Lean in Healthcare

Lean Methods
Lean Methods

Definition of Lean
Types of waste
Kaizen
Value stream mapping
Tools
• Takt time, throughput time, five Ss, spaghetti diagrams,
kaizen events, standardized work, jidoka, andon, kanban,
SMED, flow and pull, heijunka, advanced access
What Is Lean?

Elimination of waste
• Toyota Production System (TPS)
Philosophy
• Produce only what is needed, when it is needed, with no
waste
Methodology
• Determination of value added in the process
Tools
• Five Ss, kaizen event, standardized work, etc.
Lean Organization – Inverted Pyramid

Front-line Staff
Implementation

Directors & Managers

Guidance

Senior
Administration

Support
CEO
Waste (Muda)
Types of Waste (Muda)

Overproduction
Waiting
Transportation
Inventory
Motion
Overprocessing
Defects
Seven Wastes of Healthcare
Overproduction
Producing more than
the customer needs
right now
• Working ahead rather
than waiting
• Just‐in‐case thinking
• Mixing drugs in
anticipation of patient
needs
• Forcing admit to Critical
Care when not needed
Seven Wastes of Healthcare
2. Transportation
Movement of product
that does not add
value
• Moving patients for
testing or treatment
• Centralized storage
• Transporting lab
specimens
• Transporting
medication and
supplies
Seven Wastes of Healthcare
3. Motion
Movement of people that
does not add value
• Searching for charts
• Gathering supplies
• Cross ward Nursing care
Seven Wastes of Healthcare
4. Waiting
Idle time created when
material, information,
people, or equipment is not
ready
• Waiting for lab result
• Waiting for a bed
assignment
• Waiting for discharge
• Waiting for treatment
• Waiting for doctor, nurse
 Seven Wastes of Healthcare

5. Over Processing
Effort that adds no value from
the patient’s viewpoint
• Excessive paperwork
• Redundant processes
• Unnecessary tests
• Multiple bed moves
• Requiring approval of sure
things
Seven Wastes of Healthcare
6. Inventory
More materials,
medications, or goods on
hand than needed to serve
patients right now
• Lab specimen awaiting
analysis,
• ED patients waiting for
bed,
• Excess pharmacy stock
• Excess supplies
 Seven Wastes of Healthcare
7. Defects
Work that contains errors,
rework, mistakes or lacks
something necessary
• Medication errors
• Wrong patient – wrong
procedure
• Improper labeling of specimen
• Multiple puncture for blood
draw
• Failure to provide antibiotics in
time
Kaizen Philosophy
Kaizen Philosophy

Employee‐led continuous improvement

Five steps
• Specify value
• Map and improve the value stream
• Flow
• Pull
• Perfection
Even if it isn’t broken, it can be improved.
Kaizen

Masaaki Imai coined the term in his book – Kaizen : The key to
Japan’s Competitive Success (1986)

Mindset in which all employees are responsible for making

continuous incremental improvements to the functions they
perform

The aggregate effect is the cost‐effective and practical

improvements that have instant buy‐in by those who use
them
Kaizen Blitz or Event
1. Determine and define the
objectives
2. Determine the current state of the
process
Performed by 3. Determine the requirements of the
process
a team for
short period 4. Create a plan for implementation
of time 5. Implement the improvements
6. Check the effectiveness of the
improvements
7. Document and standardize the
improved process
8. Continue the cycle
Kaizen Blitz or Event
Case Study – Same day Surgery
Problem Statement
Same‐Day Surgery staff at this 230‐bed, for‐profit hospital struggled to
process patient information in a timely, organized fashion. Physicians’
orders, pre‐admission test results, and patients’ medical histories were
often missing or incorrectly filed, leading to high patient wait times
and numerous procedure cancellations per week. These delays and
cancellations caused increasing frustration among both patients and
staff.

