Leveraging Lean in the Emergency Department: Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation, 1st Edition (Paperback) book cover

Leveraging Lean in the Emergency Department

Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation, 1st Edition

By Joyce Kerpchar, Charles Protzman, George Mayzell

Productivity Press

370 pages | 107 B/W Illus.

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pub: 2014-12-03
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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 that has demonstrated significant process and quality improvements after a Lean implementation.

Emergency departments have become notorious for long wait times and questionable quality of care. By adopting Lean manufacturing concepts, hospitals can turn the emergency department into a valuable service for the hospital and the community it serves.

Leveraging Lean in the Emergency Department: Creating a Cost Effective, Standardized, High Quality, Patient-Focused Operation supplies a functional understanding of Lean emergency department processes and quality improvement techniques. It is ideal for healthcare executives, leaders, process improvement team members, and inquisitive frontline workers who want to implement and leverage Lean.

Supplying detailed descriptions of Lean tools and methodologies, the book identifies powerful Lean solutions specific to the needs of the emergency department. The first section provides an overview of Lean concepts, tools, methodologies, and applications.

The second section focuses on the application of Lean in the emergency department within the confines of the hospital or clinic. Presenting numerous examples, stories, case studies, and lessons learned, it examines the normal operation of each area in emergency departments and highlights the areas where typical problems occur.

Next, the book walks readers through various Lean initiatives and demonstrates how Lean tools and concepts have been used to achieve lasting improvements to processes and quality of care. It also supplies actionable blueprints that readers can duplicate or modify for use in their own institutions.

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 entire 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

Leveraging Lean in the Emergency Department

The Typical ED

Long Wait Times for Overcrowded Emergency Rooms across the United

Total Time Spent in the ED

Patient Satisfaction with the ED

ED Visits in 2010

The Traditional ED Model

The Current Process is Broken

Current ED Improvement Ideas

Build More Rooms

Problems with Express Care and Fast-Track Models

"Doctor in Triage" Model

Providers See Patients in the Lobby

The Problem with Protocols

Adding Staff

Filter Patients and Send Low Acuity Patients to an Off-Site Urgent Care

The Lean ED System Approach

Value Stream Map

Product Process Flow: "The Patient"

Operator Full Work Analysis

Hypothesis

Consider the Family Physician Office Flow Model

The New ED Model

Goal

The New ED Model

Discussion

Emergency Clinical Pathways/Evidence-Based Medicine

Physician Scheduling

Other Paradigms Challenged

Resistance

Systems Impact of Implementation

Ambulance Patients

Triage Sorting Criteria

Results

Physician Benefits of This Process

Patient Benefits From the New Model

Benefits to the Hospital

Applying Lean in the Emergent – Acute Care Setting

External Forces on ED Throughput

Inpatient Floors

What a Traditional Inpatient Unit looks like

Typical Problems Encountered

Lean BASICS and Six Sigma Tools Applied—Baseline

Value Stream Mapping

Hospitalist Value Stream Mapping

Inpatient Value Stream Mapping

Care Coordination Value Stream Mapping (Includes Case Management)

ED Value Stream Map

Inpatient Process Improvement Initiative

Findings

Analysis

Suggest Solutions

BASICS - Implementation—Unit-Based Model (Geographic)

Housekeeping

5S

Resistance Encountered

Stakeholders Analysis

BASICS - Check/Sustain—Results

Length of Stay

Satisfaction

Sustain - Standard Work

Conclusion

Stage for you ED Lean Project Checklist

Appendix

Appendix: Glossary

Index

About the Authors

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.

Subject Categories

BISAC Subject Codes/Headings:
BUS070080
BUSINESS & ECONOMICS / Industries / Service Industries
MED002000
MEDICAL / Administration
MED026000
MEDICAL / Emergency Medicine