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Topics • Overview of LEI
and Healthcare Value Leaders Network • Staff engagement in continuous improvement • Systems and processes for preventing errors • Role of senior leadership in “strategy deployment” 2
About LEI • Lean Enterprise
Institute, Inc. (LEI) is a nonprofit education, publishing, conference, and research organization founded by James Womack, Ph.D. in 1997 to promote and advance the principles of lean thinking in every aspect of business and across a wide range of industries. • Through its publications, summits, conferences, workshops, webinars, online forums, and website resources, LEI helps organizations transform themselves into lean enterprises, based on the principles of the Toyota Business System. 3
Our mission is to fundamentally
improve healthcare delivery through lean thinking. LEI TCVHC We educate leaders in lean thinking, facilitate networks of practioners, host an annual conference and provide resources at healthcarevalueleaders.org.
1st Network- Members • Group
Health Cooperative • Gundersen Lutheran Health System • Hotel-Dieu Grace Hospital • Iowa Health System • Johns Hopkins Medicine • Lawrence & Memorial Hospital • Lehigh Valley Health Network • McLeod Health • Mercy Medical Center • Park Nicollet Health Services • St. Boniface General Hospital • ThedaCare • UCLA Health System • University of Michigan Health System
2nd Network- Members • Akron
Children's Hospital • Alberta Health Services • Beth Israel Deaconess Medical Center • BJC Healthcare • Christie Clinic • Cleveland Clinic • Harvard Vanguard • Kaiser Permanente • Seattle Children's Hospital • St. Joseph Health System
Documenting & Celebrating Improvements Area:
STL Kaizen Wall Date: 5/31/07 of Fame What was the Problem? • What was the problem? For disposal of pipette tips, the only containers we had were “sharps” containers. This Adds extra disposal cost, as the tips are not sharp. The contai ner hole was also Hard to get tips into. What was changed, improved, implemented? Create biohazard bag holders out of urine jugs, cut the tops off. • What was changed, Photo/Diagram: improved, or implemented? Old Style Container New Container • What were the benefits? What were the benefits? Safety? Quality? Time? Waste? Cost? Reduces cost since we aren’t doing unneeded sharps disposal and we aren’t throwing the containers away each time. No safety risk. Easier to get tips into container (less motion and less arm strain, since the Container is lower and easier to get into). Tips can be dumped into a larger Biohazard bin or we can replace the bag. • Who was involved? Who was Involved? Gretchen, Beth, Janie, Franke
Data From Children’s Medical Center
Dallas Before Lean 12 Months After Starting 3. I have the opportunity to do what I do 3.11 3.92 best every day. 8. I feel free to make suggestions for 2.84 3.48 improvement. 10. I feel secure in my job. 2.32 3.42 13. Stress at work is manageable. 2.43 3.23 17. I am satisfied with the lab as a place to 2.51 3.43 work. 18. I would recommend my work area as a 2.38 3.46 good place to work to others. Grand Average 2.96 3.69
TPS Leadership • “You respect
people, you listen to them, you work together. You don’t blame them. Maybe the process was not set up well, so it was easy to make a mistake.” – Gary Convis, President TMMK (Toyota Motor Manufacturing Kentucky)
Many Errors are Preventable •
Nosocomial Infections – a.k.a. “Hospital-Acquired Infections” (HAI) – 5 to 10% of hospitalizations • 10% of these are serious bloodstream infections • 87,000 to 350,000 die annually – “Can be prevented through improved hygiene and proper line insertion standards” (1) • Allegheny: reduced bloodstream infections by 68% through standard methods and supplies • (1): U.S. Centers for Disease Control
The Quaid Case – Heparin/Hep-Lock
Hospital CMO: “This was a preventable error, involving a failure to follow our standard policies and procedures, and there is no excuse for that to occur at Cedars-Sinai.” Was this the first time the policies and procedures were not followed?
Case Example • Virginia Mason
Medical Center (2004) – Mary McClinton died after cleaning solution was injected (not dye) – Identical looking clear syringes together on tray • “Mistakes will happen,” he said, sadly. “We are exceptionally human.” – Knew about same color syringes 2 YEARS before fatal error occurred • Had switched from brown cleaning solution to clear – Radiology tech MENTIONED the problem to a supervisor 2 MONTHS before the fatality • Why does this happen? How can we prevent this?
Hoshin Kanri • Hoshin =
“compass” – Pointing the direction • Kanri = “management” or “control” • Hoshin Kanri – A process for embedding strategy and aligning an organization toward common goals • Developed by Yoji Akao (non-Toyota) • Using PDCA cycles to: – Create goals – Choose measurement points – Link daily activities to high level goals
ThedaCare Code STEMI • Starting
Point 2002 – “Did not have a clear, standardized response to heart attacks.” • Studied each process step in detail – Convinced cardiologists to let ER MD call heart attack • Reluctant, but only two false positives in two years • Posted standardized work in each room – Clear process steps and toll-gates