Tools: Kaizen, Standardized work procedures, and Poka Yoke

Case Study – Same day Surgery
Issues
• the team lacked of standardization for collecting, reviewing, and
distributing information.
• there was no central repository for patients’ pre‐surgery data, and
staff had lacked protocol for tracking patients who had been admitted.
• staff were admitting patients with missing information such as
physicians’ orders, health and physical workups, or anesthesia reviews.

The Outcome
The hospital realized:
• $75,000 annual tangible savings in payroll costs associated with staff
time spent searching for information
• 57% reduction in Same‐Day Surgery patient wait times resulting in
improved patient satisfaction.
• Elimination of loose sheets of patient information, improved
documentation accuracy and increased physician satisfaction.
 Case Study - Results of 175 Rapid Process Improvement

Weeks at Virginia Mason Medical Center

Source: Womack, J. P., A. P. Byrne, O. J. Fiume, G. S. Kaplan, and J.Toussaint. 2005. "Going Lean in Healthcare."
Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Online information available at:
http://www.ihi.org/IHI/Results/WhitePapers/GoingLeaninHealthCare.htm.
Value Stream Mapping
Value Stream Mapping

Process map of the value stream

Includes information processing and transformational
processing
Value‐added steps: “Would the patient and family be willing to
pay for this activity?”
Non‐value‐added steps
• Necessary
• Unnecessary
Value Stream Mapping Symbols

Process Name
Takt time =
Cycle Time =
# of People =

Process Box

Push Pull Transport Manual Electronic

Information Information
Value Stream Mapping Symbols

Supplier Database Sequence Kanban

Information Inventory Improvement

VSM – Exercise – OPD Lab tests

Laboratory

Reception

Test Orders

Database

Test Orders Specimen

Test Orders Label
Doctors
Office
Patient Info
0-15 0-20

Reception Phlebotomy
Takt time = 270 sec Takt time = 270 sec
Cycle Time = 240 sec Cycle Time = 180 sec
# of People = 2 # of People = 1
 VSM – Exercise – OPD Lab tests
Process Efficiency Percent
(22%) = Test Results
Value Added Time (320) Laboratory Report
Report Delivered Dispatch
Lead Time (1440) 1X daily
Reception

Report Delivered
Test Orders 1X daily

Test Results
Database

Specimen
Test Orders Delivered 2 Hourly
Specimen
Test Orders Label
Doctors Doctors
Office Office
Patient Info
0-15 0-20

Reception Phlebotomy
Takt time = 270 sec Takt time = 270 sec
Cycle Time = 240 sec Cycle Time = 180 sec
# of People = 2 # of People = 1 320 /
15 05 300 Next Day Next Day
90 10 120
Value Stream Mapping

Nurses’ time spent on Rooms Long wait after

non-patient care not available cleared to discharge
House- Anesthes- Social
Supplies Radiology Lab Pharmacy
keeping iology Services

LOS Slow Education

turnaround late
Rooms
Stabilize
unavailable
Porter
Incorrect
patient forms
Labor
Post
Patients Admitting Triage and Discharge
Partum
Delivery
0-2 hr 1-3 hr 1-8 hr 1-5 hr
30-90 min 1-3 hr 1-60 hr 20-80 hr 3 hr
Lean Tools
 Tools

Takt time Standardized work

Throughput time Kanban
Five Ss Single minute exchange of die
(SMED)
Spaghetti diagram
Flow
Kaizen blitz or event
Pull
Jidoka
Heijunka
Andon
Takt time
Takt Time

The speed with which customers

must be served to satisfy demand for the service.

Available work time/day

Takt time =
Customer demand/day
Cycle time is the time to accomplish a task in the system.

