Lean Thinking

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					Lean Thinking

Lessons from manufacturing to
improve patient experience and create
value streams that “flow”

14th August 2006
Lean & Agile Presentation

Get the “Big Question” out of the way early….

                   “This pommie bloke’s not a doctor!”

                   “What gives him the right to suggest to us,
                   how to run our hospitals?”

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Lean & Agile Presentation

 A major Japanese offensive on the US Car industry
 during the 1980’s and 1990’s.

            +1.72M vehicle                    -1.82M vehicles
             transplants                           losses

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Lean & Agile Presentation

 Ongoing devastating news
 out of Detroit

     “GM (the worlds biggest car manufacturer for 75 consecutive years) has
                  This, and announced losses of US$10.6Bn for
       now lost top spotdespite a near record automotive market 2005”
                      I.e. 17 Million Vehicles sold last year
     “Ford announced losses of US$3.6Bn for 2005”
     “Tens of thousands of staff layoffs in both Ford and GM”
        “It’s a great time to be bankruptcy protection”
      “GM recent filed Class 11 selling cars in the US…provided you are
                       NOT an American Car Manufacturer” -

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Lean & Agile Presentation

European Parallels

   European market share
                                 Influx of Japanese
   losses, Closures, Panic
      GM Vauxhall / Opel
             Mercedes            Nissan: Washington
            BMW/Rover            Nissan: Barcelona
            Ford / Jaguar         Honda: Swindon
              Renault              Toyota: Derby
                Fiat              Toyota: Hanover
               Volvo               Toyota: Lisbon
 Invetech   Volkswagen       4
Lean & Agile Presentation

            The Toyota “Conundrum”
                • Hardly Flashier Cars
                • Same Raw Materials
                • Robotic Employees?
                • Similar Price
                • Fewest defects, yet take least time to make
                • Parts supply chain have most availability with one tenth
                 the inventory
                • Shortest lead times and world class customer response,
                 yet the most profit per car by thousands of $’s
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Lean & Agile Presentation

By now things                 “Manufacturing in UK now represents only
were starting to              15% of Economy; approx’ half what it was
                              15 yrs ago” – UK BBC Radio 4: April 2006
get “personal”

                                        Est’ 75,000 Jobs

                            Many more families devastated
Lean & Agile Presentation

       ….couldn’t happen here… right?

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Lean & Agile Presentation


            The Prognosis for Manufacturing reads “TERMINAL”

            “Regular drugs” obviously don’t work, because they
                         would’ve worked by now.

                            There has to be a “better way”

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Lean & Agile Presentation

       So what’s that got to do with Healthcare?

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Lean & Agile Presentation

    The State of Manufacturing!            The State of the Healthcare?
   • Endemic Inefficiency                 • Accusations of Endemic
   • Capacity constraints                 • Capacity constraints
   • Poor Quality                         • Hospital acquired infections
                                           and avoidable injury and death
                                          • Public and political concern
   • Long lead times and crippling
                                           regarding waiting lists and

                                          • Financial deficits
   • Financial deficits

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Lean & Agile Presentation

                                            Capable staff want
Sound Familiar?                              to do a good job
                                                                  “System” doesn’t let them
                More waste & loss of

   pressure                                                            Mistakes/Errors

        Knee jerk solutions with                                            Poor Morale
           root cause never
                                                                     Poor results

            Chaos           Fire fighting               Blame           Losses
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Lean & Agile Presentation

       “There has to be a better way”

                  “Rethinking” the way we do things and
                  attack the systemic “Pathology of the
                       Disease” not only it’s symptoms

                                                 Lean Thinking


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Lean & Agile Presentation

       What Lean Thinking is not!
     • NOT about threatening safety or threatening jobs
     • NOT about “cutting corners” and or “compromising quality”
     • Not about treating patients like “widgets”
     • NOT necessarily about changing how Healthcare providers
        actually do their “value adding” work
     • NOT just about refining or “sprucing up” your current systems
     • NOT just for the car industry
     • NOT just about the “Quality Dept”
     • NOT a “passing fad” (I.e. its been 60+ years in the making)
     • NOT a “silver bullet” or “quick fix”

                                             wouldn’t work.
                       ….’cos if it was, it 13
Lean & Agile Presentation

       What Lean Thinking is
     • “Quite brilliant” systems and processes
     • “An idea” and a “different way of thinking”
     • Common Sense, yet rarely common practice
     • Profound and fundamentally different to the way we may currently
        think about processes that aim to “add value”
     • Lean is an expression of the Toyota Production System
     • Something that you need to do!!
     • Disciplined and therefore, very, very hard to sustain
     • Simple

                   …. and because it is “simple”, it works!
                      but,              so very hard to
                   sustain, people rarely stay the course
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Lean & Agile Presentation

   “If it is so hard, why bother?”

