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transcript
Introduction to Lean Principles
Planning of your work processes to improve flow
Productive Endoscopy WorkshopTuesday 15th October 2013
Amy Hodgkinson and Trevor TaylorNational Improvement Leads, NHS IQ
Simulation exercise
“The current state”
Simulation Exercise
• Practical simulation designed to introduce Lean principles
• 2 teams - all team members with a role
• 2 rounds with different focus
Simulation Exercise
1. Simulate the process within healthcare from end
to end
2. Observe the process and capture key metrics to
identify the key waste areas
3. Brainstorm improvements to the process
4. Try the key improvements and capture key
metrics to measure the success of the changes
Teams
1. Operator #1 (at step 1)
2. Operator #2 (at step 2)
3. Operator #3 (at step 3)
4. Operator #4 (at step 4)
5. Operator #5 (at step 5)
6. QA Inspector
7. Porter 1
8. Porter 2
9. Metrics/Time Keeper
10.Finance Manager
11.Observer
12.Observer
13.Observer
14.Observer
Simulation One
Objective:
• Produce 40 Endoscopy reports for scoped patients
Simulation RulesEach Operator:
• Collect lego pieces from stock room
• First operator ONLY - place sticky 1 on piece
1, sticky 10 on piece 10, 20 on piece 20, 30
on piece 30, 40 on piece 40
• Build as fast as you can
• Build according to batch size
• Call a Porter once batch size completed
• Porter will pass to next operator
• No pre-assembly
• No helping slower teammates
QA Inspector:• Check report by report – confirm pass / fail
• Inform Metrics/Time keeper
• when 1st, 10th, 20th, 30th and 40th report is
completed
• when sticky numbers 1, 10, 20, 30 and 40
arrive
• how many reports are correct (pass) /
incorrect (fail)
Simulation Rules
Process Observers - closely observe for the
following:
• How the piece moves from step to step
• How many times the operator collects stock
from the stock room
• Where work builds up
• Movement of people and pieces
• Other aspects you feel are important
Simulation Rules
Leadership Observers - closely observe for the
following:
• What do you observe about leadership in this
process?
• How do the “staff” feel about their work?
• What leadership behaviours are missing?
• How productive would this team be over the
long term?
Simulation Rules
Porter:• When called by operators 1-5, collect pieces
and transport to next operator or to the QA
Inspector
Simulation Rules
Metrics / Time keeper:• Start the process (start the stopwatch)
• Do not stop stopwatch until end of game
• Record time when 1st, 10th, 20th, 30th and 40th
reports are received by QA Inspector
• Record time when sticky numbers 1, 10, 20, 30
and 40 are received by QA Inspector
• Stop the stopwatch when 40th report and sticky
40 have been received
• Record pass/fail rate, no. of staff and cost
(request cost figures from Finance Manager)
Simulation Rules
Finance Manager:• Calculate profit and loss results and unit cost
per report
Correct Final Report £25
Incorrect Final Report £100 penalty
Inventory £5 per WIP piece
Staff & Equipment £1 per person per minute
Simulation Rules
On your marks…..
Results
What are the
principles of Lean?
What is Lean?• Perfected by Toyota – from 1928 (Deming & Ford)
• ‘Lean’ coined by Jones & Womack in 1990s
• Lean is about improving flow and eliminating waste
– getting the right things,– to the right place, – at the right time, – in the right quantities,
• while minimising waste and being flexible and open to change.
• Customer at heart of the process• Driver for Quality and Safety
Lean Thinking…
It is –
• A way of thinking
• A philosophy
• A mind set
• An approach
• A new culture
It is not –
• A management fad
• Rocket science
• A cost cutting exercise
• About making everyone
work faster
• A magic wand
• Just for manufacturing
NHS Change
Model
Lean principles support thecapability to
deliver the new NHS Change
Model
Solve problems using Root Cause Analysis,
‘Go See’ and data
Respect, challenge & grow them - become a
learning organisation
Eliminate WasteRight process will deliver the right result
Long-term Thinking and
Continuous Improvement
Ref: Liker 2004
Problem Solving
People & Partners
Process
Philosophy
The 4Ps of Lean
The continuous movement of patients, samples, request cards, reports from end to end through pathways
3Establish
Flow
Nothing is done by the upstream process until the downstream customer signals the need
4Implement
Pull
The complete elimination of waste so all activities create value for the customer
5Work to
Perfection
Define value from the customers perspective and express value in terms of specific requirements/measures
1Specify Value
2 Map the
Value StreamMap all of the steps… value added & non-value added…
Lean Principles
• Value Stream Mapping
• Process sequence charts
• Spaghetti map
• Handoff diagram
• A3 thinking / problem solving (PDCA)
• Root cause analysis
• One piece flow
• Kanban
• Demand smoothing
• Load levelling
• Takt time
• Work Combination Sheets
• Total Productive Maintenance
• Mistake Proofing
• Standard work
• Data and Measures
• Visual Management
• 5S
Lean “Tools”
• Voice of the customer
The continuous movement of patients, samples, request cards, reports from end to end through pathways
3Establish
Flow
Nothing is done by the upstream process until the downstream customer signals the need
4Implement
Pull
The complete elimination of waste so all activities create value for the customer
5Work to
Perfection
Define value from the customers perspective and express value in terms of specific requirements/measures
1Specify Value
2 Map the
Value StreamMap all of the steps… value added & non-value added…
Lean Principles
Where is the added value?
