Lean Healthcare Exchange

Understanding the complexity of healthcare payment systems is not something that most people understand.  In most businesses, a product or service is delivered to a customer in return for a pre-established price.  My research for answers turned to the internet.  I found promise in a white paper titled, “Principles of Healthcare Reimbursement”.  However, I quickly realized that I was looking for the Healthcare Reimbursement for Dummies version. 

While conducting a Lean Healthcare Kaizen Event recently, the team was excited to have identified significant improvements which resulted in a gross revenue increase of just over $1.0 million.  However, the complicated, mulit-variable equation which determines how much the hospital would actually see reduced the net gains to less than $100,000.  The “missing” $900K is not profit; it is the reduction in top line revenue healthcare organizations face every day from reduced reimbursements, payor mixes, fee schedules, DRGs, etc.

So what is a Lean Healthcare practitioner to do?  While we let Washington D.C. sort out the payment and coverage issues, some of us continue to focus our improvements on the Healthcare System.  A Lean friend, Christy G., helped me understand the healthcare reimbursement model with the following description. 

Healthcare provides a basket of care for a bucket of money.

We control what goes into the basket.  Our job as we study processes and drive out waste from the basket of care.  We use Lean Healthcare as our primary tool to review what’s in the current basket (Value Stream Mapping) and design a better basket (Ideal Care).  Nonetheless, what about the bucket?  Well, just as I learned from Sesame Street all those years ago…”there’s a hole in the bucket, Dear Liza, Dear Liza”.   There is a big hole!  The healthcare payers (including Medicare) are shopping for bigger drill bits and more powerful drills in order to make bigger and bigger holes.  As reimbursements continue to shrink, we have to get more and more creative.  We have to look for the best way to take care of the patient while making sure we don’t gift wrap the basket full of unnecessary tests and care for which the hospital will not get reimbursed. So I guess, like Dear Henry from Sesame Street, we will fix it Dear Liza, Dear Liza, Dear Liza…

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to share lean principles through hands-on learning. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting.

With the raging debate over health care, town halls all across America, have we lost sight of one of the most important goals, delivering better care while cutting costs? Griff Jenkins of Fox News sits down with the CEO of ThedaCare, Dr. John Toussaint in a one-on-one interview. They discuss the work that ThedCare has been doing and Lean tools and techniques such as Value Stream Mapping and 5S. Watch the complete interview below.

I frequently have had the privilege of working with some incredibly committed individuals and teams in lean healthcare organizations who share a tendency to being “perfectionists”. A previous mentor often reminded me that the journey is not about being perfect, rather the goal is to constantly pursue perfection to catch excellence. In the pursuit of perfection, lean processes are designed with the goal of being ideal. One aspect of an ideal process is that it is delivered 1 by 1 to meet the customer’s demand. Within most hospitals the concept of 1 by 1 is referred to as “patient flow”, a desired ideal state where patients never wait and there are no bottlenecks in care or treatment. To achieve patient flow, lean healthcare organizations need to eliminate waste and standardize work first in each phase of the value stream and then move on to improving the connections between processes. A recent team, facilitated by my colleague Marshall Leslie, demonstrated the application of these concepts in a group of ED patients who require an assessment and referral prior to admission to the hospital. The team reduced documentation by 50% and sequenced the workflow to minimize interruptions for those conducting assessments. Then they looked at the connections and found solutions to shorten response times from an average of an hour to less than 5 minutes by implementing a 1 call process. So, in your own pursuit of perfection, try looking at the steps before and after the value stream connections for the waste to eliminate then move on to improving the connections.

This week’s blog was written by Maureen Sullivan, a senior associate at HPP. Maureen brings over 28 years of healthcare experience in clinical nursing, management and quality leadership to Healthcare Performance Partners. Previously Maureen was the Director of Lean and Quality Improvement for Exempla Lutheran Medical Center and successfully led the implementation of Lutheran’s Lean production system from 2004 to 2008 demonstrating improvements in clinical quality, employee engagement, and financial stewardship. Maureen has an associate degree in Nursing from Joliet Junior College in Joliet, Illinois and a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from National Association for Healthcare Quality, certified professional in healthcare quality (CPHQ), Colorado State University in process mapping, and University of Michigan in lean healthcare.