System cycle time is equal to the longest task cycle time in the
system—the rate at which customers or products exit the
system, or “drip time.”
Calculating Takt Time
Calculating Manning Levels
Throughput Time

Time for an item to complete the entire process, which

includes:
• Waiting time
• Transport time
• Actual processing time
Example - The OPD Clinic

Cycle, Throughput, and Takt Time

Patient check-in Move to examining room
3 minutes 2 minutes

Wait 15
minutes

Nurse does Physician exam

preliminary exam and consultation Visit complete
5 minutes 20 minutes
Wait 15 Wait 10
minutes minutes
Example - The OPD Clinic

Cycle, Throughput, and Takt Time

Patient check‐in cycle time = 3 minutes.
System cycle time = cycle time for longest task = physician
exam and consultation = 20 minutes.
Throughput time = 3 + 15 + 2 + 15 + 5 + 10 + 20 = 70 minutes.

Takt time = 8 physicians × 5 hours/day

100 patients/day
= 0.4 physician hours/patient
= 24 physician minutes/patient.
Example - The OPD Clinic

Valued‐added tasks:
• Nurse preliminary exam
• Physician exam and consultation
Non‐value‐added steps, necessary:
• Patient check‐in
Value‐added time = 5 minutes (nurse preliminary exam) + 20
minutes (physician exam and consultation) = 25 minutes.
Percentage value‐added time = 25 minutes/70 minutes = 35
percent.
Case Study – Central OPD Scheduling

Problem: This 180‐bed, not‐for‐profit medical center faced the

daunting task of building efficient outpatient scheduling
procedures from the ground up. Although the center had
dedicated significant resources to a new centralized‐
scheduling department, patients still faced a high number of
postponed and cancelled procedures due to delayed, lost, or
mismatched paperwork.

Tools: Process mapping, Visual controls, Pull systems, Poka‐

Yoke, Spaghetti diagrams and Standardized work procedures
Case Study – Central OPD Scheduling

Issues Identified –
• Wide variances in the amount of time different employees took to
complete the same task
• Poor execution of critical tasks such as obtaining physician’s orders or
scheduling imminent procedures.
The Outcome –
• With the solution in place, scheduling efficiency and effectiveness
increased dramatically.
• Total work time for the scheduling process decreased 56%, accompanied
by a noticeable drop in the number of postponed or cancelled patient
procedures.
• With backup staff assigned to scheduling, the department is able to
maintain this level of excellence even during peak workload hours.
5S
5S Principles

Elimination of waste
Every body is involved, Co-operative effort
Attack root cause
Human being is not infalliable
Objectives

Improve housekeeping
Make every individual responsible for
housekeeping
Beautify by simple means
Productivity improvement by saving time,
space etc.
5S’s

Seiri - Sorting
Seiton - Systematic arrangement
Seiso - Cleaning
Inspection while cleaning
Seiketsu - Standardization
Shitsuke - Self Discipline
5S

If we do not do 5S, we can’t do any

other work efficiently.
They are features which are common to
all places and are the indicators of how
well an organization is functioning.
SEIRI = Sorting

Meaning Distinguish between necessary and

unnecessary items and eliminate the unnecessary items

Activity Establish a criteria for eliminating unwanted

items. Eliminate unwanted items either by disposing
them or by relocating them.

Success Area saved or percentage of space available

Indicator
 SEIRI = Sorting

Japanese Meaning : The Japanese meaning of “Seiri”

is to straighten and contain. Get rid of waste and put it
in order according to rules

OTHER JAPANESE MEANINGS - farmland cultivation,

Make an orderly system and straighten
 What is unnecessary

• Item is not needed

• Item is needed however quantity in stock is more

than what is needed for consumption in near future

• Contingency Parts
Critically decide the quantity of contingency parts to
be retained and criteria for such parts
 Organization
Frequency of use Storage Method

*Things you have not used Throw them out

LOW
in the past one year
*Things you have used once Store at distance OR
in the last 6-12 months Keep in store

*Things you have used only Store it in central place

once in the last 2-6 months in your zone
AVERAGE
*Things used more than once Store it in central place
a month in your zone

