This book is part of a series of titles that are a spin-off of the Shingo Prize-winning book Leveraging Lean in Healthcare: Transforming Your Enterprise into a High Quality Patient Care Delivery System. Each book in the series focuses on a specific aspect of healthcare-including emergency departments, medical laboratories, outpatient clinics, ancillary services, and surgical services-that has demonstrated significant process and quality improvements after a Lean implementation. Because ambulatory care settings play a significant role in the healthcare delivery system, it is important to understand how Lean concepts and tools can be used to deliver high-quality, cost-effective care. Leveraging Lean in Outpatient Clinics: Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation provides a functional understanding of Lean processes and quality improvement techniques in an outpatient clinic environment. This book is an ideal guide for healthcare executives, leaders, process improvement team members, and inquisitive frontline workers who want to implement and leverage Lean in outpatient clinical settings.
Supplying detailed descriptions of Lean tools and methodologies, it identifies powerful Lean solutions specific to the needs of outpatient facilities. The first section provides an overview of Lean concepts, tools, methodologies, and applications. The second section focuses on the application of Lean in the outpatient clinic environment. It presents illustrative examples of Lean deployments in primary care, GI, and preadmission testing clinics. The examples provide broad content which can be readily transferable to other outpatient clinic settings. Illustrating leadership's role in achieving departmental goals, this book will provide you with a well-rounded understanding of how Lean can be applied to achieve significant improvements throughout the complete continuum of care.
Introduction to Lean The Need for Change National and Global Competition Challenges for the Healthcare Worker Lean and Layoffs Traditional Healthcare Model Introduction - So What is Lean? Lean and Hospitals What Results can you Expect? The CEO and Lean Typical Lean Metrics and Outcomes Potential Lean Returns by Department Typical Results/Return on Investments (ROI) and Implementing Lean Lean and Systems Thinking Boiled Frog Syndrome Systems Thinking Principles Viewing the Hospital with Systems Thinking What is a Lean Business Delivery System? Lean Business Delivery System Vision Understanding the Value of the Lean Business Delivery System Just In Time: The First Pillar of the Toyota Production System Model An Example of One of the Rocks-Short-Staffed Jidoka-The Second Pillar of the Toyota Production System Jidoka Means: Never Pass on a Bad Part or Patient Applying Jidoka to Healthcare The Top of the Toyota House-Respect for Humanity Lean is a Journey Batching vs. Lean Thinking and Flow Batching vs. Lean Thinking and Flow Batching vs. Flow in a Healthcare Environment Bathing Examples Process Definition Batching Systems Why People Love to Batch? One-Piece/Patient Flow One-Piece Flow Example Group Technology Productivity - Definition Batching The Domino Effect Peak Demand Examples of Batching in Healthcare Chart Preparation Application of One-Piece Flow to Healthcare Flow-One-Piece Flow or Small Lot Lean and Change Management Implementing Lean is about Balance Lean Culture Change Paradigms Change Equation C Compelling Need to Change Why Change? V Vision N Next Steps Change and What's In It For Me Lean and Change Management Lean and Organizational Change - "Right Seat on the Right Bus" Resistance to Change Changes... Highs and Lows Rule of Unintended Consequences and Bumps in the Road Change is a Funny Thing We are all Interconnected but not Typically Measured that Way Horse Analogy Comparison to Where We are Today Employee Suggestion Systems Barriers to Change Most Loved Words Does Your Organization have Sacred Cows? Leadership and Organizational Changes Communication, Change and Lean Summary Lean Foundation Lean Foundation Baseline in the Basics Model Think-See-Act Lean System Lean Implementation Approach Utilizing the Basics Model A Customer Service Story Baseline Metrics Data, Revenue, and Hospitals The Impact of Data on Lean - Process Focused Metrics Customer Satisfaction Voice