PRINCIPLES OF LEAN
Lean Awareness Workshop
Outline
• Introduction and Welcome
• Background to Lean
• Lean Principles
• Flow Exercise
• Value-stream Mapping
• Waste Spotters Exercise
• Lean Toolbox
• Rapid Improvement Events (RIEs)
The Six Challenges
• Re-engineered care processes
• Effective use of information technology
• Knowledge and skills management
• Development of effective teams
• Co-ordination of care across pathways
• Making change possible
Institute of Medicine
Crossing the Quality Chasm: A new Health System for
the 21st Century Corrigan JM 2001
Safety Timeliness
Effectiveness
Dimensions Efficiency
of Quality
Patient Equity
-centeredness
Where Does Lean Originate?
• Developed by Toyota as the Toyota Production
System (TPS) over the last 50 years
• Study of TPS led to academics defining the
approach as “Lean”
• The application of Lean is not new – principles
have been used in many industries.
• In the last ten years, increasing application of the
Lean approach in healthcare
Lean Strategy for TPS...
•Requires a focus on whole systems and processes
•Relentless focus on delivering services/products
which meet the needs of the customer, or in healthcare,
the patient
•The application of the PDSA (Plan, Do, Study, Act)
rapid change cycle
Lean Principles
Jones & Womack, Lean Thinking-Revised, 2000
Map the
Establish
total
value in
customer/
the eyes
provider
of your
value
customer
stream
Make
Search for
value
perfection
flow
with no
with no
waste
interrup-
tions
Pull what
you want
when you
want it
Why is Lean Relevant?
• “Lean thinking is not a manufacturing tactic or a
cost reduction programme, but a management
strategy that is applicable to all organisations
because it has to do with improving processes. All
organisations – including healthcare organisations
– are composed of a series of processes, or sets of
actions, intended to create value for those who use
or depend on them (customer/patients)”
• IHI: Going Lean in Health Care, 2005
Lean in Healthcare
•Virginia Mason – USA
•Theadacare - USA
•Bolton NHS - England
•Gwent NHS – Wales
•NHS Tayside, NHS Lothian - Scotland
The Nun and the Bureaucrat
A book and DVD outlining how 2 hospitals used Lean
principles to transform their systems
• “The fact is that a patient is not a car, and never will be. So.
If that were the problem we were trying to solve, we’d be
stopped.
• However, the Toyota system is set up to identify customer
needs in very clear ways and to meet those needs in
explicit, efficient, rapid supplier-building methods.
• They’re quite superior in the world of work, so if you said
there was no work in healthcare then we’ve got a gap. But
as long as you confess that work’s there, then I’ve got a
solution.”
• G. Kenneth Turnbull, Ph.D.,
• Executive Vice President of Alcoa Business Systems
Economies of Flow
Mass/Volume Thinking Lean thinking
Economies to Scale Economies of Flow
•Big is good/cheap – fast production •Right size is good – rate-based
rates production
•Focus on operation – doing the job (s) •Focus on process – gluing jobs
together
•Specialists have skills – centralised in •Everyone has skills – and expected to
few people use them
•Information – need to know? •Information – visual
•Performance is about tradeoffs – •Performance is about root cause –
example: better quality costs money example: better quality is cheaper
•Manage by variety – by batching •Manage variety – by skills to rapidly
together similar items change from item to item
Sources of variation in a
clinical system
Staff Process Patients
age motivation
motivation unclear
skills disease
illness holiday guidelines
differ race education
shifts training
complications sex
anaesthetics
GP
Machines/rooms transcription
not the same transport
suppliers 80% is under
our control
applications
Information
Resource
Resulting in..
Systemic issues
Poor
Scheduling Absence of
Unquantified
of process
capacity and
appointment ownership
demand
s and and control
resources Overly Few defined
complex processes
pathways and no
built in waits standard
and delays working
Healthcare processes are all
about flow.
“Toyota revolutionised our expectations of production;
Federal Express revolutionised our expectations of
service. Processes that once took days or hours to
complete are now measured in minutes or seconds.
