1. Lean Healthcare & Lean Design
Mark Graban
President, Constancy, Inc
Faculty Member, Lean Enterprise Institute
Author, “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction”
2. What is Lean?
• Management Method • Design Method
– Best patient care – Patient/family-focused
– Engaging staff – Engaging staff
– Minimizing waste – Minimize waste
• Eliminating barriers – Right size / resources
– Fit your processes
– Continuous improvement – Iterative improvement of a
• Better quality at a lower one-time design innovation
cost • Better meets needs at a
lower cost, with fewer
delays
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3. Improving Radiology /MRI Access Time
Outpatient Radiology Backlog
14
12
Weeks Waiting Time
10
8
6
4
2
0
Source: Children’s Medical Center, Dallas TX
5. “Lean Construction”
• “Lean construction is a new way to design and build
capital facilities. It challenges the generally accepted
belief that there is always a trade between time, cost
and quality.”
– Maximizing value and minimizing waste
– Concurrent engineering of facility and workflow
– Value to owner defined and refined over time
– Continuous flow of work schedules
– Decentralized decision making, transparency, empowerment
http://www.leanconstruction.org/about.htm 5
6. Users of Lean Design
• Riley Hospital for Children (Indy)
• Children’s Medical Center Dallas
• Seattle Children’s Hospital
• Park Nicollet (MN)
• Virginia Mason Medical Center (Seattle)
• Beth Israel Deaconess Medical Center (Boston)
• ThedaCare (WI)
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7. Seattle Children’s Results
Source: Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value By Joan
Wellman, Pat Hagan, Howard Jeffries 7
8. Lean Capital $$ Savings
• Seattle Children’s • Avera McKennan (SD)
– Avoid $180M construction – Avoided $1.25M in ED
expansion
• LeBonheur Children’s (TN)
– $6M avoidance in new tower • Florida Health System
– $11M building cost
• Akron Children’s avoidance
– Avoid $3.5M expansion of
sterile processing • Delnor Hospital (IL)
– Defer $80M capital
expansion
9. Lean Benefits All Stakeholders
Patients • Safety & Quality
• Caring Encounters
• Less Waiting and Delay
• Pride in work
• Less frustration People • Mission
• Job security • Stewardship
• Career growth Philosophy • Stability / Growth
Caregivers Hospital
• Employees
• Medical Staff
• Administrators
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16. The 8 Types of Waste
Type of Waste Example
Defects Wrong medication given to patient
Overproduction Specimens delivered in huge batches
Transportation Patient walking football fields between
oncology clinic and chemotherapy
Waiting Patients waiting in E.D.
Employees waiting on work to do
Inventory Expired medications, excess O.R. variation
Motion RN’s walking 5 miles per day
Processing Unnecessary MRI’s when P.T. might work
Human Potential Med Techs recapping specimens
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17. The Iceberg of Lean
5S
Kaizen
VSMs A3
Kanban
Std Work Heijunka
Culture
Management System
Philosophy
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18. Lean Terms
• 5S: Workplace organization and reduction of waste
• Kaizen: continuous improvement
• A3: Format for PDSA problem solving, planning,
reporting
• Kanban: method for replenishment of supplies
• Heijunka: Level loading of workload
• Standardized work: Creating, managing, and improving
processes and protocols
• Value Stream Mapping (VSM)
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19. Bad Example of 5S
"We were offering suggestions and getting pushback on safe staffing,
yet being told to reduce the number of pens and pencils.”
– RN (Minnesota)
20. Good Example of 5S for an MD
670 ft for single procedure prep
(pre-Lean walking pattern)
Exam
Procedure
Lab
21. Reducing Podiatrist Walking
Restocking Checklist
• Created standardized cart
• Along with standardized rooms,
eliminated the need to leave the room
during patient encounters
23. LEAN – the 7 “sees”
1. See for yourself (“go to the ‘gemba’”)
2. See what people do (observe first hand)
3. See how people spend their time (activity follow sheet)
4. See where people go (spaghetti chart)
5. See what really happens to your patients (value stream
maps)
6. See who your teammates really are (value stream maps)
7. See the wasted effort (waste / ‘muda’)
Applies to design and management
24. Patient-Centered Care
• “Where care comes to you.”
• In the same room:
– lab draws
– nursing assessment
– physician exam
– IV therapy administration
– Music therapy
– Counseling / spiritual care
– scheduling of future
appointments
• “It’s kinda all about you.”
Park Nicollet Frauenshuh Cancer
Center 24
25. Lean Design Results –
Chanhassen Clinic (PN)
• Decrease walking:
– For patient reduced 27%
– For nurse reduced 27%
– For clinician reduced 42%
• Reduce inventory:
– Reduced 21 exam rooms
– Reduced 1 procedure room
– Reduced construction cost $196,200
– Total project reduction $357,300
• 20% reduction of square footage:
– Created flexibility, team work among disciplines; lean concept of 'open
room'; less steps for patient and staff; improved flow and visual control.