 By now you might have a couple of Kaizen or 5S events under your belt as part of your lean healthcare journey.   Some teams might have established sustainable measures in their areas and Leadership is conducting gemba walks regularly.  The 30-60-90 day follow-up and the lean momentum are progressing and visible.  There is clear evidence that the objectives set by the team(s) are being met and the metrics are headed on the right track.  Small teams are solving problems using A3 thinking.  So what’s next? Continue with the lean improvements? Absolutely.  Spread the lean healthcare methodology throughout the organization, most definitely. Lean is a never ending journey and your focus should always be the goal of zero waste.   In all this good news there should be more good news. Could there be more? Yes, celebrate!  Celebrating wins and successes are just as important as achieving a target.  It’s a common step that I often see organizations leave out of the events and the entire transformation.  I don’t believe it’s done intentionally, but rather that so much focus and energy is directed on meeting the objectives or that there is little belief that lean will work or that lean can really work in a well established organization.

In the first two years of my lean journey we seldom stopped to “smell the roses” so to speak and celebrate all the wins and successes we accomplished in each event.  In fact, celebrating wins and recognizing team or members’ achievements was never in our yearly strategic lean plan or Hoshin pPanning.  I came to believe that part of the reasoning was because we have tried so many different tools, education programs, and process improvement projects in the past, and were not sure if each event was going to be a success or even if lean was going to work in our work environment.  It’s not that management did not want to recognize people or celebrate wins, we really did not know how or when, and by the time we got to it the teams the members had already moved on to another project or event.  A common phrase that I often heard and later I picked up myself was “you’re doing a good job but!”, and like many others, I too only remember the BUT part.  Leaving the team or members feeling that what was just accomplished was good but more is needed and not completely appreciated. 

A few years ago, I revisited a team who I had coached and trained on Standardized Work and the 5S tool.  The first thing that caught my eye was a 4 feet by 8 feet white board that the team placed in front of the department’s entrance that told the story of the department’s lean journey and where they were before the lean engagement, the current state, and what their ultimate future target was.  At a glance, I could tell that the team had integrated visual control and standardized their daily work.  A second board displayed leading metrics trends from inventory reduction to reducing lead time and the defects (waste) the team was working on. The supervisor proudly guided me to the 5S board which indicated that the 5S score had improved by more than 40%.  The supervisor also shared with me that both the work environment and morale had improved. As I listened and observed all the creativity the team had come up with to eliminate waste and sustain progress, I turned to the supervisor and asked if the team, along with management, had stopped to celebrate all these successes.  He looked at me and then paused before answering the question and, seconds later, he turned to the team apologizing to them. “You know, we really have not done that. Thanks have been said during events and follow-ups but not a celebration of recognition to the team and individuals who have gone beyond the call of duty.” I realized that I had unintentionally put the supervisor in a tough position but it allowed him, the team, and management to reflect on a wonderful story and transformation process the department had gone thru.  At first, little attention was devoted to improving the department’s process issues, and the department stuck out like a sore thumb on the overall Value Stream Map. However, today it was a different story, not because of what I did, but because what the team had done, and what the team was doing to take ownership of their area.  Before leaving the department, a time and date was decided by management and the team when and where the celebration would take place.

When celebrating wins and recognizing members, it’s more than just the delicious snacks, drinks, and the nice thank you speech.  You are celebrating a new beginning, the collaboration of team work, the success of each individual on the team who at one time might have had doubts about lean and the will to change.  By celebrating success, you are feeding the growth for change and cultivating a safe environment in which individuals would want to add more value to their daily work.  My mentor once told me that very little is mentioned about celebrating wins because most teams and organizations really do not believe they can win and they certainly do not believe they can succeed after a failure.

As you continue in your lean healthcare journey it is important to celebrate and share success from kaizen and 5S events, and A3 problem-solving. Don’t forget to involve the people whose jobs have changed. They helped make the organization better, and deserve to share in the celebration. There will always be more waste to eliminate and in turn more celebrations.  So stop and smell the roses every chance you and your team get.