The challenge is to revolutionise our expectations of
healthcare: to design a continuous flow of work for
clinicians and seamless experience of care for patients”
Don Berwick, “Reducing Delays and Waiting Times
Throughout the Healthcare System” IHI 1996
Value-Stream Thinking
• “Stop looking at aggregated activities and
isolated machines…Start looking at all
the specific activities and see how they
interact with each other.”
Womack and Jones
What does it do to our patients?
• When a patient experiences a service it is either
good - and therefore what they expect - or it is bad.
Patients do not experience “averages”
• As consumers in the outside world we have
expectations of good quality and service, if these
expectations are not met then we take our business
elsewhere…
• In health our patients do not readily have that
choice.
Process Map
A process map answers questions, such as…
• What is the waste in the process?
• Where are any blockages to flow?
• How long does each process step take?
• How many handovers are there?
Mapping and analysis of the
Process
Increasing level of detail
Two Elements to Every Job
Value Adding Non-Value Adding
Valuable Effort Valueless Obvious
Effort Waste
Costs Time Costs Time
Costs Money Cost Money
Adds Value Adds No Value
VALUABLE WASTE
Types of Waste
• Toyota’s Seven Wastes
• * Transport
• * Inventory (work in progress)
• * Motion
• * Waiting Time
• * Over-processing
• * Over-production
• * Defects
• TIMWOOD
Wastes in a Healthcare Process
Lean waste Examples in radiology
Defects Running unnecessary scans; forms not being signed, faxes sent that
are illegible
Overproduction Undertaking multiple scans
Excess inventory Extra supplies
Excess processing The process for ringing porters in the evening is to ring the Help Desk
and then to be routed to the porters; entering duplicate information;
printing paper reports to send in post
Unnecessary motion Time spent looking for staff; entering duplicate information; looking for
parts and forms; interruptions from other staff
Unnecessary Transportation of scan results in post
transportation
Waiting Waiting for referrals/scans; waiting for reports/signatures; waiting for
patients, doctors, porters
Underutilised staff Helpers in waiting rooms; secretaries waiting for reports to be signed
Lean Thinking – Improving flow and eliminating waste
- Neil Westwood, NHS Institute for Innovation
and Improvement
Standardisation
•This is an important challenge in healthcare
delivery
•It requires agreement from all groups in the
pathway of the best way to do the job
•Requires a clear way in which this is shared
•Needs a clear procedure for agreeing any
process changes
•Performance management to track adherence
Lean Tools
• Value-stream mapping
• PDSA cycles
• Understanding Demand, Capacity and
Variation
• Root Cause Analysis – often called 5 Whys
and How (5W + H)
• 6S/Visual management
• Glenday Sieve
• Rapid Improvement Events (RIEs)
Lean Principles
Jones & Womack, Lean Thinking-Revised, 2000
Map the
Establish
total
value in
customer/
the eyes
provider
of your
value
customer
stream
Make
Search for
value
perfection
flow with
with no
no
waste
interrup-
tions
Pull what
you want
when you
want it
„Flow‟ in health care
Progressive uninterrupted movement of patients,
information and equipment between
departments, staff groups or organisations as
part of their care pathway.
- NHS Modernisation Agency,
2005
Effective flow is a property of
the entire system
Patient Pathway
Micro-system Micro-system Micro-system Micro-system
Teams make day to day, minute by minute decisions in their own
micro-systems without a view of the whole system. Even if they
have optimised their own system it may do nothing for the whole
patient pathway.
Patients need to flow through the healthcare system, however if
underlying processes are inefficient we will not manage patients
effectively.
Effective flow in action – Unscheduled
Care Collaborative 5 Patient Flows
Group 1 -
Minor Injury &
Illness
Group 2 – Acute
Assessment Group 5 -
Out of Hospital Care
Group 3 –
Medical Admissions
Group 4 –
Surgical
Admissions
Advantages of Improving
Patient Flow
• Improved patient outcomes and improved service quality
• Reduced time that patients stay in hospital, improving
patient experience and freeing up inpatient capacity
• Reduced DNAs, improved resource utilisation and
improved overall value for money
• Improved discharge pathways and reduced variation in
length of stay
• Improved appropriateness of care – to make sure that
patients get the right treatment, from the right
professional, in the right place, at the right time
- Planned Care Improvement Programme, Patient Flow in
Planned Care, IST, 2007