Table Of ContentHealthcare Management / Process Improvement MPK Leveraging Lean in the
This book is part of a series of titles that are a spin-off of the Shingo Prize-winning book ayzerotzmerpch
laa
Leveraging Lean in Healthcare: Transforming Your Enterprise into a High Quality Patient lnr
Care Delivery System. Each book in the series focuses on a specific aspect of healthcare that Emergency Department
has demonstrated significant process and quality improvements after a Lean implementation.
L
Emergency departments have become notorious for long wait times and questionable quality of
e
care. By adopting Lean manufacturing concepts, hospitals can turn the emergency department
v Creating a Cost Effective, Standardized,
into a valuable service for the hospital and the community it serves. e
r
a High Quality, Patient-Focused Operation
Leveraging Lean in the Emergency Department: Creating a Cost Effective, Standardized,
g
High Quality, Patient-Focused Operation supplies a functional understanding of Lean
i
emergency department processes and quality improvement techniques. It is ideal for healthcare n
Joyce Kerpchar Charles Protzman George Mayzell, MD
• •
executives, leaders, process improvement team members, and inquisitive frontline workers g
who want to implement and leverage Lean. L
e
Supplying detailed descriptions of Lean tools and methodologies, the book identifies powerful a
n
Lean solutions specific to the needs of the emergency department. The first section provides
an overview of Lean concepts, tools, methodologies, and applications. i
n
The second section focuses on the application of Lean in the emergency department within t
h
the confines of the hospital or clinic. Presenting numerous examples, stories, case studies, and
e
lessons learned, it examines the normal operation of each area in emergency departments and
E
highlights the areas where typical problems occur.
m
Next, the book walks readers through various Lean initiatives and demonstrates how Lean e
r
tools and concepts have been used to achieve lasting improvements to processes and quality
g
of care. It also supplies actionable blueprints that readers can duplicate or modify for use in
e
their own institutions. n
c
Illustrating leadership’s role in achieving departmental goals, this book will provide you with y
a well-rounded understanding of how Lean can be applied to achieve significant improvements D
throughout the entire continuum of care.
e
p
a
r
t
m
e
n
K23163 t
6000 Broken Sound Parkway, NW
Suite 300, Boca Raton, FL 33487 ISBN: 978-1-4822-3731-3
711 Third Avenue 90000
New York, NY 10017
an informa business
2 Park Square, Milton Park
www.crcpress.com Abingdon, Oxon OX14 4RN, UK
9 781482 237313
www.productivitypress.com
K23163 cvr mech.indd 1 11/13/14 10:24 AM
Leveraging Lean in the
Emergency Department
Creating a Cost Effective, Standardized,
High Quality, Patient-Focused Operation
Leveraging Lean in the
Emergency Department
Creating a Cost Effective, Standardized,
High Quality, Patient-Focused Operation
Joyce Kerpchar • Charles Protzman • George Mayzell, MD
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2015 by Charles Protzman, Joyce Kerpchar, and George Mayzell
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20141107
International Standard Book Number-13: 978-1-4822-3732-0 (eBook - PDF)
This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been
made to publish reliable data and information, but the author and publisher cannot assume responsibility for the valid-
ity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright
holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this
form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may
rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or uti-
lized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopy-
ing, microfilming, and recording, or in any information storage or retrieval system, without written permission from the
publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://
www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923,
978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For
organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Contents
Preface: Leveraging Lean in the Emergency Department .............................................................xvii
Acknowledgments ...........................................................................................................................xxi
Authors .........................................................................................................................................xxiii
SECTION I
Chapter 1 Introduction to Lean .....................................................................................................3
The Need for Change ...................................................................................................3
National and Global Competition .................................................................................4
Challenges for the Healthcare Worker .........................................................................5
Lean and Layoffs .....................................................................................................5
Traditional Healthcare Model ......................................................................................5
Introduction – So What Is Lean? .................................................................................7
Lean and Hospitals .......................................................................................................8
What Results Can You Expect? ...............................................................................9
The CEO and Lean .....................................................................................................10
Typical Lean Metrics and Outcomes .........................................................................11
Potential Lean Returns by Department .................................................................11
Typical Results/Return on Investments (ROI) and Implementing Lean ...............11
Lean and Systems Thinking .......................................................................................16
Boiled Frog Syndrome...........................................................................................16
Systems Thinking Principles .................................................................................16
Viewing the Hospital with Systems Thinking ......................................................17
What Is a Lean Business Delivery System? ...............................................................20
Lean Business Delivery System Vision .................................................................21
Understanding the Value of the Lean Business Delivery System .........................21
Just In Time: The First Pillar of the Toyota Production System Model ................22
An Example of One of the Rocks—Short-Staffed ...........................................23
Jidoka—The Second Pillar of the Toyota Production System ...............................24
Jidoka Means: Never Pass on a Bad Part or Patient ..............................................25
Applying Jidoka to Healthcare ..............................................................................25
The Top of the Toyota House—Respect for Humanity ..............................................26
Lean Is a Journey .......................................................................................................27
Chapter 2 Batching vs. Lean Thinking and Flow .......................................................................29
Batching vs. Lean Thinking and Flow .......................................................................29
Batching vs. Flow in a Healthcare Environment .......................................................30
Batching Examples ................................................................................................30
Process Definition .............................................................................................30
Batching Systems ..................................................................................................31
Why People Love to Batch? ...................................................................................31
One-Piece/Patient Flow ....................................................................................33