HIGH *Things used once a week Store near the workplace

*Things used daily or hourly Store near the workplace
 Identifying unnecessary

1. Parts & Work in Process (WIP)

• Things fallen back behind the machine or rolled under it
• Broken items inside the machine
• Things under the racks/ platform
• Extra WIP
• Stock of rejected items
• Items accumulated over period for rework
• Material awaiting disposal decision
• Material brought for some trial, still lying even after trial
• Small qty of material no longer in use
 Identifying unnecessary

2. Tools, Toolings, Measuring devices

• Old jigs, tools not in use are lying
• Modified tools, tooling for trial, are lying after trial
• Worn out items like bushes, liners, toggles etc. lying
• Broken tools, bits, etc. may be lying
• Measuring equipment not required for the operation
being performed, is lying

3. Contingency Parts
• Many times storage place for contingency parts become
a last refuge for broken parts, surplus items and things
nobody is likely to use
 Identifying unnecessary

4. Shelves and Lockers

• Shelves and lockers tends to collect things that nobody
ever uses, like surplus, broken items etc.

5. Passages and Corners

• Dust, material not required seem to gather in corner

6. Besides Pillars and under the stairs

• These places tends to collect junk, spittoon etc.

7. Walls and Bulletin Boards

• Old out dated notices which have lost their relevance
• Posters or bulletins on wall
• Dust, remains of torn notices, cell tape pieces
 Identifying unnecessary

8.Floor, Pits, Partitions

• Defective parts
• Protection caps, covers
• Packing material
• Hardware items , small items
• Even tools, tooling
Items dropped on the floor are never picked

9.Computer Hard Disk

• Many unwanted, outdated, temporary files pile up
 Improvement methods

1. Flow Process Chart (Procedural Analysis)

Drawing a process flow chart for the system
eg. How to make and use category wise grouping

2. Operational Analysis
Preparing the sequence of operations for system
eg. How to perform Seiri (sorting)

3. Check List
A check sheet is used to decide what sort of main system
and sub system are necessary.
Dealing with papers

How to reduce papers on

your table ?
1. Make a single pile of papers
2. Go through them and sort in
following categories

a) Immediate action
b) Low priority
c) Pending
d) Reading material
e) For information
Dealing with papers

How to reduce papers on

your table ?

4 D Principle

DO
DELEGATE
DELAY
DUMP
SEITION = Systematic Arrangement

Meaning To determine type of storage and layout that

will ensure easy accessibility for everyone .

Activity - Functional storage

- Creating place for everything and putting
everything in its place

Success - Time saved in searching

Indicator - Time saved in material handling
SEITION = Systematic Arrangement

Japanese Meaning:
Dictionary meaning of Seiton is “to be correctly
prepared” and “to prepare correctly”.

In short these means :

(a) arrange correctly in accordance with the correct
method of doing activities and
(b) make thorough preparations so that activities can
be done even if they occur abruptly
SEITION = Systematic Arrangement

The main target areas for Seri-Seiton improvement are :

Tool-setting and preparation operations, line balancing and
process planning, parts supply to assembly line, peak time
problems etc.

Improvement Methods

Kit Method / Assembly box method / Outside tool setting

Cassettisation / Parallel operations / Changes in

assignment method
SEITION = Systematic Arrangement

How to achieve Systematic Arrangement ?

• Decide where things belong

• Decide how things should be put away

• Obey the Put away rules

SEITION = Systematic Arrangement

How to achieve Systematic Arrangement ?

• Decide where things belong

- Standardize Nomenclature
- Determine an analytical method of storage

• Decide how things should be put away

- Name & locations to everything. Label both item
and location
- Store material functionally
- Prevent mistakes with coding by shapes & colour
contd..
SEITION = Systematic Arrangement

How to achieve Systematic Arrangement ?

• Decide how things should be put away

- Follow first in first out rule
- If two identical items are to be located, then store
them separately, colour code them.