of the Customer Surveys The VIP Visit Easy to Do Business With Centralized = Batching What Does All This Have to Do with Hospitals? Customer Value-Added Proposition Customer Quality Index Baseline the Process Value Stream Map (VSM) the Process Value Stream Discussion Value Stream Mapping and Healthcare Value Streams Objectives Traditional Hospital Systems - SILOS Lean Goals Parts of a Value Stream Map Value Stream Map Icons Value Stream Map Definitions Day 1 Day 2 Day 3 Day 4 Day 5 Current State Value Stream Mapping Ideal State Future State Value Stream Mapping Value Stream Map Project Lists, Prioritization Matrix, and Tracking Value Stream Layout Maps (sometimes referred to as Skitumi maps) Baselining the Process-Data Collection and Analysis-Current State Takt Time/Production Smoothing Available Time Customer Demand Peak Demand Cycle Time Cycle Time and Takt Time-What's The Difference? Designing Cycle Time to Takt Time Length of Stay (LOS) Length of Stay (LOS) Length of Stay is Directly Correlated to Inventory Length of Stay-A Key Metric Reducing Length of Stay Number of Staff Required Total Labor Time Quiz Weighted Average Financial Metrics Measuring Inventory and Cash Flow Work in Process Inventory Sales of Reimbursement per Employee Contribution Margin Cost Per Case Data and What People Think Sustainability and Accountability Process Owners Do Not Always have the Skill Sets Necessary to Manage in a Lean Environment Notes Basic Lean Concepts and Tools - Assessment and Analyze Levels of Waste Low-Hanging Fruit Five S Wastes The Seven (Eight) Wastes How do you Find Waste? 30-30-30 Exercise People Equipment Communication Visual Controls Leadership Cost of Waste Baseline Entitlement Benchmark Five Why's Example Another Tool to Get Rid of Waste: The Five W's and Two H's Root Cause Analysis-A3 Strategy Fishbones and Lean Problem-Solving Model Problem Statements Lean Tools - Analyze/Assessment BASICS-Assess the Process Step One: Understand and Assess the Overall Process Value-Added Non-Value-Added Activities/Work Non-Value-Added but Necessary Work Unnecessary Work Idle Time Warranted IDLE Time Exceptions The Patient Physical Examination Step 1: Process Flow Analysis (PFA)-Following the Product/Patient Mapping the Process-Identifying Process Boxes Product Process Flow Analysis Tool The Four Components Of PFA - Tips Analysis Basic Lean Tools Understanding Types of Storage Raw Material Storage Work in Process Storage Finished Goods Storage Further Delineating Storage-Types of Work in Process Lot Delay Potential Lean Solution Example #1 Potential Lean Solution Example #2 Between Process Delay Within Process Delay Why Break Down Types of Storage? Total Throughput Time Product Process Flow Worksheet Product Flow Point-to-Point Diagrams How to Do a Point-to-Point Diagram Network of Process vs. Operations Defined Group Technology Matrix-Stratification Analysis Example: Group Technology Applied to a Surgical Services Unit Step II: Assess the Process-Operator Analysis or Full Work Analysis Why Make the Operator's (Staff Person's) Job Easier? Total Labor Time Workload Balancing How To Balance The Work Separate Worker from Machine Machine Time vs. Labor Time Diagrams: Spaghetti Diagramming-Operator Walk Patterns How to Do a Spaghetti Diagram Network of Process vs. Operations Defined Motion Study-Just When You Thought You Were "There" Time is a Shadow of Motion 100% Efficiency with Humans Operator Resistance Step III: Assess the Process-Changeover Analysis Internal Vs External Time Four Parts of a Setup/Changeover Process Healthcare Setup Translation Why Reduce Setups? Benefits of Smed/SMER (Single Minute Exchange of Rooms) Summary Putting It All Together Understanding Demand and Resource Needs Appropriate Resourcing Can Drive Metrics True Bottlenecks Cross-Training How to Construct a Cross-Training Matrix Heijunka-Sequencing Activities, Load Balancing Standard Work Story Job Breakdown/Work Flow Analysis Developing Standard Work Standard Work Form Work Standards Eventually Standard Work Can Lead to Semi- or Complete Automation Leader Standard Work Capacity Analysis-Part Production Capacity Sheet Layout Design Master Layouts Creativity Before Capital Lean Layout Design-Configurations-Determining the New Flow for the Area The "U-Shaped" Layout Straight Line Layouts