Read Utilizing Lean Management Principles; Rapid Process Improvement to Improve Patient Critical Use Equipment Processes text version

"Brains before Bucks"

Critical Use Equipment Rapid Process Improvement Case Study

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Allen Caudle, Vice President, Supply Chain Tom Moench, Director, Strategic Improvement Swedish Health Services Ken Fortune, Director, Logistics Swedish Medical Center Seattle, Washington

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Swedish Health Services Swedish Health Services

Hospital Hospital Division Division

Home Home Health & Health & Hospice Hospice

Physician Physician Division Division

Joint Joint Ventures Ventures

Foundations Foundations

Research Research && Education Education

MOBs MOBs

Largest Hospital System in the Pacific Northwest 3 Acute Care Facilities 25 City Blocks and 5.5 million Ft2 1,286 Total Beds Not for Profit ­ 501c3 Organization Net Revenues - $930 million in 2003 6,970 Employees 1,444 Physicians

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Agenda

Introduce "Lean Thinking" Describe the Rapid Process Improvement (RPI) Workshop Approach Review the Results of an RPI Workshop Share Sustaining & Improvement Activities Share Reflections on the Changing Role of the Supply Chain manager Q&A

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The Gold Standard

Treat the patient care constraint like Gold -- Align the organization and deliver The Gold Standard to our customers and clinical service partners!

Pyxis Med Surg Supply Implementation RPI Critical Use Equipment RPI

Periop Svcs/ Supply Chain/ Clin. Info System RPI Redesign

Patient Care

Bed Turnover RPI - Environmental Svcs

Nursing Unit Storeroom 5S

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What is the Toyota Production System or "Lean Thinking?"

Request Value Stream Time Line Revenue

1. Value - define precisely what delights customers 2. Value Stream = Service Lines - identify all processes 3. Flow - make value steps flow by removing waste in every form 4. Just-in-Time - design & provide precisely what customers want precisely when they want it 5. Perfection - pursue through Daily Management

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10 Leadership Practices for Managing & Sustaining Lean Operations

Employee Development

1. Establish a Good, Two-way Relationship

2. Set Context 3. Plan & Resource 4. Assign Tasks 5. Improve Work Continuously

Goal Achievement

6. Select & Orient Staff 7. Coach & Develop Staff 8. Assess Judgment & Discretion 9. Recognizing & Rewarding Staff 10. Reassign, Correct or Dismiss

· Quality/Safety · Patient Satisfaction 10 · Lead-time

Success Requires 3 Stratum Leadership & a Management Guidance Team

CEO COO VP DIR Mgr DIR Mgr VP DIR

Management Guidance Team

· Epidemiology & Nursing · Cross-org. alignment -BioMed, Envir. Services, Sterile Processing,

3 Stratum Leadership

· Authorizing manager · Process Manager · Experts in the Process

DIR

Mgr

Mgr

Customer

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Our RPI Project Management Process

Executive Commitment

WORKSHOP WEEK Hold the

A S P D Sustainable Improvement

ASSESSMENT Go/No Go?

PLAN RPI Blueprint

RPI

Gains

30 Day Review

60 Day Review

DAILY MANAGEMENT (RPI Newspaper)

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Activities of the Four Phases

Assessment Planning Workshop Daily Mgmt

Initial meeting Process review Site Visit Assess managers Feedback - Opportunities

- Risks - Scope

Go/No Go decision

Workshop Objectives Process boundaries Timing set Participant preparation Management preparation Data collection Agenda set

Learn tools Analyze process Eliminate waste Implement short-term plans Develop follow-up plans

Complete workshop actions Implement Daily Mgmt Check results and hold gains Spread to other areas

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The Executive Challenge

Authorizing Executives: Allen Caudle, VP Supply Chain Pat Anderson, VP Nursing Services, First Hill Campus Cal Knight, COO, First Hill Campus Mary McHugh, VP Support Svcs (Darren Redick, VP Facilities) Stakeholding Executive Marcel Loh -- COO Providence Campus

Mission: Improve the handling, cleaning, maintenance and availability of critical use equipment on the nursing floors.

