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CH. 1 - AN OPEN LETTER TO HEALTH CARE PROVIDERS

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Lean Production

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Term applied to the production methods pioneerd in Japan after World War II by Kiichiro Toyoda and Taiichi Ohno o fthe Toyota Motor Corporation. Lean s a production strategy in which all parts of the production system are focused to eliminate waste whhile continuously increasing the percentage of value added work. The term was coined by John Drafcick of the international Motor Vehicle Program at Massachusetts Institute of Technology. It was the first publicized in the book The Machine that Changed the World: The Story of Lean prdouction by James P. Womack, Eaniet T. Jones, and Daniel Roos (1991).

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Muda

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Waste, meaning any activity, service, or supplyt hat consumes time, money and other resources, but creates no value

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Kaizen

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Continuous incremental improvement (the straw that stirs the drink)

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Sensei

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Personal trainer with the mastery of a body of knowledge, in this case Lean production

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Jidoka

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The intelligent use of both people and technology, with the ability (even obligation) to stop any process at the first sign of an abnormality; in other words, a system that keeps the patient safe, not that gets them harmed or killed; maximizes the use of machines and creates a defect free environment

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The seven healthcare flows

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(1) Patients (2) Clinicians (3) Medication (4) Supplies (5) Information (6) Equipment (7) Process Engineering

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Pull Production

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System where parts, supplies, informationand serves are pulled by itnernal and external customers exactly when they are needed

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Lean thinking

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Cutting waste by 1/2 over and over again

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CH. 2 - ELIMINATING WASTE WILL TRANSFORM AMERICAN HEALTHCARE

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Waste of Overproduction

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Making photocopies of a form that that is never used, providing copies of reports to people who have not asked for them and will not actually read them, processing piles of documents that sit in queue at the next workstation, Ccing email unnecessarily

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Value Stream

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The speicfic activities required to provide a specific service to a patient

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Waste of Time on Hand (Waiting)

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Patients waiting to see their physician; Clinic service representatives waiting on thephone to schedule appoitnments; early morning admissions waiting for surgeries that won't be performed until later int eh day; Patients waiting for support services such as internal transport; Staff waiting for office eqipment (e.g, computer or photocopier) to be repaired before being able to work; Staff waiting for a meeting that is starting late

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Standard Work

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A prescribed, reepatable sequence of steps (or actions) that balances people's work to takt time

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Waste of Stock on Hand (Inventory)

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Stockpiling office and clnical suplies that won't beused for weeks or months; Storing excess supplies whose "use by" date expires before they're used; Maintaining expensive implants that can be ordered on a just-in-time basis

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Kanban

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A way of automaticalluy signalling when new parts, supplies, or services are needed. In japanese, kanban means sign, sign borard, doorplate, poster, billboard, or card, but is taken more broadly tomean any kind of signal

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Rapid Process Improvement Workshop (RPIW or kaizen event)

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A team of of people who do the work , fully engaged in a rigourse and disciplined five day process, suignthe tools ofLean to achieve immediate results int eh elimination of waste.

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Waste of Movement

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Physiicans and staff looking for items that hsould be clearly labeled; Physicians walking to another location to check an online note during a patient exam; Clinicians going from one buldign on campus to another to attend a meeting

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Walk Time

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Time spent walking form one location to another

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Cell

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Work area

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Waste of Defective Products (Defects)

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Fixing errors made in documents; Misfiling documents; Dealing with service complaints; Making mistakes due to incorrect information or miscommunication; Filling out inpatient admission cards incorrectly; Handwriting orders in an illegible manner; Sending bills with an incorrect address

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Andon

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Visual control device, usually a light, that alerts supervisors to factor floor needs or problems

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Waste in Transportation

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Moving individual files form one location to another; Moving supplies into and out of a storage area; Moving eqipment for surgeries inand out of theoperating room; Moving eqipment for procedures in andout of procedure rooms; Transferring Charts from other buildngs onsite

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Waste in Processing

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Performing tests that areen't needd; Redundant capture of informatin on admission; Recording and logging the same data multiple times; Writing information by hand, when direct input to a word procesor could eliminates this step; Producing a paper copy when a computer file is sufficient.