This week’s blog was written by Alex Maldonado, an assoicate with HPP. Alex’s professional experience includes process improvement, operational, and leadership positions in the medical delivery systems and appliance manufacturing industries with Baxter Healthcare and Whirlpool. Alex has had a successful track record in improving results-driven processes with an emphasis in personnel training, project leadership, and operating systems designed to improve customer service and sustainability. He has led the development and implementation of processes to support Lean initiatives that reduce critical path lead-time, reduce expediting costs, capital improvement projects, inventory reduction, and trained and educated staff/employees in Lean Methodology. Alex is well recognized in the following areas: Value Stream Mapping, Hoshin Strategic Planning, Office and Floor 5S, Total Productive Maintenance (TPM), Process Failure Modes and Effect Analysis (PFMEA), Quality Improvements and Mistake Proofing, Six Sigma, Cellular Design, Standardize Work, Pull Systems (kanb an), Equipment Design and Installation (DFLMA), and Safety Programs. He has a B.S. in Industrial Technology Engineering from Mississippi State University and has also completed the Six-Sigma black belt program.

As a Lean Clinical Design Consultant with 10 years experience working along side well meaning hospital employees in the planning and design of numerous building projects, I have come to recognize the signs and symptoms of a very insidious infirmity. I have termed it Post Traumatic Space Deprivation Disorder or PTSD(D). It can dramatically distort reality, lead to improper allocation of square footage and interfere with project goals such as improving the quality of care and operational efficiency.

Just as is the case of the mainstream mental health affliction, post traumatic stress disorder, hospital caregivers have endured great difficulty, frustration, and even helplessness in performing their daily responsibilities. They have battled the inefficiencies of aging, antiquated environments with semi-private patient rooms, cluttered workspaces, and distant, small supply closets. When called upon to participate in the design of a new work environment, excitement can quickly turn into anxiety. Making decisions about process and space can be overwhelming even for lean thinkers.

Even under the most ideal circumstance, as when an organization is one to two years into their lean transformation, the typical design process focuses on floor plan development by individual departments which can create work process barriers for today’s extremely multidisciplinary treatment model. Left unchecked, PTSD can negatively influence attempts to reduce waste in the new environment and even contribute to the most dastardly budget buster; scope creep.
The symptoms associated with PTSD are remarkably similar to those of its medical counterpart. Early recognition and aggressive treatment is essential in overcoming the negative effects of PTSD.

Symptoms of Post Traumatic Space Deprivation:

• Flashbacks – Valiant attempts to recreate a perceived happier time in the past (like medical school or a previous work situation)
• Bad Dreams – Exaggerated memories of the rare or occasional occurrences when limited space or capacity caused delays in patient care delivery. (”Feeling like you must build the church to accommodate the crowd on Easter Sunday”)
• Frightening Thoughts – An uncontrollable fear of not having enough storage space, windows and bathrooms.
• Rationalizing – Creating endless logical reasons for maintaining sub-optimal or dysfunctional current state processes. (Holding on to “the way we do it now”)

Steps to Overcoming Post Traumatic Space Deprivation:

1. Get on the Lean Path and Stick to it! – It is never too late to begin transforming culture and process using lean thinking. One word of caution – Lean design is a little like purchasing a size 6 wedding gown on clearance in January and vowing to lose 50 pounds before your June wedding. There are no refunds on new construction if you have “fallen off the lean wagon”!
2. Value Stream Map Current State Processes – Value stream map current state processes and pay special attention to understanding how the environment may have shaped process. Identifying existing building barriers will prevent them from being transferred in the new environment.
3. Perform Direct Observations – There is no substitute for going to the Gemba or where the work is done. It is rare that the reality of direct observation matches how the process is perceived to be working.
4. Utilize 3P (Production Preparation Process) – Develop ideal future state processes by focusing on waste elimination in process design. Lean processes can then accurately inform the architectural design.
5. 5S the Current State Environment – The exercise will not only give design participants a more accurate picture of how much space is really necessary to accommodate supplies and equipment in the future state, it will improve efficiency and staff satisfaction with the existing work environment.