26. Staff Engagement to Reduce
Waste (Riverside Lab)
Final Layout
Core Cell
Processing Chem/Hem/+ Manual
Lean Team,
Analysis Driven
Comparing Alternatives
For Flow and TAT
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27. Riverside Results
Metric Before After
Potassium IP TAT 74 min (June 06 avg) 48 min (Nov 06 avg)
(35.1% reduction)
Troponin ER TAT 54 min (June 06 avg) 34 min (Nov 06 avg)
(37.0% reduction)
% of Results on 62% (10/10) 85% (Nov 06 avg)
Chart < 7 AM
Specimen Travel 146 feet 67 feet
Distance Chemistry (54% reduction)
Hem. Tech Walking 1620 to 2028 feet/ 500 to 800 feet/hour
(estimated based on std work)
Distance per Hour hour
Square Footage 228 sq ft freed up
(behind manual area, to side of
special chemistry)
28. 8 Flows of Lean
1. Flow of Patients
2. Flow of Families
3. Flow of Providers
4. Flow of Medications
5. Flow of Supplies
6. Flow of Information
7. Flow of Equipment
8. Flow of Instruments/Processes
30. Look Across the Value Stream -
Oncology
Patients Scheduled 5/2/06
Oncologist Schedule Start running
18 out of chairs
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10
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6 Idle Time
4
2
0
7:00
8:00
9:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
31. Seattle Children’s Bellevue
• 32% reduction in original
space estimate Recovery
• Opened on time
• $3.5M under the $70M
budget O.R.
• “Frankly this is the best
“one piece flow” for
ambulatory surgery I Induction Induction
have observed anywhere
in the world.”
– John Toussaint, MD
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33. Riley Design Process
• Their lead architect:
– “Building design is often a reaction to their current state”
• Too much equipment – more space --- not the best answer
– “Taking those extra months to understand what they really
wanted and what their ideal state was going to be was very
helpful.”
– Telling architects to not draw anything for 2 sets of user
meetings – strange to them
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34. Understanding Current State
• 3-day workshops
– NICU
– Burn unit
– Oncology
• Structured observation
by staff members
– Qualitative
– Quantitative
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36. Layouts Drive Waste of Motion
Med Tech Walk Pharmacy Tech
Pattern (5.1 miles/day!)
Miles per Day!
Cancer Center RN
37. Activity Follow
• Shadowing a person
– Focus on the process, not finding fault w/ person
• Identifying tasks / activities done each minute
• Tracking interruptions
• Do spaghetti diagram in parallel
44. Envisioning Future State
• Current: Transporting patients in the burn unit
– Wouldn’t it be great to have a procedure room in the unit?
– Avoid having to go all the way to the O.R.
– “Not dragging that child all the way across the hospital.”
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46. “Whenever there is
CARE for a
PATIENT, there is a
value stream. The
challenge lies in
seeing it.”
Paraphrasing Rother & Shook
47. What is a Value Stream?
Supplier Customer
Request Made Product or Service
or Need Identified PROCESS STEPS Delivered
Reception Prep Procedure Recovery Reports & Invoice
VALUE STREAM
Value Stream: All steps, both value creating and non value-
creating, required to complete a service from
beginning to end.
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48. This is a Value Stream Problem
This is Not Always an “ED Problem”
• Beds unavailable
• Admission delays
• Discharge delays
Building a bigger ED might not help
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49. What is a Value Stream Map?
• A diagram of a process from beginning to end at a
level that people can see interactions between
departments, floors and processes.
Information
Registration Referring
Lab Dept MD
Work
Scheduling
Patient
Assessment Dept
Dept
Product/Patient
Check Pre-Op OR PACU Recovery Go
In Prep Home
50. The Mapping Team
• Create a Cross Functional Team Consisting of:
– VSM Facilitator
• Responsible for leading the team through the VSM process.
– Process Experts
• People who have in-depth knowledge of the Value Stream
you are mapping.
– Process Neophytes
• People who are not familiar with the Value Stream you are
mapping.
51. Go to the “Gemba”
• Cannot be a conference room exercise
• Three versions of a process:
1. What should happen
2. What we think happens
3. What actually happens
• “Gemba” = “actual place,” where the work occurs
55. Types of Future States
• “Ideal” Future State
– Long-term vision
– Dream big – don’t worry about constraints
• “Practical” Future State
– What is achievable in the short to mid-term
59. After the VSMs
• Architect:
• Apply VSM to adjacencies and set based design
• React to what they wanted their ideal state to be, not just problems in
their current state
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60. Iterations at Riley
• Architect:
– “Use PDCA thinking throughout”
– More detailed room design through each iteration
– Started mockups before we drew anything, based on the ideal
state (the tub room)
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61. Lean Design Summary
• Goals: Best patient care; best workplace
• You will come up with the best design for your own
Institute
• Time investment
– Staff time
– More planning, longer iteration time
• Payoff
– Faster build (less rework and less cost)
– More likely to have best outcome (from iterative learning)
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