     • Profound and demonstrable improvements
        commonplace in lean interventions
     • An opportunity to really engage with clinicians, doctors and
        nurses and learn with them “a better way”
     • An opportunity to improve the safety of workplaces for your
        patients and professionals
     • An opportunity to rethink what you do from the patients
        (customers) perspective
     • To have fun learning how

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Lean & Agile Presentation

Lean is looking at processes
from the point of view of “Value”

                                                       Admission                   Lead Time                                    Discharge

                                                                                       Green: Value Adding time
                                                                                       (consultation,theatre, treatment etc.)
               The green
               portion of the                      Adding Value
               lead time that
               actually adds
               value to the                       Adding Cost
               end customer                        or “Waste)

                                                                                    Red: Non-Value Adding Process time
                                                                                    (waiting, moving, counting, queuing)

   “In most organizations there is at least 9x more non-value adding activity (during
     a patient journey) than there is activity that meets the patients needs”
                       Source: Nigel Edwards, policy Director NHS Confederation
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Lean & Agile Presentation

Identifying and then removing Complexity, Waste and
“Non-Value Adding activity

                                             Admission       Lead Time                Discharge

                                                                  Green: Value Adding time
                                                                  (consultation,theatre, treatment etc.)
     Lean is fundamentally
     about reducing /         Adding Value
     eliminating the red
     stuff and not
     necessarily about        Adding Cost
     reducing the time         or “Waste)
     allocated in green.

                                                                     Red: Non-Value Adding Process time
                                                                     (waiting, moving, counting, queuing)

“Lean focuses improvement effort on things that matter to patients and clinicians
  that currently get in the way of and interrupt care”
                                               Source: Nigel Edwards, policy Director NHS Confederation
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Lean & Agile Presentation

 Waste = Anything that the “customer” wouldn’t pay for?

     • Over production – Processes that produce more than is immediately
            required right now by the next process step right now.
     • Delays – queues, waiting lists (An inevitable symptom of overproduction)
     • Inventory – stock sitting in stores (people in waiting lists) not being
            worked upon (engaged in care)

     • Unnecessary Transportation – moving product (patients)around
     • Excessive Motion – people walking, bending, searching, stretching etc.
     • Over Processing – unnecessary/duplicated process steps, complexity etc.
     • Defective products – scrap, rework (Errors in clinical care etc).
     • “Mushrooms” and untapped resources– not using the human
            potential and “brainpower’ of the experts in your organisation
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Lean & Agile Presentation

     Constraint Theory

   • At what rate can the customer of the process below expect product?                    /hr

             A         B        C         D            E         F
            100/hr   100/hr    70/hr     50/hr        100/hr   500/hr

                                                                          “The customer”

   • If we were to improve step C to produce 100/hr at what
            rate can the customer now expect product?
   • Alternatively, if we were to improve step D to produce
            100/hr at what rate can the customer now expect product?

   • You are the CEO and a keen young engineer comes to you
            with a suggestion to spend $0.5M on a robot that will speed
            up A to 200/hr. Do you reach for your cheque book?
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Lean & Agile Presentation

     Process Thinking and Constraint Theory
                                                              Lets install a ROBOT

  Raw       Machining
                          Fabrication     Sub      Painting                          Despatch   Finished
 Material                                                        Final Assembly
                                        Assembly                                                 goods

       Should we fail to map our whole processes – end-to-end…..

                        • Good ideas of “local impact” only e.g.
                          indiscriminately adding more beds
                        • “Well intentioned” but essentially “knee jerk”
                          improvement activity
                        • Lots of effort doing the things that “appear”
                        • But is this real and lasting improvement???
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Lean & Agile Presentation

     “Learning to See” at the MCG

             • Why do you think football coaches sit up in the stand?

             • It doesn’t matter how much we run about on the pitch, if it is not
                affecting the scoreboard……who cares?

             • If we can’t “see the whole picture”, how do we know where and
                what type of effort apply?
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Lean & Agile Presentation

“Learning to See” the Current State Map of the whole process
showing “what really happens” from the patients viewpoint

 Only 100 minutes of “Value” spread during 6 visits over 31 Weeks
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                               Source: “Lean Thinking for the NHS”: Dan Jones & Alan Mitchell, LEA UK
Lean & Agile Presentation

 Developing the Future State Value Stream Map

             “Patients continually flowing through each step with each
             subsequent step “pulling” treatment, resources and skills towards
             it, one at a time, only and exactly when it is required”

                      Admission         Diagnosis      Treatment           Discharge

                            Pathology     Radiology        Laundry    Pharmacy

                                           Supporting Processes
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                                                                     Source: “Lean Thinking for the NHS”: Dan Jones & Alan Mitchell, LEA UK
Lean & Agile Presentation

  Continuous Flow
            Once a “raw material” has been “picked up” in the system , it should not be put
            down until all of the processing (value adding) steps have been completed
             “Allowing the patient to go where he/she “needs to go”

                                                                    Finished Goods

                                                              Finished Goods
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Lean & Agile Presentation

     Processes can seem “simple”

                                    Making Aluminium Windows
                                                         Timber   Glass

              Cutting   Machining     Pre-Assy   Frame   Reveal   Glazing   Despatch

              Cutting   Machining                 Sash


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Lean & Agile Presentation

   Material Flow Mapping by product / process family

                   Window Frames

     The Moving Pane ( “Sash” )

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Lean & Agile Presentation

   My particular favourite
   Spot your factory….