• Obey the rules

- Put the things back to their location after
their use
SEITION = Systematic Arrangement

USE :

1 ) Signboards

2) Colour codes

3) Outline markings

4) Labels
SEITION = Systematic Arrangement

Functional

Storage
SEITION = Systematic Arrangement

• Store frequently used material

Usage
near the workplace and less
Frequency
frequently at some distance

• Heavy material should be stored

Weight & at lower levels/layers
Shape of the • Place directly on the material
Material handling device for ease of
handling

Functional Storage
SEITION = Systematic Arrangement

• Same category of material may be

Category stored in one location.
Eg. Allen Screws, Oil Seals

Operation • All items required for an

Wise operation may be stored in one
location.
Eg. Allen key, spanner etc hand
tools required for setting m/c

Functional Storage
SEITION = Systematic Arrangement

• Outlining and Placement Marks

- Mark boundaries of dept., aisles, Machines
- Follow straight line, right angle rule
- Nothing shall be kept outside the boundaries

• Stands and shelves

- Keep only required number of stands and shelves
- Standardize height, size
- Provide casters where necessary so that it can be
moved
SEITION = Systematic Arrangement

• Wires and Ducts

- Colour code
- When there are multiple connections - bundle the
wires, label them and make sure that they are in
straight line /right angle and firmly anchored

• Machine-tools & Tools

- Put the tools in the order you need them
- Location of the tool should be such that it can be
put away with one hand
- Try to eliminate some hand tools by permanently
attaching it to the bolt head
SEITION = Systematic Arrangement

• Blades, Dies, Other important consumables

- Store them in the protected place
- Maintain these things regularly by applying rust
preventive, oiling etc.

• WIP- Work In Process

- Designate a place for each component/part
- Decide on how much quantity to be stored
- Ensure that there is no damage to good part
during transit, they do not get rusty and they are
not mislabeled
SEITION = Systematic Arrangement

• Oils
- Reduce number of oils used (Standardize)
- Colour code for oil
- Safety aspects - fire prevention, pollution, leak,
spillage

• Instrumentation & Measuring Devices

- Label them, show direction of flow
SEISO = Cleaning
Meaning
Meaning Cleaning
Cleaningtrash,
trash,filth,
filth,dust
dustand
andother
other
foreign
foreignmatter.
matter.Cleaning
Cleaningas asaaform
formof
of
Inspection
Inspection

Activity - Keep workplace spotlessly clean

- Inspection while cleaning
- Finding minor problems with cleaning
inspection

Success - Reduction in machine down time

Indicator - Reduction in no. of accidents
SEISO = Cleaning

Japanese Meaning :

Dictionary meaning “to clean up” and “getting rid of dirt

and unclean items”

While cleaning potential defects such as abrasion,

damage, loose parts, deformities, leaks temp., vibration,
abnormal sound etc. are revealed hence Seiso is
Inspection
SEISO = Cleaning

• Here cleaning means more than just keeping

things clean. Cleaning should be viewed as a
form of Visual Inspection

• Preventive measures should be taken to tackle

problems of dust, grim, burrs, leakage etc.
Root cause of the problem should be identified
and it should be eliminated
SEISO = Cleaning
Various Minor Defects
= Trash = Dirt =Knocking
= Loose parts = Leaks =Scattering
=Skips =Curvature =Abrasion
=Rust =Scratches =Eccentricity
=Lurching =Abnormal =Vibration
Movements
=Abnormal =Heat =Abnormal
Sounds & smells
=Faded colour =Hisses
SEISO = Cleaning

5 Minutes Every day for cleaning

• Devote 5 minutes everyday for cleaning your

work area

• Participation of everyone is required

• Attack hard to clean places regularly

SEISO = Cleaning

Cleaning-Inspection points for most equipment

Grime, clogging, dust balls, rust,

Cleaning
leakage etc.

