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                         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!

				
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