• Making the appointment
• Registration
• Waiting
• Diagnosis
• Treatment
A visit to the Doctors
The Customer defines Value Added
• Who is your
customer?
• What do they need /
want?
• How do you know?
• Do you understand
the ‘voice of your
customer’?
The continuous movement of patients, samples, request cards, reports from end to end through pathways
3Establish
Flow
Nothing is done by the upstream process until the downstream customer signals the need
4Implement
Pull
The complete elimination of waste so all activities create value for the customer
5Work to
Perfection
Define value from the customers perspective and express value in terms of specific requirements/measures
1Specify Value
2 Map the
Value StreamMap all of the steps… value added & non-value added…
Lean Principles
Value
UnnecessaryWaste
NecessaryWaste
MinimizeEliminateValue Added Activity
� Any activity that changes the
form, fit, or function of a
product/transaction
— OR —
� Something customers are
willing to pay for
Maximize
Understanding Value & Waste
Non-Value Added ActivityAny activity that absorbs resources
but adds no value is a Waste
Types of Waste - Simple Mnemonic• Doesn’t add value to the patient, healthcare provider or staff
– Transport
– Inventory
– Motion
– Automating an inefficient process
– Waiting
– Overproduction
– Over processing
– Defects
– Skills appropriate to task
WASTE-
costs
money and
adds time!
NEW Process
‘Old’ process
Spaghetti mapping
Things to think about…• Focus on 80% of the time (green stream)…people will always
remember the exceptions
• Look for bottlenecks & “batching” (Triage, vetting,
authorisation) – what stops flow?
• Look for “work arounds”… often duplication
• Focus on what “adds value” from the patient perspective
• Is unpredictable demand really unpredictable?
• Where are you losing capacity?
• Is everyone following the same system / protocol ? (standard
working)
• Could visual display help save time?
The continuous movement of patients, samples, request cards, reports from end to end through pathways
3Establish
Flow
Nothing is done by the upstream process until the downstream customer signals the need
4Implement
Pull
The complete elimination of waste so all activities create value for the customer
5Work to
Perfection
Define value from the customers perspective and express value in terms of specific requirements/measures
1Specify Value
2 Map the
Value StreamMap all of the steps… value added & non-value added…
Lean Principles
Flow
• Batching
• Searching
• Variation in way things are
done
• Poor layout / excess walking
• Variation in demand
• Variation in turn around times
What stops flow ?
� Eliminate batching
� 5S
� Standard working
� Visual Management
� Ergonomic layout
� Level demand
� Stabilise process
Operator 1
Batch size 10
Operator 2
Batch size 10
Operator 3
Batch size 10
10 minutes
1 min
20 minutes
30 minutes
3 step process
3 operators
Batch size 10
Batch production
Operator 1
Batch size 1
Operator 2
Batch size 1
Operator 3
Batch size 1
3 mins
1 min
4 mins
12 minutes
5 mins3 step process
3 operators
Batch size 1
1 min
1 min
One piece flow
The continuous movement of patients, samples, request cards, reports from end to end through pathways
3Establish
Flow
Nothing is done by the upstream process until the downstream customer signals the need
4Implement
Pull
The complete elimination of waste so all activities create value for the customer
5Work to
Perfection
Define value from the customers perspective and express value in terms of specific requirements/measures
1Specify Value
2 Map the
Value StreamMap all of the steps… value added & non-value added…
Lean Principles
supplier customer
One more
please!Okay
• A notification system of requesting either:
• work to be completed, or
• delivery instructions for work completed
• Nothing is done by the upstream supplier until the downstream customer signals the need
Pull: Customer centric
Pull
The continuous movement of patients, samples, request cards, reports from end to end through pathways
3Establish
Flow
Nothing is done by the upstream process until the downstream customer signals the need
4Implement
Pull
The complete elimination of waste so all activities create value for the customer
5Work to
Perfection
Define value from the customers perspective and express value in terms of specific requirements/measures
1Specify Value
2 Map the
Value StreamMap all of the steps… value added & non-value added…
Lean Principles
What is the point of Lean?
