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





ISBN 9781482234237
Published December 3, 2014 by Productivity Press
360 Pages - 104 B/W Illustrations

 
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Book Description

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.

Table of Contents

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

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Author(s)

Biography

W. Protzman, III, MBA, CPM is a Shingo Prize-winning author and internationally renowned Lean consultant with over 31 years’ experience in materials and operations management. He spent more than 13 years with AlliedSignal, now Honeywell, where he was an aerospace strategic operations manager and the first AlliedSignal Lean Master. He has received numerous special recognition and cost-reduction awards. Charles was an external consultant for DBED’s World Class Maryland Consortium while he was with AlliedSignal. He had input into the resulting World Class Criteria document and assisted in the first three initial DBED World Class Company Assessments. Charles has taught students in Lean principles and Total Quality from all over the world.

In November of 1997, Charles Protzman formed Business Improvement Group, LLC (B.I.G.). B.I.G. is located in Baltimore, Maryland and specializes in implementing Lean Thinking. Charles has spent the last 18 years implementing successful Lean product line conversions, kaizen events, and administrative business system improvements (transactional Lean) across the globe.

Charles participated in numerous benchmarking and site visits including a two-week trip to Japan in June 1996 where he worked with Hitachi in a kaizen event. He is a Master facilitator and trainer in TQM, total quality speed, facilitation, career development, change management, benchmarking, leadership, systems thinking, high performance work teams, team building, Myers Briggs Styles Indicator, Lean thinking and supply chain management. He also participated in Baldridge Examiner and Six Sigma management courses. He was an assistant program manager during Desert Storm for the Patriot missile-to-missile fuse development and production program.

Joyce Kerpchar, PA
is a Shingo Prize-winning author and health care expert, with over 30 years of healthcare industry experience and currently serves as a director at Florida Hospital Orlando, which is part of the Adventist Health System, an acute-care, tertiary hospital caring for more than 1.5 million patients a year. She joined Florida Hospital in 2001, and has held a variety of roles, as interim director of strategic for surgical services, director of the Institute for Surgical Advancement, a senior consultant implementing Lean across the eight campuses in a variety of clinical departments, is a Six Sigma Black Belt and is a certified MBTI instructor, product and project manager roles developing and implementing software applications.

She began her career as a board certified physician’s assistant in cardiovascular and thoracic surgery and primary care medicine. Prior to joining Florida Hospital, she held a variety of administrative positions in healthcare-related industries, which included managed care operations and contracting for a PruCare/Prudential Healthcare who served 200,000 members in nine counties in Central Florida, Product Management for Avio Corporation, a provider of information technology for ambulatory healthcare organization, and was a partner in a consulting firm which specialized in business and market entry strategy for high tech start-ups.

Ms. Kerpchar is passionate about leveraging Lean in healthcare processes, to eliminate waste and reduce errors, to improve the overall quality and reduce the cost of providing healthcare.

Dr. George Mayzell, MD, MBA, FACP is the senior chief medical officer and chief clinical integration officer for Adventist Midwest Health. He joined the organization in January 2013 after serving as CEO of Health Choice and senior vice president of Methodist Le Bonheur Healthcare in Memphis, Tenn.

Dr. Mayzell has more than 30 years of experience in medicine and is a board certified internist and geriatrician. He received his medical degree from the University of Medicine and Dentistry of New Jersey and his MBA from Jacksonville University.

He previously served as senior medical director of managed care for University of Florida and Shands Hospital. He spent more than 10 years with Blue Cross Blue Shield of Florida, working as regional medical director for care and quality and corporate managing medical director for pharmacy and care. Additionally, he has more than 10 years of practice experience.

Mayzell has co-authored two books, Leveraging Lean in Healthcare and Physician Alignment: Constructing Viable Roadmaps for the Future.

Featured Author Profiles

Author - Charles William Protzman
Author

Charles William Protzman

CEO /President, Business Improvement Group
Towson, MD, USA

Learn more about Charles William Protzman »