Parallel Layouts Other Layout Considerations Guidelines to Layout Re-design-Non-Negotiable How Do We Know When the Layout is Right? Work Station Design Stand Up vs. Sit Down Stations with Chart Flow Work Station Design Summary Master Layouts and Lean Design Lean and Architects Do We Really Need to Add More Rooms or Space? Layouts Drive Waste in the Form of Increased Labor Costs-Consider Adjacencies Some Practical Examples of Lean Designs Nursing Floors Other Design Considerations Lean and Regulatory Environment Rate Companies on the Ability to Sustain Continuous Improvement Plan for Every Part-Amount of Supplies/Inventory Needed Labeling Kanban What Parts Do We Kanban? Constant Time or Constant Quantity Implementing Lean in a Healthcare Environment How to Implement Lean Methodology The Lean System Implementation-Are You Ready for It? What Type of Commitment is Required? What is Kaikaku? Kakushin Importance of Lean Pilots Keep the Ownership with the Line Organization Lean Implementation Objections and Retail Sales Techniques Objections are Good! Types of Closing Questions General Overarching Lean Implementation Tips Team Charters Guidelines for the Supervisor Train the Staff in the New Process Types of Training Overview Training On the Job Lean Training Executive Training The Lean Implementation Model General Discussion of the Four Methods Kaizen (Method 3) vs. the Traditional Point Kaizen (Method 2) Event Approach Kaizen Point Kaizen Events Potential Pitfalls of the Traditional Point Kaizen Approach Disadvantages of Point Kaizen Events Used for First Time Implementation Advantages/Results of Kaizen Events Visual Management System Components Five S Visual Displays Visual Controls Story Visual Management System Lean Goal is Zero Defects-Difference Between an Error and a Defect Poka Yoke Types of Control and Warning Devices Examples of Cause and Effect Total Productivity Maintenance Total Productivity Maintenance Goals Overall Equipment Effectiveness New Maintenance Paradigm Lean and Maintenance in Hospitals Construction Challenges Hospital and IT Systems BASICS-Checking the New Process BASICS-Sustaining the Process Sustaining Tools Sustain Plans/Control Plans Leader Standard Work Visual Management Accountability Discipline Staff Involvement You Get What You Expect; You Deserve What You Tolerate Additional Sustaining Tools Repeat the Cycle! Lean Practitioners. Lean Hospital Implementation (System Kaizen and Point Kaizen) Lessons Learned Create the Leadership Road Map Make Sure Your Organization is Ready Create a Lean Steering Committee-But Make It the Senior Leadership Team Lean Consultants Should Report to the CEO Create a Lean Organizational Infrastructure Communication Plan Training Plan Leadership Cannot Stay in Their Ivory Tower Leadership Must Lead and Drive Lean Changes, Not Just Support Them Leaders Must Participate in Lean. You Cannot "Get It" in a Two hour or Four Hour PowerPoint Pitch Don't Let Lean Turn into Finance-Driven FTE Witch Hunts Work to Establish the Lean Culture, Not Just the Tools Insist On Updating Standard Work Do Not Reward Work Arounds Don't Encourage the Victim Syndrome Physician Resistance to Lean Get Everyone Involved in the Analysis Phase Give Lean System Implementation Time to Work Before Trying to Change the Underpinnings Dedicate Resources Up Front Include a Strategy for Accountability and Sustaining as Part of the Continuous Improvement Road Map Listen to Your Lean Consultants/Experts Adopt and Integrate Standard Work and Create a Suggestion and Reward Systems Don't Leave Managers in Place Who Aren't Going to Get It Don't Lay People Off After Lean Implementation Don't Shortcut the Tools Encourage Lean Architectural Designs Include a "Go Forward" Person on the Team Train, Train, Train Create an Escalation Process Identify the Process Owner and the Team Leader Up Front Change Reward System It's Just a Bump in the Road Multiple Site Rollout Strategies Site/Area Selection Trying to Implement Several Projects at Once without Sufficient Resources Executives and Lean Introduction Been There, Done That More than just a Competitive Advantage Board of Directors Training Differences Between Lean and Six Sigma Define Reality for the Lean Initiative Resources and Accountability Lean Should Be Where the Action Is Removing Barriers