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Case Study Goals

Goals: Establish single-point accountability for the process 90% improvement in availability of clean, ready to use (patient ready) equipment 50% reduction in lead time for patient ready, critical use equipment 30% reduction in labor expenditure in process

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Voice of the "Internal Customer"

Clinical Assessment Team

Judy Davido, RN, Mgr. of Transport Judy Lewis, RN, Mgr. of MedSurg Unit Steve Hoppe, RN, Mgr. of CICU Lydia Chan, RN, Mgr. of PACU Joyce Burris, Mgr. Sterile Processing Carlotta Reynolds, RN, Mgr. of Oncology

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Voice of the "Internal Customer"

Critical Use Equipment (CUE) Defined: · IV Pumps (i.e. triple, single, syringe, patient controlled analgesic [PCA]) · Sequential compression devices [SCDs] · Doppler - ultrasound · Suction heads (e.g., intermittent, continuous, multiple)

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Patient Care Staff Satisfaction Survey

5 5 = Always Satisfied 4.7 4.5 4.2 4.6

Satisfaction with CUE Availability

1 = Always Frustrated 4

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2.8 2.3 2.3

7SW 6E & 7E 8E 12E

2.2

Improving

2

1

Before

After

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Source: Judy Lewis, RN, Carlotta Reynolds, RN, Steve Hoppe, RN - Written Survey

Selecting the Workshop Team

· · · · · · · ·

Steve Hoppe, 8E Nurse Mgr. Judy Lewis, 7SW Nurse Mgr. Carlotta Reynolds, 12E Nurse Mgr Diana Ronning, Mgr. Envir. Svcs. Gerry Siruno, Mgr., Pyxis Ashok Prasad, Serv. Rep, MSC Dave Walker, CS Tech III, SPD Mary Harrell, Environment of Care Team

· · · · · · · · ·

Marsha Trickey, NAC, 12E Mavis Van DeLicht, Inf. Control Steven Guy, HR Sharon Scott, Decision Support Judi Hoff, Mgr Med. Staff Svcs Martin Stabler, Cost of Care Mgmt Allen Caudle, VP, Supply Chain Ken Fortune, Dir., Logistics Tom Moench, RPI Consultant,

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Generic 5 Day Workshop Agenda

Day 1 Understand the As Is · Kickoff · Becoming a team · Identifying waste · The 3 Actuals Walk · Analysis of the 3 Actuals Walk Day 2 Envision Perfection · Learn more lean tools · Create a vision · Identify implementation projects · Report to Mgmt Guidance Team (MGT) Day 3 Day 4 Day 5 Communicate and Celebrate · Identify new process results · Determine Daily Management plan · Report to MGT stakeholders and colleagues · Celebrate!

Implement

Implement

· Communicate · Communicate with work areas with work areas · "Trystorm" · Trystorming work on continues projects to · Develop move, change, measures to rearrange monitor · Identify & follow-up implement visual controls

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Spirit of Improvement Ground Rules

Brains before bucks Substitute "we don't know how to, do it yet" for "we can't Challenge assumptions -ask the "5 Why's" Take initiative at all levels Remember -- workshop participants are the experts "Don't just plan -- Do!" Better to get 50% improvement today than perfection someday Listen respectfully--twice as much as you speak Trust the process Have fun!

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Collision Course with the "Hidden Hospital"

Visible Hospital

· Clinical care · Customer Satisfaction · "The Dirt Line" · Budgets Over-processing Inventory Correction Waiting Space

Hidden Hospital

Searching Transport Complexity

Over-producing

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3 Actuals Walk

"The time that provides me with the most vital information about management is the time I spend in the plant, not in the vice president's office." -- Taiichi Ohno

Go to the Actual Place Talk to the Actual People Observe the Actual Process

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The 20 Year Problem · Nursing -- required desperation cleaning: 1) wipe down dirty pumps and use again, 2) wipe & share pumps between patients on unit, 3) scavenge clean pumps from other units Material Service Center (MSC)-- Inventory control inadequate & not enough equipment to give the nursing units what they needed Lead time to turnaround a pump from discharge to patient-readiness ~ 21 hours with at least 22 queue areas throughout the house

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·

·

Before - Equipment Room

· Poor access · 4 pumps past PM · Inventory needs unknown Not Plugged In

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IV Pump Transit on First Hill Campus

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First Hill Campus SPD Cleaning

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Waste of Searching in the Materials Service Center (MSC)

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How long a wait?

1400 1200

Average Lead Time ( Minutes)

1260 (21 hrs)

BEFORE (IV Pumps)

1000 800 600 400 200 0

BEFORE (SCDs)

Source: Environment of Care Techs -- hand collected

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Waste in Bed Turnover

Source: CUE RPI 3 Actuals Walk

Patient and Nursing wait for a clean bed

Waste of Transport

ES search for supplies and equipment

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Waste in CUE Transport Bed Turnover

Source: CUE RPI 3 Actuals Walk

Unit Secretary, Nursing, and Patient wait for a clean bed Waste of Transport

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Why Focus on Waste?

Most processes are 90­95% non-value-added waste. Focusing on eliminating waste is the best leverage for an improvement effort. Quality and service level are enhanced.

