Answer Just-in-time at Jimmy's 1. List the elements in St. James's new approach which could be seen as deriving from JIT principles of manufacturing. At the more philosophical level of JIT, the case describes the concept of waste identification and elimination. Waste is seen as a wide range of non- added value activities and costs. In this case students should be able to spot most of the following: excess inventory use of expensive items in lieu of low-cost ones duplicated inventory purchasing administration (too many suppliers) too many buyers excess materials in standard packs cancelled appointments in Urology surgery process complexity in Urology administration The first six of these are typical of wastes that can be identified in manufacturing operations, as they involve material management. The last two concern process management in administration systems, and as the textbook points out 'some processes are themselves waste(ful)'. a) The main emphasis in the case is on elimination of waste in the purchasing system. Referring to Chapter 13, on supply chain planning and control, we see that Jimmy's relationship with suppliers is changing from a medium-term trading commitment towards a more stable long-term relationship with fewer suppliers. Some characteristics of these relationships appear to correspond to Lamming's lean supply concept particularly with respect to delivery practices. However, it is worth discussing the conditions that make this possible and the risks involved. In this case, the main problem appears to be the medical staff's preferences for a wide range of different types of materials. To reduce input variety means standardisation, and this can be achieved by negotiation/persuasion, or by imposition/conflict. Jimmy's Supplies Manager seems to have used the former approach using cross-functional task forces. Suppliers must be assessed for their capability and interest, in order to ensure that they are likely never to fail to deliver as promised. The risks, then, are around the actual dependability and quality of the suppliers. As is emphasized in the case, low cost (of the purchased items) is no longer the predominant issue: long-term value for money in the overall purchasing/inventory processes is more critical. But it may be more difficult to measure! So perhaps there is an element of faith (or hope) involved here. b) Another element of improvement allied to JIT principles is the use of cellular operations. The case describes the complexity of the existing system for Urology admissions, which involved 59 handovers of information. One approach in class would be to ask the students what sort of information might have been involved, and which departments would have been responsible for providing it. Most people have some idea of the main functional areas in a hospital, and so you should be able to derive a list of around 20 pieces of information, and a variety of departments. You could then ask why the traditional large organisation, such as a hospital, divides up in this way. Arguments for functional organisation include: economies of scale faster learning of narrow work content tasks (specialisation) safety (e.g. in X-Ray and pharmacy) security of information convenient position, near inputs to the operation clear boundaries of responsibility concentration of expertise and training. The application of cellular principles involved making just four people responsible for a dedicated, self-contained admissions system. While the case does not give details, we can surmise that this must have involved devising a new process which cut across the functional boundaries, and gave much broader responsibilities to the employees. Some safeguards would have been made to ensure that neither the patient nor the employee was exposed to the risk of mistakes, such as the failure to notice that clinical tests had not been completed before admission. Most problems would have been 'political' since the redesigned system was faster and simpler. Opposition would be expected from managers of existing functions who might have seen this as undermining their department and expertise. These problems are common in manufacturing where production cells are first established in a batch/process layout environment. c) Another example was the use of kanban systems for some inventory management. This development was clearly in its infancy, but the case illustrates the simplicity of this approach. You should remind yourself that some students who have not seen the bureaucracy of a conventional purchasing system might not appreciate the radical changes suggested here! What is described is really a two-bin system for consumable independent items. Developments described in the case indicate that the empty carton will become the kanban communication direct with purchasing, eliminating the waste effort of the Ward Sister. It is useful to discuss the applicability of such systems for other items, and compare this case with the approaches used in the Temple University Hospital boxed example in this chapter. 2. What further ideas from JIT manufacturing do you think could be applied in a hospital setting such as St. James's? There are many issues which could be discussed here. Those that have experienced outpatient treatment in a general hospital might refer to the obvious 'wastes' involved with patient waiting (WIP). These can be reduced or eliminated by better scheduling. However, the complexity of the product range offered by a conventional clinic and its supporting centralised functions makes smooth scheduling virtually impossible, and WIP is used to buffer out the fluctuations in arrival and processing times. Perhaps the best approach here could be to separate high volume repetitive 'products' and create treatment cells or plant-within-plant operations. These types of operation, with more focused product ranges, allow more levelled schedules and much lower WIP, often with reduced overheads and less WIP storage space (waiting rooms). If you wish to pursue this argument with the class a good case to use is Shouldice Hospital (from the Case Clearing House) which describes the flow process of a focused hernia hospital in Toronto. Other areas of waste reduction that could be identified by students are: Motion reduction: Better layout can be designed into new hospitals to reduce the amount of patient and material transport required (portering). In existing hospitals this may be difficult to achieve because of old buildings and a history of incremental, ad-hoc developments. Defective goods reduction: Inspection-based approaches to quality still prevail in many hospitals. Prevention-oriented quality should reduce quality costs in the long term. It is interesting to note that surgery generally adheres to these principles anyway: good outcomes are achieved by attention to the quality conformance of inputs and processes (purchased items, training of surgeons and nurses, attention to tidiness, obsession with cleanliness and sterility, use of standardised procedures, etc.). This approach, applied to all areas of a hospital, should bring dividends in reduction in failure costs including rework. The involvement of everyone: Many aspects of this (as described in this chapter) are being introduced in the more progressive hospitals. It could be argued that JIT is only made possible by first establishing TQM principles and practices at every level in the hospital. Some hospitals have successfully introduced cross-functional teams for (waste reduction) problem resolution and improvement activities. In some cases, functional teams have developed service performance standards for their own work (e.g. porters, intensive care nursing). Other JIT Techniques: Most of the ten techniques outlined in the chapter have, at first sight, little relevance to a hospital. However, some ideas which might come out of a discussion, or from assessed work, include: Total Productive Maintenance: A particularly important technique in areas where critical pieces of expensive machinery are involved (e.g. scanners, X-Ray, intensive care). Improved up-time not only improves clinical safety, but also reduces the costs of rescheduling and lost utilisation. Set-up reduction: This approach could be important for activities such as bed linen changing, operating theatre set-ups, and clinic changeovers. Visibility: Increasingly seen around wards, clinics, etc., to show utilisation, waiting times, problem analysis, etc. Kanbans: Could (perhaps) be applied to moving of patients as well as materials!