No oil, Low oil, leakage, filter clogging,

Oils dirty oil, dirty or bent oil lines, clogged
drainage, oil spillage, worn& torn ports
etc.
SEISO = Cleaning

Cleaning-Inspection points for most equipment

Loose bolts, welding detachment,

Tightening
loose parts, vibration or bumping
noise, friction

Heat Oil tanks, motors, heater, axles, control

panels, washing/ cleaning water,
bearing, wiring etc.
SEISO = Cleaning

Cleaning-Inspection points for most equipment

Breakage, cracks, dent on sliding

Breakage,
parts, handle has come off, broken
Cracks
switches, wire joints come off, wires
are broken or crack, crack dial of
various pre. gauges, meters etc.
SEISO = Cleaning

Function wise Cleaning check list of equipment

Compressed Air lines, air valves,

Pneumatics connections, meters, filters,
reservoirs etc.

Hydraulic oil tank, oil valves,

Hydraulics filters, pumps, hoses, gauges,
cylinders etc.
SEISO = Cleaning

Function wise Cleaning check list of equipment

Mech & Motor fan, fan belt, couplings,

Power Train Joints, pulleys, chains, pump
bearings etc.

Control panel, lamps, light, switch,

Electrical sensors, wiring, ducts, fuses etc.
SEISO = Cleaning

Function wise Cleaning check list of equipment

Tools, fixtures, gauges, dies,

Toolings
measuring instruments, etc.

Furnaces, rollers, chutes,

Equipment
CNC machines, etc.
Specific
SEIKETSU = Standardization

Meaning
Meaning Setting
Settingupupstandards
standards//Norms
Normsfor
foraaneat,
neat,
clean,
clean,workplace
workplaceand
anddetails
detailsof
ofhow
howto
to
maintain
maintainthe
thenorm
norm(Procedure)
(Procedure)

Activity - Innovative visual management

- Colour coding
- Early detection of problem and early action

Success Increase in 5S indicator

Indicator
SEIKETSU = Standardization

Japanese Meaning :

Dictionary meaning
“unsoiled things, purity and cleanliness”

Clean manners ,

Clean cloths, clean politician

It is the proof that 3 S’s are being faithfully carried out.

SEIKETSU = Standardization

Tools used for analysis :

MTTR
MTBF
OEE
SEIKETSU = Standardization

• Regularizing 5S activities so that abnormalities

are revealed

• Make it easy for everyone to identify the state of

normal or abnormal condition

• For maintaining previous 3S, deploy visual

management
SEIKETSU = Standardization

• It has been estimated by scientific study that

60% of all human activities starts with sight

• 5S is easy to do once.It is consistency that is

difficult. That is why Visual Management is so
important, so that everybody will know that there is
some problem.

Visual Management
SEIKETSU = Standardization
What visual control communicates ?

It grabs one or more of our senses in order to

• Alert us to an abnormality
• Help us recover quickly
• Promote adherence and prevention
• Enable successful self management
SEIKETSU = Standardization
Some methods for visual communication

⇒ Colour coding
⇒ Use of Labels
⇒ Danger alerts
⇒ Indication where things should be put
⇒ Directional arrows/ marks
⇒ Transparent covers
⇒ Performance indicators
SEIKETSU = Standardization
Some methods for visual communication

Labels
⇒ Precision management labels
⇒ Inspection labels
⇒ Temperature labels
⇒ Responsibility labels
SEIKETSU = Standardization
Points to remember in making visual control tools

1. Make them easy to see from distance

2. Put the display on the things
3. Everyone can tell what is right and what is wrong
4. Anybody can follow them and make necessary
corrections easily
5. Work place should look brighter & orderly
SEIKETSU = Standardization

Some everyday visual management examples

♦ Traffic signal
♦ Zebra crossing
♦ In car - Petrol indicator
- Speed indicator
♦ Direction arrows
♦ Electric danger sign etc.
SEIKETSU = Standardization
Some visual communication signs
 SHITSUKE = Self Discipline

Meaning
Meaning Every
Everyone
onesticks
sticksto
tothe
therule
ruleand
andmakes
makesitit
aahabit
habit
Activity - Participation of everyone in developing
good habits
- Regular audits and aiming for higher
level

