Presentation given April 15 2010 to networking meeting group.

1. Massachusetts Hospital Lean Network
Mark Graban
Senior Fellow, Lean Enterprise Institute
Author, “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction”

2. 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

3. 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

4. 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.

6. 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

7. 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

8. “Equally Important Pillars” of The
Toyota Way

9. Different Types of Kaizen
Very few
Large problems Mgmt
Kaizen
Six
Few Sigma
Medium problems
Kaizen
Event
Many
Small problems
Daily Kaizen
Adapted from: “The Toyota” Way Fieldbook, Liker and Meier

10. The Problem with Ignoring
“Respect for Humanity”
Found posted in a hospital lab
(during Lean assessment)

11. Engaging Employees
From Locked Box To Visual Idea System

12. One Idea Card Format
FRONT BACK

13. Idea Board – Microbiology Lab

14. 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

15. Kaizen Wall of Fame – Core Lab

16. Value of Kaizen in a Hospital?
• $4,000 per employee (Toyota)
– Just the quantifiable benefit
• What about benefits from:
– Better Quality
–
–
–
Morale
Patient Satisfaction
Less Waiting Time
= $$ ?

17. Employee Quote
“This is the best thing
we’ve done in my 20
years. We’re finally
fixing things.”

18. 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

19. 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)

20. 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

21. Make Errors Less Likely to Occur
(Source: ThedaCare)

22. 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?

23. The Quaid Case – Heparin/Hep-
Lock
New Design
Old Design

24. Outpatient MRI Scenario

25. 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?

26. 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

27. Top Down and Bottom Up
Source: Lean Hospitals, Graban

28. Purpose: What’s True North?
Quality Decrease Defects and Waiting Time
by 50% each year
Customer
Business Engagement
Increase Productivity No. of Suggestions
10% each year Implemented

29. “True North” Metrics & A3s
Source: ThedaCare

30. ThedaCare Mother A3s
VS’s Metrics
Value
Stream
Review
Area
Safety
People
Shared Growth
Productivity
• Eventually shift to “Continuous Daily Improvement” 30

31. “Breakthrough A3” - Safety
• Expect 50% improvement in these breakthrough A3s 31

32. Safety A3 - Detail
32

33. Standardized Metrics Board
Delivery
• Weekly review of metrics by Senior Leadership Team 33

34. Align Measures @ Each Level
Patient &
Improve Employee
Safety
Emergency
Inpatient Outpatient
Dept
Med/Surg Telemetry Clinics Surgery
Patient Falls
Clinic A Clinic B
Sprains &
Strains Physician A Physician B

35. Remember This:
The problem
is the process
(or lack thereof)…
not the people

36. ThedaCare “Door to Balloon” Time
100
90
80
70 91
60
Minutes
50 65
40
30 52
20
10
37
0
2005 2006 2007 2008

37. 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

38. ThedaCare Coronary Bypass
Improvement
12
1

39. For More Information or Follow Up:
• Email:
– mgraban@lean.org
• Lean Enterprise Institute:
– www.lean.org
• Healthcare Value Leaders:
– www.healthcarevalueleaders.org
• Blog:
– www.leanblog.org
• Twitter:
– www.twitter.com/LeanBlog
– www.twitter.com/LEIhealthcare
– www.twitter.com/HCVLN