Measurements to Drive Outcomes Who is to Blame? You are What You Measure Control or Sustain Process Lean and Audits "Project-itis" Human Error Factor Fair and Just Culture Communication, Communication, and more Communication Gemba - Where the Truth Can Be Found What Questions Should You Ask When Doing a Gemba Walk? Meetings Paying for Suggestions Physician Engagement The Cog in the Chain of Command Value Stream Managers in the Lean Organization Role of the External Consultant Summary Punch List of Considerations/Ideas for the Executive Leader Roles and Responsibilities of Managers and Supervisors Setting the Stage: Role of Managers and Supervisors Do You Really Want to Know What I See? Do You Really Want to Know What I Think Key Responsibilities and Tools for Managers and Supervisors Communication Identify and Provide Resources Time Management and the "Fires" Standard Work and Healthcare Following Standard Work Does Not Mean We Stop Thinking Implementation Problems with Behaviors Understanding Employee Satisfaction Management and Supervisor Performance Delegation The Journey of a Lean Sensei with a Star Wars Analogy On-Line Lean Training What It Means to Have a Lean Culture Organizational Dissemination of Lean Understanding what a Lean Culture Looks Like-"the People Piece" Importance of the 50% People Piece People vs. Task-We Need a Balance Vision Organizational Value Systems Pearls of Advice Managing Resistance to a Lean Culture Change Lean Culture Assessment Assessment Issues and Discussion Motivation and Continuous Improvement High-Level Steps to Implementing a Lean Culture Step 1: Utilize Skip Levels to See What Your Employees are Thinking Step 2: Education and Training Step 3: Create a Pull for Lean Step 4: Create a Lean Implementation Plan Step 5: Create a Lean Steering Committee Step 6: Baseline Metrics Step 7: Implement a Pilot-Utilize the BASICS Model Step 8: Gemba Walks Step 9: Sustain-Hoshin and Suggestion System Step 10: Continuous Improvement Barriers to Continuous Improvement Effort to Overcome Each Barrier Types Work to Sustain and Improve with Lean How Do You Get the CEO on Board? Story...Lean in County Government Committing the Right Resources to Sustain Human Resources and Lean Sustaining the Continuous Improvement Culture Lean in the Outpatient Clinic Setting Primary Care Clinics Overview Access to the Clinic Standardize Appointment Lengths Emergency Visits Arrival to Physician Health Insurance Portability and Accountability Act and Lean Staffing Calculating Staffing Results Achieved Gastrointestinal Outpatient Clinic Process Flow Analysis Hospital "X" Outpatient Gastrointestinal Clinic The Lean Gemba Assessment Walk Lean Capacity Analysis (Peeling Back the Onion) Registration Pre-Op Consult Room Recovery Length of Stay Considerations The Rest of the Story Staffing Summary Root Cause Staffing Other Considerations Comparison Before Proposed After Final Result Pre-Testing Clinic-The Path to Patient Readiness Typical Pre-Testing "Patient Readiness for Surgery" Projects The Pre-Testing Clinic Model Traditional Pre-Testing Process Need for Standard Orders Standard Pre-Testing and Pre-Op Order Sets Lean Solution How to: The Procedure to Create Standard Orders for "Medical Clearance for Surgery" Key Considerations Standard Orders Rollout-General Lean Project System Implementation Considerations Physician Acceptance and Adoption How to Implement the Physician Office Component Physician Office Education Selection of Pilot Offices Necessity for Pre-Testing Necessity to Schedule Pre-Testing at least 3-10 days (whenever possible) Prior to the Surgery Date Lean Pre-Testing Model Pre-Testing Infrastructure Traditional Process Flow and Issues of the "Readiness for Surgery Process" Pre-Testing Phone Call Process Pre-Testing Patient Interview The Pre-Testing Model-Patient Visit Problems Typically Encountered Hospital X Lean Results in Pre-Testing are Proven Level Loading the Schedule Hospital B-Standard Work-Thoughts and Discussions Surrounding the Introduction of Standard Work to Staff in a Pre-Testing Clinic Step 1-Grab the charts Step 2-Introduce yourself to the patient Step 3-Take vitals Lessons Learned and Ideas Implemented from Various Lean Pre-Testing Initiatives Results Pre-Testing Model Calculations Conclusion Appendix: Glossary Index