PTSD can be overcome through diligent application of basic lean principles. Design team participants can redirect their natural human tendencies toward more value added design solutions that focus on healthcare’s most important customer – the patient.

This week’s blog was written by Teresa Carpenter, the Director of Lean Clinical & Facilities Design at HPP. Teresa brings a unique perspective to lean healthcare as a registered nurse with extensive architectural design and facilities planning experience. Teresa began her career in healthcare working through the ranks from Admitting Clerk to Patient Care Director of various critical care units, medical-surgical units, and support departments such as Respiratory Therapy and Cardiac Rehabilitation in several South Carolina facilities. With over 12 years experience in the acute care environment, Teresa moved to our Nashville area where she spent almost a decade as Clinical Operations Coordinator for an internationally recognized leader in healthcare architectural design. Teresa facilitated process engineering services as a component of the design process for hospital renovations, as well as large-scale green field and replacement facility projects. Among these projects, she was the lead planner on the nationally recognized St. Joseph’s Hospital in West Bend, Wisconsin, the world’s first hospital designed to reduce medical error. Teresa holds a bachelor’s degree in Business Administration from the College of Charleston, and a degree in nursing from Trident College in Charleston, South Carolina.

Zealous guardianship of the status quo is a very common barrier encountered by healthcare delivery systems attempting to adopt and implement lean healthcare.  It is amazing to witness the extent to which this behavior is present in nearly all organizations interested in pursuing the lean healthcare journey.  During Kaizen Events this guardianship manifests in one of two ways:  1.) either an amazingly strong reluctance to change or, 2.) proposed changes to current state that are so enmeshed in what we have today as to be nearly indistinguishable.  How this guardianship is approached and managed during an event can mean the difference between “bold moves” and “rearrangement of the sock drawer for the tenth time”.

There are four things facilitators, coaches and leaders must keep in mind when dealing with guardianship of the status quo during a lean healthcare transformation. 1.) Honor the past. The segments of the value stream under consideration have been developed by the participants of the event or their forerunners.  At times there can be an unspoken and even unconscious sense that to change is to dishonor what is currently in place and what it took to get there. 2.) Challenge the team. Team members must be adequately challenged to the extent that the need for change is undeniable and a healthy dissatisfaction with the status quo has been created. During a Kaizen Event direct process observation goes a long way toward the accomplishment of this objective but more is required to truly embolden teams. It is also important to keep in mind that the event team is only a cross section of the extended team when implementing.  3.) Create and communicate a new vision.  Teams need to know that what they will build is better than what they already have…not only for themselves but for the extended community as well. By building in constituencies beyond just the participants, systems thinking is promoted.  This is an essential step, combined with honoring the past in empowering teams to let go, to adopt something new, and to take bold moves. 4.) Engage the team. This seems so fundamental that it almost questions its mention in this article. Engaging the team, however, moves well beyond their active participation in the event. It is a process of creating internal champions, one at a time. 

The Scientific Method, applied while testing solutions, will ultimately prove or disprove the quality of the “bold moves” selected for implementation. However, regardless of the quality of the solutions or counter-measures, unless there is acceptance, there is no net improvement. Things must change from current state toward future state in objective reality. This means that ultimately, along the way, every mind in the organization must be engaged. Facilitators, coaches, and leaders that recognize this and that understand that honoring the past, challenging the team, creating and communicating a new vision are prerequisites to engaging the team, will find their fields well prepared when planting the seeds of lean healthcare. Those that fail at this should not be discouraged as the lesson will repeat itself, again, (hopefully not and again and again…) until learned.

