mqs project selection criteria
MQS Project Selection Criteria

Quality

Safety

Efficiency

Appropriateness

Service

  • Critical UMHS priority
  • Opportunity for improvement – large gaps between optimal and current practice
  • Opportunity to expand upstream and downstream; and to translate sideways
  • Existence of a clinical champion
  • Visibility – potential for creating a model line
  • Learning opportunity – for the workers and leaders
michigan quality system project selection process
Michigan Quality System Project Selection Process
  • Select Areas:
    • Prioritization Committee (COO, CFO, CMO, CIO, Chief of Nursing, Group Practice Director, Director of Ambulatory Care)
  • Project leads:
    • Process Owner, Corporate Sponsor
    • Determine scope, participants and timing
  • Leadership panel:
    • All the leaders who need to approve the Future State Value Stream Map and the plan to get there
    • They support the implementation
two models of project support in the michigan quality system
Two Models of Project Support In the Michigan Quality System
  • Central coaches:
    • Assigned by central Prioritization Committee
    • Complex, cross silo projects
    • Majors: CV, OR, ED, 5B ward, supply chain, home care
  • Area coaches:
    • Assigned by their department
    • Within line management
    • Areas: Amb Care, Group Practice, Pathology, Medicine, Psych, Childrens, Radiology, Radiation Oncology …

All coaches collaborate as a community of learners:

    • Share strategies and tactics
    • Build standard work for coaches: the MQS model
    • Mentor other coaches
slide67

Unevenness

Unreasonable-ness

GM’s Categorization of Waste

CURRENT

THINKING

REQUIRED

THINKING

Processing

Correction

P

C

Over

Production

Inventory

O

TYPES OFWASTE

I

WASTE

W

M

M

Motion

Waiting

Material

Movement

WASTE NOT DEFINED

REACT TO LARGE EXAMPLES

REACTIVE IMPROVEMENT

WASTE IS "TANGIBLE"

IDENTIFY MANY SMALL OPPORTUNITIES

LEADS TO LARGE OVERALL CHANGE

CONTINUOUS IMPROVEMENT

Source: GMS Training

slide69

Eight Forms of Waste in Healthcare

  • Overproduction and Production of Unwanted Products:
  • The most important form of waste – worsens all the others.
  • Any health care service that does not add value to the patient
  • Antibiotics for respiratory infections
  • CT screening for coronary disease with no symptoms
  • Medication given early, testing and treatment done ahead of time to suit staff schedules and equipment use
  • Appropriateness – key dimension of QI in health care!
  • Material Movement:
  • Moving patients, meds, specimens, samples, equipment
  • Worker Motion:
  • Searching for patients, meds, charts, supplies, paperwork
  • Long clinic halls
  • No printer in exam room for prescriptions, patient education
  • Adapted From Long, Mersereau, Billi
slide70

Eight Forms of Waste of Healthcare

  • Waiting:
  • ER staff waiting for admission, can’t see next patient
  • Waiting for test results, records, information
  • Nurse waits for med, blood draw, transport, OR cleaning
  • Over-processing:
  • Bed moves, retesting, repeat paperwork, repeat registration, multiple consent forms, logging requests
  • Inventory:
  • Bed assignments, pharmacy stock, lab supplies, specimens awaiting analysis
  • Patient waiting for anything – tests, visits, discharge, phone cues
  • Correction of defects:
  • Medication errors, wrong patient, wrong procedure, missing or incomplete information, blood re-draws, misdirected results, wrong bills
  • Wasted creativity of employees:
  • Resident trying to find a Livonia infusion center
lean thinking seeing problems as interconnected
Lean Thinking: seeing problems as interconnected

5 admissions on “call day”, none for next 2-3 days

  • Waste: -Muda
    • Errors (no beds on home unit)
    • Worker motion (patients scattered on 5 floors)
    • Inventory (patients waiting for rounds, orders, D/C)
    • Workers waiting (for the COW to arrive from last floor)
  • Uneven workload, variability -Mura
    • Busy call day, “recovering” next day
    • Batch orders till end of rounds (none -> rush)
  • Stress of overburden -Muri
    • Physicians, nurses, clerks rushing through work
    • Duty hour limits; nurse and PA shortages
slide72

January/February 2001 – Volume 20, Number 1

HEALTH

AFFAIRS

“Every good improvement effort starts with an ugly story.”

Don Genord, GM

Interview:

A Founder of Quality Assessment

Encounters A Troubled System Firsthand

By Fitzhugh Mullan, p137-141

“At the University of Michigan, the outpatient and inpatient teams are entirely separate…There are areas where no one takes responsibility, where planning is weak, where I am left on my own

…The system is the problem…Things won’t improve until something is done about the design of the system…The system is the responsibility of the doctors and the leadership.

…….tell the committee that Donabedian said they have a problem.”

michigan quality system strategy for lean transformation
Michigan Quality System:Strategy for Lean Transformation

1. People Development - Leaders -Managers - Frontline Staff

  • “Just-in-time” training: Learn Lean by Doing
  • Coaching and mentoring
  • Courses, talks, web resources, book club

2. Process Improvement - Focused on institutional priorities

  • Value stream analyses and workshops
  • Rapid-cycle improvement and “Just do it” activities
  • Lean in daily work
working to cross the chasm at umhs the ideal patient care experience
Working to Cross the Chasm at UMHS:The Ideal Patient Care Experience

A) Each patient will have an Advanced Medical Home

  • continuity of care across INPT, OPT, ED, home, non-UM…

B) We will use Patient and Family Cantered Care in design and operations.

C) We use Evidence-based Standard Work.

D)Safety will be a System Property.

E) We deliver care in an Environment of Service Excellence.

F)Care Coordinated Around the Patient’s Needs

  • minimize and managing handoffs
  • communicate effectively among providers,
  • understand the patients' goals, needs, values, lifestyle, and make their health care work within that framework.

G) We will provide Facilities and Amenities that Promote Health and Well-being.