Value Added

Waste

95%

5%

Lead Time

Cycle Time

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35% is "Wasteful Work"

Murphy Leadership Institute. 2003

HOSPITALS: 71 EMPLOYEES: 74,827

...employee commitment increased 1% ...employee perception of quality increased by 0.9% ... Operating margin increased by 0.25%

As time spent on wasteful work decreased by 1%...

Source:

Improvement increased in...

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Before Process Map

Value added 2- 4 min

· 74% of all work time to make pumps available was Rework · 45% of rework was in nursing alone

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Vision - Room Resident CUE

1 - Syringe Pump

2 - XL3 Pumps

1 - PCA Pump

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"After" Process Map The CUE Vision Summarized

Patient Rooms Room Resident CUE (XL1, XL3, PCA, SCD, ESP) Cleaned in the room at D/C

Clean in Room Excess CUE

Broken/ PM

Replace

Unit CUE Safety Stock

MSC Central Inventory MSC Returns MSC Delivery Sterile Processing

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BioMed/Abbott

A Visual Workplace - Cardiac ICU

AFTER RPI 3/27/03

Know what & how many to deliver Know what to remove

BEFORE RPI 3/27/03

Know when to do Preventative Maintenance

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Where will we get the needed pumps? BEFORE

Patient Room = Syringe Pump = IV Pump Patient Room with Room Resident CUE

AFTER

Unit CUE Safety Stock

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MSC Central Inventory

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?

Soiled Utility Room

Clean in Room

?

?

MSC Central Inventory

Soiled Utility Room

BioMed Repair

xx

Sterile Processing

BioMed Repair

xx

Sterile Processing

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Timeliness Lead-time Reduction Lead Time = Average Bed Turnover (BTO) Time

1400 1200

Average BTO ( Minutes)

1260 (21 hrs)

BEFORE (IV Pumps)

1000 800 600 400 200 0

BEFORE (SCDs)

Improving

Lead Time = Min Per BTO

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7SW

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8E

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12E

Source: Environment of Care Techs -- hand collected 39

Patient Care Staff Satisfaction Survey

5 5 = Always Satisfied 4.7 4.5 4.2 4.6

Satisfaction with CUE Availability

1 = Always Frustrated 4

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2.8 2.3 2.3

7SW 6E & 7E 8E 12E

2.2

Improving

2

1

Before

After

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Source: Judy Lewis, RN, Carlotta Reynolds, RN, Steve Hoppe, RN - Written Survey

Nurse Feedback

"PCA and IV pumps--always clean, zeroed and in the room--this policy works very well to improve quality care & time with my patients." -- Cardiac ICU nurse "The new CUE RPI is very effective & markedly decreased/eliminated wait time for the equipment when needed." -- Cardiac ICU nurse "Availability depends on housekeepers. Other units pillage." -- Oncology nurse "These pumps are now always available in the room or clean utility room that I don't spend any time looking for them." -- MedSurg nurse

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Patient Safety Infection Control BEFORE -- Problematic -- Increased public exposure: hallways & elevators -- Increased employee exposure -- SPD, BioMed, outside vendors -- No containment AFTER -- Contained -- Cleaning cycle contained on unit -- Exposure limited to unit specific personnel, patients and guests

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Cost Cost-Lead Time Profile

$14

$14

Labor Supplies Wait Area = The Profile

Cost Per Pump Per Room Cleaned

$12 $10 $8 $6 $4 $2 $0 0

Before RPI

(1264 mins $12.52/pump)

$12 $10 $8 $6

After RPI

(~34 mins $0.67)

$4 $2 $0

200

400

600

800

1000

1200 43

Lead Time (mins)

Source: Decision Support

First Hill Cost Savings Forecast

Annual CUE Processing Cost Estimate $600,000 RN $500,000 Total $ First Hill* $400,000 $300,000 $200,000 $100,000

* Includes MSC delivery/ restocking labor

Source: Organizational Effectiveness & Decision Support

MSC Tech I ECT I

54%

SPD Tech I

7%

Improving

$0

BEFORE RPI

1

AFTER FULL IMPLEMENTATION

2

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Sustainability Audit

Daily Assessment Form for Critical Use Equipment

Date UNIT Time Items in Kanbans Inspector(s) Safety Tags visible Equip. Repair Tags avail. PM dates OK Tape condition OK Photos correct Par Items Plugged in Score (Total Defects)