This week’s blog was written by Bradley Shultz, a director and consultant for HPP. Before joining HPP, Bradley was serving as Vice President of Operations & Quality for Infinity Resources Inc. where he pioneered the application of Lean, Six-Sigma, Work-Out™, and CAP (Change Acceleration Process) in the retail market sector. Bradley began his career in manufacturing with GE Healthcare and was working as a Manufacturing/Quality Engineer when GE adopted the Six-Sigma methodology from Motorola. In 1995, GE Healthcare began providing consulting services based upon these tools to its customers through its Performance Solutions business unit, pioneering the application of Six-Sigma in healthcare. Bradley joined Performance Solutions in 1996 during its infancy and remained with the business unit for seven years. Bradley’s educational background includes: a Bachelor of Science degree in Business Administration from Cardinal Stritch University in Milwaukee, Post Graduate Certification in Quality Engineering from Milwaukee School of Engineering, a Master of Arts degree in Business Administration from Marquette University in Milwaukee, Six-Sigma Master Black Belt Certification from General Electric, and Front-Line Leadership Development Certification from Achieve Global.

When and how to “cash the check” from Lean Healthcare process improvements is not always obvious.  Rightly so, CFOs will say: “If I can’t see the financial savings in the P&L, then they don’t count.” 

Lean is not a social program.  It’s a process improvement system that improves all aspects of the business case simultaneously when Waste is eliminated.  In healthcare, business case (outcome) metrics can be categorized into: Satisfaction, Quality, Time, and Financial.  Time includes patient access to services, the time to complete those services, and employee time to deliver them.

When Waste is eliminated, time is “freed up” for staff and leadership.  For example, staff doesn’t have to search for supplies or perform rework due to a recurring defect. Leadership doesn’t have to deal with a recurring problem.  But time is usually not freed up in 1 full-time equivalent (FTE) increments. And while continual productivity improvement is a business requirement, you cannot lay people off because of gains due to Lean.  If you do, no one will sign up for the next improvement activity.  So, what should leaders do to “cash the check” in a Lean Healthcare environment without it being perceived as another cost reduction program?

Make Productivity Visible

Productivity is a measure of cost, not production.  It measures how much input is required to deliver a certain amount of output (output/input).  When looking at labor productivity, possible productivity calculations are patients/labor-hour and service-units/FTE. Once the appropriate productivity metric for a given Value Stream process is determined, track it daily and post it in a visible location for all staff to see.  Discuss it at least weekly.  Let people know that productivity must be continually improved and that eliminating Waste is the only way to achieve it without overburdening staff.  This creates an opportunity for dialogue allowing leadership to communicate the business reality while letting staff know that we are not going to continue adding work or reducing FTEs without improving processes to free up a proportionate amount of time.

Track all Time Saved and Dollarize its Potential

If we think of freed up time from Lean as being stored in a “time bank”, it may help us to see its value to the customer and organization.  This time passes through three phases.  First, it is identified (phase 1) during Lean improvement activities like kaizen events as time that will be freed up once tested solutions are fully implemented (phase 2).   It is at this point that leadership must decide how to monetize (phase 3) the time savings.  The freed up time can either be invested, cashed, or both.  For example, freed up nursing time can be “invested” in more direct patient care (time with the patients) in order to improve other outcomes like satisfaction, infection rates or fall rates.  Or it can be “cashed” by actions such as increasing volume with existing staff (revenue increase), reducing overtime (cost reduction), not filling a planned position (cost avoidance), or reducing budgeted FTEs.  If you reduce budgeted FTEs, staff must feel confident that a proportionate amount of Waste has been eliminated and that no one will lose their jobs as a result.  Attrition and internal transfer are examples of ways to achieve your commitment to no one losing their jobs due to Lean.  In Lean thinking, it is important that leadership track and dollarize the time savings in all three phases in order to see its value.  In many cases it will be difficult to quantify the exact impact to the P&L, but if we don’t quantify freed up people’s time, we cannot see its potential or actual financial value to the organization. 

Reducing wait time and defects for patients frees them up to do the things they want to be doing, which increases their satisfaction with healthcare services.  Eliminating Waste for staff frees up time to improve productivity without overburdening them.  When it comes down to it, “It’s About Time.”