                                                                Sashes                                          Sashes


                                              Gun s
                                              N a il
                                              N ai l

                                                                                  Security Door Rack

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Lean & Agile Presentation

   Healthcare is not like that,

                            Day Care Unit: Wirral Hospital, UK

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                                          Source: “Lean Thinking for the NHS”: Dan Jones & Alan Mitchell, LEA UK
Lean & Agile Presentation

   Healthcare is not like that,

                            Discharge Process: Bolton Hospital, UK

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Lean & Agile Presentation

     Process Complexity vs Quality?

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                                Source: “Lean Thinking for the NHS”: Dan Jones & Alan Mitchell, LEA UK
Lean & Agile Presentation

     The 5 Principles of Lean Thinking

                  • Specify “Value” from the patients viewpoint
                  • Identify all the steps that constitute the “Value
                  • Eliminate waste steps and activity
                  • Make the remaining value-creating steps
                      “flow” rhythmically and uninterrupted
                  • As flow is introduced, allow demand to pull
                  • Repeat this process until a state of
                      “perfection” is reached

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Lean & Agile Presentation

What it will take…

            • A profound and fundamental change to the
              way we approach what we do today

            • A realization that “tweaking the current
              processes or the way in which we measure
              them” will NOT suffice anymore

            • A “Leap of Faith” for some…….

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Lean & Agile Presentation

 What does a “Lean Culture” look like

      • “It’s the way we do things around here”
      • Lean Culture is achieved when Lean Thinking is fundamental
            and important to all stakeholders ALL the time
      • Lean Culture is “fostered in the lunchroom”
      • Lean solves problems slowly and methodically with data and
            the “end-to-end” value stream in mind……..yet makes its
            decisions quickly
      • Lean Cultures makes all its decisions based on Lean Principles
            naturally and intuitively (I.e “when the boss is not watching)

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Lean & Agile Presentation

 Health Warning!

   • Lean Thinking is often counter-intuitive will challenge conventional and
      deep seated ideas associated with Efficiency and Economies of Scale.
   • Lean will often “trade-off” local efficiencies against their effects on the
      system as a whole
   • Lean Thinking may be disincentive as reflected in current funding
   • Lean thinking will almost always fundamentally change the way people
      perceive their roles
   • Lean is not a “Quick Fix” and will not resolve immediate financial crises
   • Most counter-intuitive of all, is the idea that we can achieve more by
      working the system less hard.

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Lean & Agile Presentation

 Current Lean Models that actually work!!

                            A Training Program for Clinical System Engineers:

             Currently assisting 6 major Victorian hospitals to “Go Lean”
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Lean & Agile Presentation

 Real Improvements!
  “We can do 15 to 20% more work, often safer with same resources and budget.
  Everything has improved: cost, quality,delivery, service, staff morale”
  – Professor David Ben-Tovim Flinders Medical Centre, SA
                            “Lean engages the enthusiasm of frontline staff”
                                            – David Fillingham- Bolton NHS Trust
  “Dramatic improvement in quality, mortality, errors, patient satisfaction, morale along
  with increased throughput with same resources and better utilisation of theatres”
                            – Professor Dan Jones, Lean Enterprise Academy, UK

   “Opportunities identified in reducing time taken to process samples for
   endocrinology and haematinics from between 24-30hrs to between 2-3 hrs”

              “Staff currently have to work very hard just to get into a position where they
              can do there job properly”- Lean addresses the obstacles in everyday work
              to release true capacity
     “A true Win-Win-Win for all stakeholders            – Professor Dan Jones, Lean Enterprise Academy, UK

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                                                  Source: “Lean Thinking for the NHS”: Dan Jones & Alan Mitchell, LEA UK
Lean & Agile Presentation

 What does a “Lean Leader” look like

            • “Walks the walk” and “Talks the talk” ALL THE TIME
            • Is prepared to stick to his guns through “Choppy Water”
            • Is prepared to “let go” and allow others to make mistakes
             as they learn. i.e. “Lead” rather than “Manage”
            • Encourages people to “Think” rather than “Do”
            • Be prepared to acknowledge that “in the past we may
             have been wrong”
            • Realizes that Lean is “about the journey” and a “forever
            • Doesn’t take him or herself too seriously
            • Is prepared to make it FUN!
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Lean & Agile Presentation

 What did you have for breakfast today?

 Lean is not only about being involved , but being truly committed!!

                 “Involved in Project”        “Committed to Vision”
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Lean & Agile Presentation

 So what are YOU waiting for?

                 • Lean is not about “waiting for somebody else
                   to drive it”
                 • Not a directive imposed by the DHS
                 • …(or any other administrative body for that
                 • Must be driven at local level
                 • Must be fearless and driven with enthusiasm

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Lean & Agile Presentation

                            All “too hard”?

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