Introduction to lean amy hodgkinson & trevor taylor

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)





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


3Establish

Flow


4Implement

Pull


5Work to

Perfection


1Specify Value

2 Map the


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’?


3Establish

Flow


4Implement

Pull


5Work to

Perfection


1Specify Value

2 Map the


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?


3Establish

Flow


4Implement

Pull


5Work to

Perfection


1Specify Value

2 Map the


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


3Establish

Flow


4Implement

Pull


5Work to

Perfection


1Specify Value

2 Map the


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


3Establish

Flow


4Implement

Pull


5Work to

Perfection


1Specify Value

2 Map the


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



• Spaghetti map

• Handoff diagram



• One piece flow

• Kanban


• Load levelling

• Takt time




• Standard work



• 5S

Lean “Tools”


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



• Spaghetti map

• Handoff diagram



• One piece flow

• Kanban


• Load levelling

• Takt time




• Standard work



• 5S

Lean “Tools”


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



• Spaghetti map

• Handoff diagram



• One piece flow

• Kanban


• Load levelling

• Takt time




• Standard work



• 5S

Lean “Tools”


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

[email protected]

www.nhsiq.nhs.uk

www.england.nhs.uk/ourwork/qual-clin-lead/nhsiq/

Thank you

Date post:	20-Feb-2017
Category:	Health & Medicine
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Introduction to lean amy hodgkinson & trevor taylor

Health & Medicine