• Improving quality & eliminating defects
– Poor quality costs money in re-work and time
• New future state
– In god we trust, everyone else brings data!
– What are you going to measure to ‘prove’ the change is an improvement?
• PDCA / A3 thinking
– Structured problem solving & RCA
– Cycle of continuous quality improvement (CQI)
Model for
Improvement –
the three questions
A3 Thinking
• Structured thinking way - thinking deeply
• Follows a series of standard steps
• Rigorous application of Plan Do Study/Check
Act (PDCA) cycle
• Output is a concise, condensed document -
A3 Report (11 x 17 inch paper)
Title: A3 Problem Solving -
Problem Statement:
Version: Date:Author: Team:
Current state:
Goal:
Root cause analysis:
Future state:
Action plan:
Next Steps:
Waste identified:
Results and measures:
PLA
N
PLA
ND
OC
HE
CK
/ A
CT
Use data to establish the
facts
Root Cause Analysis
• The cause(s) that, if taken care of, would
eliminate all future occurrences of the problem
Cause and Effect / Fishbone
Why? Why? Why? Why? Why?
Results are not being reported back to GP in addition to OP
clinic
Why? Results system has not been coded to report to GP
as well as OP clinic
Why? Person booking in did not include GP information
when booking in
Why? Request to report to GP not on request card
Why? OP clinician did not complete the field on
the request card
Why? Process for completing request cards is
not standardised
You need data to evidence improvement
“It feels like it has improved…” or
“I think it has improved…”
is not enough
• Value Stream Mapping
• Process sequence charts
• Spaghetti map
• Handoff diagram
• A3 thinking / problem solving (PDCA)
• Root cause analysis
• One piece flow
• Kanban
• Demand smoothing
• Load levelling
• Takt time
• Work Combination Sheets
• Total Productive Maintenance
• Mistake Proofing
• Standard work
• Data and Measures
• Visual Management
• 5S
Lean “Tools”
• Voice of the customer
Visual Management
• The most important step in developing
standardisation.
• Define the ‘normal state’ (standard).
• To visualise deviations from the standard
(problems)
• Indicate if there is a shift from what is expected
• We are visual creatures
Examples of Visual Management
Stop/Start
Audit
• Value Stream Mapping
• Process sequence charts
• Spaghetti map
• Handoff diagram
• A3 thinking / problem solving (PDCA)
• Root cause analysis
• One piece flow
• Kanban
• Demand smoothing
• Load levelling
• Takt time
• Work Combination Sheets
• Total Productive Maintenance
• Mistake Proofing
• Standard work
• Data and Measures
• Visual Management
• 5S
Lean “Tools”
• Voice of the customer
What do these organisations have
in common??
Why Standard work?
• Creating the best possible work method, with the least
amount of ‘waste’ to produce the best quality result.
• Maximise quality and safety
• Reduce variation
• Reliable and repeatable process
CONSISTENT METHOD = CONSISTENT RESULTS
• Value Stream Mapping
• Process sequence charts
• Spaghetti map
• Handoff diagram
• A3 thinking / problem solving (PDCA)
• Root cause analysis
• One piece flow
• Kanban
• Demand smoothing
• Load levelling
• Takt time
• Work Combination Sheets
• Total Productive Maintenance
• Mistake Proofing
• Standard work
• Data and Measures
• Visual Management
• 5S
Lean “Tools”
• Voice of the customer
If only
we had
more
space!
Is this safe?
5S• Sort: Deals with the contents of a workplace and removes all
items that are not needed there.
• Set in Order: Designating locations to enable easy access to needed items.
• Shine: Refers not just to cleaning, but to "being proud" about the way the workplace is organised.
• Standardise: Refers to having standards that everyone agrees & adheres to. Visual management is an important aspect to facilitate easy understanding of these standards.
• Sustain: Refers to training of and communication with allemployees to ensure continuous 5S application.
Before 5S
After 5S
A place for everything
and everything in its place
Simulation exercise
Designing your
“future state”
Designing your “Future State”
• 5 mins - What waste exists in the “Current State”?
• 5 mins - Discuss and agree what changes you will make to improve your process
NEW Objective:
• Produce 40 Endoscopy reports in 5 minutes
On your marks…..
Results
Success• Understand the principles
• Processes not people
• Accept all aspects (challenge the status quo)
• Implementation (not recommendations!)
• Implement carefully (ever mindful of VOC)
• Systematic implementation (not just 5S)
• Leadership
• Communication
@NHSIQ
enquiries@nhsiq.nhs.uk
www.nhsiq.nhs.uk
www.england.nhs.uk/ourwork/qual-clin-lead/nhsiq/
Thank you