Success High employee morale

Indicator Involvement of all people
 SHITSUKE = Self Discipline

Japanese
JapaneseMeaning
Meaning::
Dictionary
Dictionarymeaning
meaningisis
“learning
“learningof
ofthe
themanners”
manners”
“having
“havingmanners,
manners,dressing
dressingneatly”
neatly”OR
OR
“training
“trainingchildren
childrenfor
forgood
goodcustoms”
customs”
 SHITSUKE = Self Discipline

Activities
Activities::
5S
5SCommittee
Committee
5S
5STraining
Training
5S
5SCompetition
Competition//evaluation
evaluation
5S
5SMonth
Month
Posters
Posters,,Literature
Literatureetc.
etc.
 SHITSUKE = Self Discipline

We need everyone to maintain 5S guidelines.

To maintain DISCIPLINE, we need to practice and

repeat until it becomes a way of life.

Discipline is the Core of 5S

 SHITSUKE = Self Discipline

Discipline means making a steady habit of properly

maintaining correct procedure.
procedure

Time and effort involved in establishing proper

arrangement and orderliness will be in vain if we do
not have discipline to maintain it.
SHITSUKE = Self Discipline
Pledge
It shall be my constant effort to maintain my workplace
in good order by

„ Assigning a place for everything & keeping

everything in its place

„ Sorting out unwanted material periodically &

discarding them

„ Keeping my work area neat & clean everyday

 Organization

Departments into areas

Coordinators at department level
Coordinator at each area level
Training for all
Audit each area and make action check list
Implement actions
Audit and evaluation on continuous basis
Five Ss
Sort
• Separate and remove clutter and items unneeded in the
workspace.
• Extraneous items impede the flow of work.
Set in Order
• Organize what is left to minimize movement and make things clear.
Shine (and inspect)
• Clean area, storage, equipment, etc. and inspect for warning signs
of breakdowns.
Standardize
• Set up an area with 5‐S supplies (cleaning supplies, labels, colored
tape, other organizational items) and schedule time and
responsibility for restoring work area to its proper condition
regularly.
Sustain
• Audit area regularly, expand 5‐S to other areas.
Spaghetti Diagrams
Spaghetti Diagram

Educating Rounds Medication

Discharge With
Process Doctor

Booking
Investigation

Call Bell &

Bedpan
Instruction for Spaghetti Diagram

1. Select the process to be mapped. ‐ It is generally good

to start with work processes that are executed
repeatedly and frequently. These processes will give
the best returns on time invested.
2. Follow a person through the current state work
process. ‐ If desired, have the person wear a
pedometer to know distance traveled (this can also be
approximated if the floor layout is to scale). As you
follow, draw the person's motion on the floor layout
(you should not lift your pencil off of the paper, it
should be 1 continuous line).
*Also note any safety or ergonomic hazards while you observe*
Instruction for Spaghetti Diagram (Continued…)
3. Discuss the current state. ‐ Talk about the total distance
traveled and discuss ways that it could be reduced by
moving equipment, bringing materials closer to the
workplace, eliminating rework steps, or changing the order
of steps.
4. Draw a map of the future state and implement. ‐ Draw a
map that anticipates the future state workflow based on
the brainstormed ideas. Develop an action plan to
implement the future state.
5. Verify the future state by following a person through it.
Verify that the future state works as you expected. Make
corrections where necessary
6. Communicate and make permanent. ‐ Communicate and
train all users of the area on the new process. Show them
the current state and future state spaghetti maps. Change
standard work so that the new process becomes standard.
Ask for feedback to continuously improve the process.
Case Study – Nursing Team Redesign
Problem Statement
The Nursing Staff at this 230 bed for profit (Point of Use) hospital
struggled with processes and systems that impacted their ability to
spend time at the patient’s bed side. A study performed on one
nursing unit revealed that approximately 32% of a nurse’s day was
dedicated to activities that were considered non‐value added or waste.
In total, 46% of nursing time was spent on tasks related to patient care
while the remaining 54% was directed towards regulatory tasks and
waste.