One-Piece Flow Example ......................................................................................36
v
vi Contents
Group Technology .................................................................................................38
Productivity - Definition ............................................................................................38
Batching the Domino Effect ......................................................................................38
Peak Demand .............................................................................................................38
Examples of Batching in Healthcare .....................................................................39
Chart Preparation..............................................................................................39
The Chart Problem ...........................................................................................40
Application of One-Piece Flow to Healthcare ...........................................................40
Flow—One-Piece Flow or Small Lot ........................................................................42
Chapter 3 Lean and Change Management ..................................................................................45
Implementing Lean Is about Balance .........................................................................45
Lean Culture Change .................................................................................................45
Paradigms ..............................................................................................................46
Change Equation ...................................................................................................46
C ∙ Compelling Need to Change ............................................................................47
Why Change? .........................................................................................................47
V ∙ Vision ...............................................................................................................49
N ∙ Next Steps ........................................................................................................50
S ∙ Sustain ..............................................................................................................50
Change and What’s In It For Me ...........................................................................50
Lean and Change Management ..................................................................................51
Lean and Organizational Change - “Right Seat on the Right Bus” ...........................51
Resistance to Change .............................................................................................52
Changes… Highs and Lows ..................................................................................52
Rule of Unintended Consequences and Bumps in the Road .................................53
Change Is a Funny Thing ......................................................................................53
We Are All Interconnected but Not Typically Measured That Way .....................53
Horse Analogy .......................................................................................................53
Comparison to Where We Are Today ...................................................................54
Employee Suggestion Systems ..............................................................................54
Barriers to Change .................................................................................................55
Most Loved Words ................................................................................................56
Does Your Organization Have Sacred Cows? .......................................................56
Leadership and Organizational Changes ...................................................................57
Communication, Change and Lean ............................................................................58
Summary ...............................................................................................................59
Chapter 4 Lean Foundation .........................................................................................................61
Lean Foundation - The BASICS Model - Baseline ....................................................61
Think—See—Act Lean ........................................................................................61
System Lean Implementation Approach Utilizing the Basics Model ........................61
A Customer Service Story .....................................................................................64
Baseline Metrics .........................................................................................................66
Data, Revenue, and Hospitals ................................................................................66
The Impact of Data on Lean – Process Focused Metrics ..........................................67
Customer Satisfaction ............................................................................................67
Voice of the Customer Surveys .............................................................................68
The VIP Visit .............................................................................................................69
Easy to Do Business With .....................................................................................69
Contents vii
Centralized = Batching ..............................................................................................70
What Does All This Have to Do with Hospitals? .................................................70
Customer Value-Added Proposition ...........................................................................70
Customer Quality Index ........................................................................................71
KANO Model ........................................................................................................71
Baseline the Process ...................................................................................................72
Value Stream Map (VSM) the Process .................................................................72
Value Stream Discussion .......................................................................................74
Value Stream Mapping and Healthcare .................................................................74
Value Streams Objectives ......................................................................................75
Traditional Hospital Systems - SILOS ..................................................................75
Lean Goals.............................................................................................................75
Parts of a Value Stream Map .................................................................................76
Value Stream Map Icons .......................................................................................76
Value Stream Map Definitions ..............................................................................76
Day 1 .................................................................................................................78
Day 2 .................................................................................................................78
Day 3 .................................................................................................................78
Day 4 .................................................................................................................78
Day 5 .................................................................................................................79
Current State Value Stream Mapping ...................................................................79
Ideal State ..............................................................................................................79
Future State Value Stream Mapping .....................................................................80
Value Stream Map Project Lists, Prioritization Matrix, and Tracking .................80
Value Stream Layout Maps (Sometimes Referred to as Skitumi Maps) ...............84
Baselining the Process—Data Collection and Analysis—Current State ..................84