Dwayne Keller holds the position of Vice President of Healthcare Performance Partners (HPP). Dwayne has overseen the introduction and implementation of Lean Healthcare in various hospital and clinical systems throughout the USA. He coaches at all levels of Healthcare organizations, from CEO to front line staff to deliver improved outcomes via Lean. His deep understanding of Lean as a holistic process improvement “system,” and leadership guidance in connecting Lean implementation to each organization’s specific business case needs in a visual way, sets him apart in the industry. Dwayne has also been a speaker and lecturer at various Lean Enterprise conferences as well as a presenter at the Shingo Prize Conference. Dwayne began his career with DuPont as an Engineer and as an Industrial Engineer & Production Manager at Michelin Tire Corporation, he introduced Just-In-Time and Teamwork into two of their largest manufacturing operations. After earning his MBA, he spent three years in Michelin’s Marketing Department helping to transform it into a customer-focused research and data-driven organization. Dwayne joined Alcoa’s AFL Telecommunications Division as Plant Manager and later Director of Operations and drove implementation of the “Alcoa Business System” (ABS), which is its Lean Enterprise system, to meet business goals. Dwayne holds Master’s and Bachelor’s degrees in Mechanical Engineering from Bucknell University and a MBA from Clemson University.

I was sitting at the stop light and just as the light changed, my wife said “There’s a blue light.”  So I hesitated before going, checking for a police car.
“Why didn’t you go?” she asked. 
“Because you said there was a blue light.”
Confused, we both let the conversation fade away.

After several instances of this, I asked her why she kept telling me she saw a blue light and she asked why I didn’t go when the light turned blue. 
“When the light turned blue?”  Hmmm.  Sounds like we have a failure to communicate.

My wife is from Japan and in Japan, the shade of green used on some traffic lights here in the United States (a bluish, aquamarine sort of green) would be called “blue”.  I think I would call the “go” light on a traffic light “green”, even if it was purple, because for me “green” and “go” are synonymous.  Unfortunately, I cannot convey in writing the big “ah-hah” feeling we both had when we finally figured this out.

So it must be because of the language difference, right?  Maybe not.  You would be amazed to see the number of times we see communication problems because of unclear definitions and using the same word to mean different things in healthcare.

A recent value stream mapping exercise brought out the fact that one root cause of patient flow problems in a surgery department was that “ready” did not mean the same thing to everyone. 
For a surgeon or circulating nurse, “ready” meant “the patient can roll to the OR”. 
For an outpatient nurse, “ready” meant “I have done everything that I am supposed to do.” Patient prepped, IV started,  labs drawn and sent to lab.  But, the lab results may not be back and H&P needs to be signed.  Was she wrong?  Not really.  From her perspective, she was “ready” to move on to the next patient.

So you can imagine the communication problems that resulted from this.

But this is not an isolated incident.  I have seen this same “ready” problem at hospitals in two different states.  I have seen heated discussions over what was and was not happening in a process only to find out (after 3 days!) that the root of the miscommunication was using the same word to mean different things. 

The doctor tells the patient that they have “discharged” them.  For the doctor this meant they wrote the order.  But the nurse may have to draw final labs and give discharge instructions before the patient can leave the building.  Transport will say they have discharged the patient when they take them to their car.  Bed Control may say the patient was NOT discharged even if the patient is gone because the discharge is not entered into the electronic tracking system.  You’ll get three or four different answers depending on who you ask.  And the patient feels like they have been kidnapped because they can’t leave even though the doctor already “discharged” them.

So the next time you are trying to understand a process, don’t assume you know what people mean. Listen to make sure that they are not using the same words to mean different things.  You may have a few ah-hah moments of your own.

This week’s blog was written by Richard Tucker a director with HPP who assists clients throughout the USA with Lean Healthcare transformations. Richard has over sixteen years of experience in business and industry fields in operational and leadership positions. His experience includes new program installation and launch, operations improvement, lean manufacturing implementation (internally and with suppliers), leadership development and supplier program management from prototyping through launch. Additionally, he has many years of Lean experience having worked with a major Japanese automaker, and received much of his experience and formal training in the Toyota Production System, Lean Manufacturing, and Shainin Statistical Engineering while in Japan. Richard’s educational background includes BS and MS degrees from Tennessee Technological University in Cookeville, Tennessee.

