1st Edition

Leveraging Lean in Outpatient Clinics Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation

    360 Pages 104 B/W Illustrations
    by Productivity Press

    360 Pages
    by Productivity Press

    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
         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

    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
         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

    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
         Visual Controls
    Cost of Waste
    Baseline Entitlement Benchmark
    Five Why’s
    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
         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)

    Putting It All Together
    Understanding Demand and Resource Needs
    Appropriate Resourcing Can Drive Metrics
         True Bottlenecks
         How to Construct a Cross-Training Matrix
    Heijunka—Sequencing Activities, Load Balancing
    Standard Work
         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
         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?
         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
              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
         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
         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
         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
         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?
         Paying for Suggestions
         Physician Engagement
         The Cog in the Chain of Command
         Value Stream Managers in the Lean Organization
         Role of the External Consultant
    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
         Identify and Provide Resources
         Time Management and the "Fires"
    Standard Work and Healthcare
         Following Standard Work Does Not Mean We Stop Thinking
    Problems with Behaviors
    Understanding Employee Satisfaction
    Management and Supervisor Performance
    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
         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
    Access to the Clinic
         Standardize Appointment Lengths
         Emergency Visits
    Arrival to Physician
         Health Insurance Portability and Accountability Act and Lean
         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)
         Consult Room
         Length of Stay Considerations
              The Rest of the Story
         Root Cause
    Other Considerations
         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
         Pre-Testing Model Calculations

    Appendix: Glossary



    Joyce Kerpchar, Charles Protzman, George Mayzell