Takt Time/Production Smoothing .........................................................................84
Available Time ......................................................................................................84
Customer Demand .................................................................................................84
Peak Demand .........................................................................................................85
Cycle Time .............................................................................................................86
Cycle Time and Takt Time—What’s the Difference? ...........................................86
Designing Cycle Time to Takt Time .....................................................................87
Length of Stay (LOS) ............................................................................................88
Length of Stay Is Directly Correlated to Inventory...............................................89
Length of Stay—A Key Metric .............................................................................89
Reducing Length of Stay ............................................................................................90
Number of Staff Required .....................................................................................91
Total Labor Time ...................................................................................................92
Quiz .......................................................................................................................92
Weighted Average ..................................................................................................92
Financial Metrics ........................................................................................................93
Measuring Inventory and Cash Flow ....................................................................93
Work in Process Inventory ....................................................................................94
Sales of Reimbursement Per Employee .................................................................94
Contribution Margin ..............................................................................................95
Cost Per Case .........................................................................................................95
Data and What People Think ................................................................................95
Sustainability and Accountability ..............................................................................96
Process Owners Do Not Always Have the Skill Sets Necessary to Manage
in a Lean Environment ..........................................................................................97
viii Contents
Chapter 5 Basic Lean Concepts and Tools – Assessment and Analyze .....................................99
Levels of Waste ..........................................................................................................99
Low-Hanging Fruit ................................................................................................99
Five S Wastes .........................................................................................................99
The Seven (Eight) Wastes ......................................................................................99
How Do You Find Waste? ........................................................................................102
30-30-30 Exercise ................................................................................................103
People ..................................................................................................................103
Equipment ............................................................................................................103
Communication ...................................................................................................104
Visual Controls ....................................................................................................104
Leadership ...........................................................................................................104
Cost of Waste ............................................................................................................106
Baseline Entitlement Benchmark .............................................................................106
Five Why’s ................................................................................................................106
Example: ..............................................................................................................106
Another Tool to Get Rid of Waste: The Five W’s and Two H’s ...............................107
Root Cause Analysis—A3 Strategy .........................................................................107
Fishbones and Lean ..................................................................................................108
Problem-Solving Model ...........................................................................................108
Problem Statements ..................................................................................................110
Lean Tools - Analyze/Assessment ............................................................................111
Basics—Assess the Process .................................................................................113
Step One: Understand and Assess the Overall Process ..................................113
Value-Added ........................................................................................................113
Non-Value-Added Activities/Work ......................................................................114
Non-Value-Added But Necessary Work ..............................................................114
Unnecessary Work ...............................................................................................114
Idle Time .............................................................................................................114
Warranted IDLE Time Exceptions ......................................................................114
The Patient Physical Examination ..................................................................115
Step 1: Process Flow Analysis (PFA)—Following the Product/Patient ..................115
Mapping the Process—Identifying Process Boxes .............................................116
Product Process Flow Analysis Tool ........................................................................116
The Four Components of PFA - Tips Analysis ........................................................117
Basic Lean Tools Understanding Types of Storage ..................................................119
Raw Material Storage ..........................................................................................119
Work in Process Storage ......................................................................................119
Finished Goods Storage.......................................................................................120
Further Delineating Storage—Types of Work in Process ...................................120
Lot Delay .............................................................................................................120
Potential Lean Solution Example #1 ...................................................................121
Potential Lean Solution Example #2 ...................................................................121
Between Process Delay .......................................................................................121
Within Process Delay ..........................................................................................122
Why Break Down Types of Storage? ..................................................................122
Total Throughput Time .......................................................................................122
Product Flow Analysis Worksheet ......................................................................123
Product Flow Point-to-Point Diagrams ...............................................................123
How to Do a Point-to-Point Diagram ..................................................................125