With the rapid improvements that often result from Kaizen Events, organizations can easily fall into a trap of looking at Lean Healthcare as a “quick fix”. Those quick results are a necessary component of the Kaizen process; however, Kaizen Events are only part of a true “transformation”. For true sustainability and transformation to occur, improvements must be made at three key levels of the organization: strategic, Value Stream, and daily work.

From a strategic perspective, there is a process to adopting Lean as the primary operating methodology within an organization. We work closely with leadership teams within an organization from the onset of a transformation activity to coach on Lean Thinking. Developing Lean Leadership skills requires time and experience. 

Understanding Value Streams are an important element for deployment of Lean Tools. As Lean practitioners, we map value streams and leverage Lean tools to identify and eliminate waste. As mentioned earlier, rapid results are one outcome from improvement at this level. However, there are additional aspects of the transformation process that take place during a Kaizen Event as front line workers, staff, and physicians begin to look at their work differently. They begin to change their long-held beliefs about their work through this experience, which leads to new actions. These new actions are necessary to deliver and sustain improved outcomes.

For true continuous improvement, workers must begin to leverage Lean Healthcare tools and waste reduction efforts into the problems that occur every day. We typically see this transformation occur more quickly in staff and leaders who are exposed to Lean Thinking during Kaizen Events. However, we are often limited in the number of people who can be directly involved in events during the early phases of a transformation effort. By training everyone in an organization in Lean Thinking, we will help those not yet involved in a Kaizen Event begin to identify and eliminate waste, as well as support the Kaizen Event process changes.

Many groups would be content to leverage Lean by simply using the recipe approach - a dash of Kaizen Events, a sprinkle of metrics, a pinch of employee involvement. However, working only at the Value Stream Level will short circuit the improvement effort. At HPP we feel strongly that two key elements to the sustainability efforts at any organization implementing Lean are:

1. Strategic leadership sessions where an organization can create alignment around a Lean vision.
2. Ongoing Lean training for ALL staff, providers, and leadership.  We have found the use of our simulation-based Lean Healthcare training methods (ex. HPP’s Healing Healthcare™ Pharmacy Simulation or Job Instruction Simulation) help to better explain Lean Healthcare methodolgies and Lean Tools as they apply specifically to healthcare. Whether you use these methods or others, what is important is that you continuously train staff in how to lead in a Lean system and/or how apply the principles to their daily work.

This week’s article was written by Tom Stoffel, a director & consultant for HPP. Before joining HPP, Tom served as President of Transformation Group, Inc,. Tom developed TGI Healing Healthcare – a brand of Lean Healthcare training tools designed to make lasting improvements. Tom has led healthcare organizations in both the development of high-level Lean Strategies down to hands-on implementation of Lean in a clinical setting. Tom has achieved the levels of Certified Lean Specialist from the Business Improvement Group and the National Institute of Standards and Technology (NIST), along with being an ASQ Certified Quality Engineer. These certifications build on an Engineering Degree from the University of Michigan. Training experience includes Lean, Quality, and Leadership Training, as well as serving as an Adjunct Faculty Member at Waubonsee Community College.

In the year 1906 Italian born economist Vilfredo Pareto made a very famous observation while studying the wealth and property distribution in Italy. What he found in his study by applying a mathematical algorithm was that about eighty percent (80%) of the wealth was controlled by only twenty percent (20%) of the people. This fact in itself was not a significant observation at the time but during the early nineteen thirties (1930’s) a management pioneer by the name of Dr. Joseph Juran credited this finding as a significant principle and he surnamed it the “Pareto Principle.” Juran began to apply and generalize this principle often referring to it as the “vital few or the 80/20 rule.” Today a pareto chart is used to graphically display data cause types from largest to smallest in a bar chart form. Using the top twenty percent (20%) cause type application, one can focus efforts toward eighty percent (80%) problem effect resolution by focusing on the first one (1), two (2), or three (3) bars that usually make up twenty percent (20%) of the cause types.