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The Seven Types of Waste in Healthcare System

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(1) Overproduction (2) Waste of time (3) Too much inventory (4) Wasted movement (5) defects (6) Waste in transporting items (7) Waste in processing

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CH. 4 - THE LEAN HOUSE AND MODEL LINES

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GPS = Global Production System (Lean House)

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A generic and graphic representation of the Toyota Production System (Lean)

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Heijunka

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Scheduling products and services in a such a way as t elminate bottlnecks and maximize throughput (leveled production)

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Stop the line

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Where any staff member can stop any process or procedure if that staff member believes proceeding would wad ersely affect patient safety or negatively impact efficient operations

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Takt Time

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Proudction time aligned with demand (market demand)

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One-piece flow

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In one piece flow, all eqipment, other supplies, and iformation are physcally grouped together ito enable one person to perform allthe steps necessary to complete a process or action. It is the opposite of batching work.

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Standard Work in Pogress (SWIP)

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The amoutn of work-in process inventory on the floor to provide patient care for the day

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Operational availability

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Avaibility of heathcare equipment when needed

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Stardard Wrok Sheet

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A document identifiying the Steps necessary to complete a task, who houyld perform each step, and the reasonable (repeatable) amoutn of time to cmplete each step

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5S process

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(1) Sort (2) Simplify (3) Sweep (4) Standardize (5) Self Discipline

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Value Stream Map

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A pictorial repesentation of the steps ain a value system eother as a current or future (desired) state

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JIT

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Just In Time Production - producing only what's needed when and wehre its needed.

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CH. 5 - YOUR LEAN ACTION PLAN

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Kaikaku

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Broad-scale and radical improvement

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3P

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Proudciton, Preparation, Process

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Greenfield

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A new facility or process

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Brownfield

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An established facility or process

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Cycle Time

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The moutn of time it takes to complete a task or process; NOT the same as lead time

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Catch-Ball Process

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wher egoals are proposed and discussed by people all the way down and up the chain of command

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MBO

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Management by Objectives - a directive which is not based on ensuring that the prospoed targets can be achieved or that the chain of command ahs the means to do so.

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MBP

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Management by Policy ; "Catch-ball process'" Highly particpative; Opposite of management by objective (MBO), How goals are determined, how plans to achieve the goals are establsihed, and how measures are created to ensure progress toward the goals.

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Gemba

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Wher ethe work gets done; e.g., the facotyr or hospital floor

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KPO

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Kaizen Promotion Office

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KOT

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Kaizen Operations Teams

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CH. 7 - FLOW IN A HEALTHCARE ENVIRONMENT

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Pokayoke

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The Japanese term for a mistake-proofing device or procedure to prevent defects

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FIFO

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First in First Out

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PRN

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As needed

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Muri

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Unreasonableness

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CPOE

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Computerized physician Order Entry

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Point of use

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Where medicaiton storage is located where the patient is treated

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Monument

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Immovable piece of eqipment or furnishing

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ELM

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Extended Lab Menu - staff provides blood tsting equipment onsite for a 30 minute turnoaround time, with lab results available at the time of the patient's appointment.

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CH. 8 - KANBAN AND THE SUPPLY CHAIN

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Par level

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In kanban, the level of supplies and inventory considered prudent ot maintain on hand

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Sleeping Inventory

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Inventory that has largely been forgotten

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Even Flow

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Porcesses working in concern with ech other to prevent bottlnecks

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Kit

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All material needed at point of use put I a single container

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CH. 9 - LEAN COMES TO VIRGINIA MASON MEDICAL CENTER

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Stardard Operations

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Working to customer requirements of takt time, standard work,a nd standard work-in-process

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CH. 10 - VIRGINIA MASON MEDICAL CENTER CASE STUDIES

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Spaghetti chart

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A diagram of a patient and staff flow

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Cascade Scheduling

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Staggering start times for patient sand staff

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Tools For Improvement Journey

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(1) 3P (2) RPTWs (3) Standard work (4) Focus on Flow (5) Pull Production System (6) 5S workplace organization

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5 whys process

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Taiichi Ohno's practice of asking why five times whever a problem was encountered tin order to ifentify the root case of the problem so that effective coutnermeasures culd be deveoped and implemented.

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CH. 12 - PARK NICOLLET HEALTH SERVICES CASE STUDIES