Comments/Action Items

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Sustaining

2 1.8 1.6

5 to 7 Units

7 to 8 Units

8 to 9 Units

Defects/Day/Unit

1.4 1.2 1 0.8 0.6 0.4 0.2 0

9/ 03 10 /6 10 /1 3 10 /2 7 11 /0 3 11 /1 7 12 /1 12 /1 5 12 /2 1/ 9 6/ 04 1/ 14 1/ 22

9/ 2

Audit Date

2/ 2 2/ 17 3/ 2 3/ 15 3/ 31 4/ 14 42 7 5/ 13

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Implementing Across System

Point Improvements

Point Point Point

Line Improvements

Line Line Vertical Development

Build a foundation

Link the islands of improvement

Cube Improvements

Height (third dimension)

Plane Improvements

Plane

Replicate the model improvements

Expand to planes beyond

© Mathews & Associates

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Summary

· Took 1 year from initial VP meeting to end of RPI Workshop (Oct `02 - Oct `03) · Involved 2 COOs and 4 VPs to implement · Was co- lead by a VP & Director · Demonstrates the RPI workshop and documents estimated cost impact · Point-Line-Plane story -- CUE Rollout RPIs with Rapid Bed Turnaround RPI -- BioMedical 5S initiative -- ongoing -- Med/Surg New Supply Implementation RPI - 30 Day Period -- Periop/Supply Chain Lean Initiative --Planning Phase

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How Our Roles Have Changed!

· Not just "Suits on the floor" or "box movers"-viewed as effective, problem solvers · Established 1-on-1 relationships with front line staff and cross-organizationally · Have bridged the operational gap between nursing and logistics · Function with a deeper, personal understanding of the whole clinical setting and how Supply Chain and support more effectively · No longer the "5% Losers" -- soon to educate the Management Team

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Lean Production Approach in Healthcare

Virginia Mason Medical Center Swedish Medical Center University of Washington Medical Center Children's Hospital & Regional Medical Center Rochester General Hospital Strong Memorial Hospital PeaceHealth Pittsburgh Regional Healthcare Initiative

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Further Reading

Articles: Beyond Toyota: How to Root Out Waste and Pursue Perfection. James P. Womack & Daniel T. Jones. Harvard Business Review, Sept/Oct 1996 Reducing Operating Room Delays by Improving OR Efficiency. Charles M. Kilo, MD & Ron Kirshner, MD. Institute for Healthcare Improvement, 1997 -- Available by email* Decoding the DNA of the Toyota Production System. Steven Spear & H. Kent Bowen. Harvard Business Review, Sept/Oct 1999 The Lean Service Machine. Cynthia Karen Swank. Harvard Business Review, Oct 2003 Lean Health Care? It works! Patricia Panchak. Industry Week. Com, Nov 1, 2003 -- Available by email* The Lean Enterprise Meets Health Care. Jeff McAuliffe, Tom Moench and Joan Wellman. Hospitals & Healthcare Networks Online. February 10, 2004

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Further Reading

Books: The Goal: A Process of Ongoing Improvement. 1984. Eliyahu Goldratt & Jeff Fox The Toyota Production System. Beyond Large Scale Production. 1988. Taiichi Ohno Executive Leadership. 1990. Elliott Jaques Lean Thinking: Banish Waste and Create Wealth in Your Corporation. 1996. James P. Womack & Daniel T. Jones Becoming Lean. 1997. Jeffrey K. Liker The Lean Office: How to Use Just-in-Time Techniques to Streamline your Office. 1997. Jim Thompson Value Stream Management for the Lean Office. 2003. Don Tapping & Tom Shuker The Toyota Way. 2003. Jeffrey Liker

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Lean Glossary

· Batch-and-queue = the mass-production practice of making large lots of part or product and

then sending the batch to wait in the queue before the next operation in the production process · Flow = the progressive achievement of tasks along a process (value-stream) so that the product proceeds from input to output and into the hands of the customer with no stoppages, scrap, or backflows. · Kanban = Japanese word meaning "signal" or visual record." · Lead-time = is the total time a customer or service partner must wait to receive a product or service after making a request · One-piece flow (single-piece or one-touch flow) = a situation where products proceed, one complete product at a time, ideally being touched only once by a person, through various operations in design, order taking, and production without interruptions, back flows, or scrap · Rapid Process Improvement = an improvement/management development approach that uses a fast cycle, reliable method based on lean methods to dramatically improve a work process with breakthroughs in quality, cost, service delivery, safety and morale · Spaghetti chart = a map of the path taken by a specific person or unit of work as it travels through the value stream so name because it looks like a plate of spaghetti · Value-added = those activities that transform inputs into outputs by changing the form, fit or function of materials or information; activities that are perceived as valuable by the customer. · Visual workplace = visual tools and methods used to manage production abnormalities 54

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