Value Stream Mapping

Value Stream Mapping is probably the most widely utilized lean tool used to analyze business and production systems. The Value Stream Mapping process begins by first establishing the process scope based on the business case scenario (the problem you are trying to solve). Next, a “Current State Map” is drawn using a set of standard icons. The result is a snap-shot in time of the process being mapped.

Value Stream Mapping is somewhat different than other types of process mapping in the fact that both the steps or process flow are shown at the bottom of the map and the information that drives the steps is shown at the top of the map. In addition, all the steps or processes are mapped with one key point in mind; the customer. Knowing and understanding who and exactly what the customer expects is a key tenant in lean. Value Stream Mapping helps to formally clarify what the customers’ requirements are. More importantly, the process and information flows that support that customer are identified. In lean, the organizational challenge is to identify the true customer requirements and develop a process to do only that. This is the essence of lean and the premise that makes Value Stream Mapping a great tool.

Applying the Pareto Principle to Value Stream Mapping:

The third step involved in Value Stream Mapping is called the “Future State Map.” In this step a vision for the future of the value stream is determined. The goal is to improve by focusing on the correct improvement projects that really make a difference and effect the total system lead time. It is in the Future State Mapping step that the pareto principle can be applied. If truly eighty percent (80%) of the results can be driven by the correct twenty percent (20%) of the improvement projects identified then, it is imperative that the correct projects are identified. The pareto principle will hold true in this case if and only if the correct projects are identified and implemented.

Improvements for the future state are identified by systematically evaluating the information flow and key process steps from the Current State Map. In a sense, the Current State Map is used as a launching pad for the Future State Map. This process always begins at the customer. As each step and the information flow is evaluated, brainstorming begins on what might be improved for the future. The value stream lead time which is measured at the bottom of the Current State Map becomes the basis for prioritization of the projects and activities that will be directed to improve the value stream.

The opportunities for improvement that are identified during the Future State Mapping analysis are known as “Kaizen Bursts.” These kaizen bursts are best classified by type of activity that must be conducted or completed in order to achieve the future state vision. Typically, those activities fall into one of three types of activities. First, there are those activities that require a team in some type of dedicated focused rapid improvement activity or what is commonly known as a “Kaizen Event”. Kaizen Events are usually five (5) days in duration and the associates involved are one hundred percent (100%) dedicated to workshop related activities. Second, there are those types of activities that require a focused team approach. In this type of activity, associates may work on and off on a project for a specific amount of time. The associate carries on regular work duties but participates for periods of time with a focused team on project work related to the Future State Map. Finally, there may be individual tasks identified. Individual tasks are activities that do not require a group or a team approach. These tasks are assigned and can be completed quickly utilizing one person.

How Does One Eat An Elephant?

The age old question of “How do you eat an elephant?” is very applicable when it comes to implementing the future state map. One simply cannot eat an elephant all at once. It must be consumed one bite at a time. The same is true with value stream mapping. There are usually many projects and activities that can be improved within a given value stream. There can be so many items identified to improve that an organization can become consumed with activities to do. Without focus, Value Stream Mapping will not just open up a can of “to do” but it may open up an entire case of it.

The pareto principle will keep the organization focused on the one bite at a time. Not only will it be “one bite at a time” but it will be the correct bite first. In order to do this, the correct twenty percent (20%) of the projects must be identified. This is simply determined by relating the projects to the effect on the lead time as a basis for selection. In general this will narrow down the projects greatly. The cream always rises to the top and the vital few are born.

Implementation

Value Stream Mapping is a great tool. It really helps the organization to see the whole related to the customer. However, in the end it is just a tool. It is not lean in a bottle. The end result of the initial activity is a vision for the future called the Future State Map and a plan to implement it. That is it. So, what should we say then? “Go get busy and do it!”

This week’s article was written by Ronnie Daughtry. Ronnie is Manager of Project Operations and a Senior Lean Consultant with The ACCESS Group (TAG) , HPP’s affiliate company. He has over seventeen years of experience holding various leadership and managerial roles in lean manufacturing, continuous improvement, supplier quality engineering, manufacturing operations, and human resources. The balance of his various leadership roles have been in the automotive sector for Robert Bosch Corporation in many locations in North America, South America, and Europe.