Tools: JIT, Spaghetti diagrams and Standardized work

procedures
Case Study – Nursing Team Redesign
Issues encountered –
• Reduce Waste in the Process
• Improve Flow for Caregivers and Increase Patient Care
• Decrease Wasted Motion
• Document Equipment/Maintenance Issues
• Standardize Nursing Floor Processes

The Outcome –
• Standardized Patient Room Layout/Equipment
• Patient Supplies Stocked at the Point of Use
• 43% Overall Waste Reduction
• 30% Increase in Care Related Activities
• 27% Increase in Bedside Time
• 12% Decrease in Wasted Motion (Steps)
Standardized Work
Standardized Work

Written documentation of the way in which each step in a

process should be performed
Not a rigid system of compliance, but a means of
communicating and codifying current best practices
Apollo Gleneagles Hospitals care pathways
Standardized Work
Standardized Work - Definition

“Standardized work is A TOOL FOR MAINTAINING

PRODUCTIVITY, QUALITY, AND SAFETY, at high levels”

“Standardized work is defined as work in which the

sequence of job elements has been efficiently organized,
and is repeatedly followed by a team member”

“Standardized work is a process whose goal is kaizen. If

standardized work doesn’t change, we are regressing”
Why Standardized Work

Provides a basis for employee training.

Establishes process stability.
Reveals clear stop and start points for each process.
Assists audit and problem solving.
Creates baseline for kaizen.
Enables effective employee involvement and
pokayoke.
Maintains organizational knowledge
Elements of Standardized Work

Takt Time and Cycle Time

1. Takt Time = Daily operating time / Required quantity per day
2. Cycle Time = Actual time for process
3. Goal is to synchronize takt time and cycle time

Work Sequence
1. The order in which the work is done in a given process.
2. Can be a powerful tool to define safety and ergonomic issues

In‐Process Stock
1. Minimum number of unfinished work pieces required for the
operator to complete the process
Implementing Standardized Work

Evaluate the
current
situation

Implement standard work VSM – Current state

Conduct training Standard work sheet
Communicate changes Observation sheet
Share information Combination sheet
Implement new Percent load charts Identify areas of
standard work opportunity
Lean
Conduct Pilots
Transformation
ID Constraints
Money Saved process
Non Value Add
Enhanced Revenue
Muda
Floor Space & Time Savings
Human Resources
5S, Leveling, Quick
Changeover, Kanban,
Substantiate Visual Controls, Andon,
Poka Yoke, DMAIC Modify the
and enumerate
existing process
improvements
Misconceptions of Standardized Work

Standardized work is sometimes mistaken to be a static work

process.

Workers may feel threatened that their jobs are at risk and
therefore may not participate fully in optimizing the
process.

Standardized work may not show immediate results due to

other factors:
• worker attrition
• additional training requirement
• improvement cycle just beginning
Tools of Standardized Work
Tools of Standardized Work
Tools of Standardized Work
Summary of Standardized Work

Standardized work is a method of defining efficient work

process that are repeatedly followed by workers.

Standardized work often aims to maintain productivity,

quality, and safety at high levels.

Improvement is endless and eternal (Toyota Proverb)

Case Study – Operating Room Turnover
Problem Statement
The O.R. staff of this 250 bed community not for profit
major medical center wanted to reduce the changeover
and setup between surgical cases in this eleven O.R. suite
inpatient surgery department. The staff recognized that
improved overall efficiency in this process would result in
improved patient care, improved physician satisfaction and
greater O.R. capacity without increasing staff.

Tools: SMED, Kaizen, Value Stream Mapping, and Poka Yoke

Case Study – Operating Room Turnover

Outcomes
The O.R. staff realized an initial reduction of 46% of time
dedicated to the O.R. turnover process. Since inception of
lean management, efficiency has grown to a 60% reduction
of time needed in the O.R. changeover process.
Case Study – Operating Room Turnover
Case Study – Operating Room Turnover
Jidoka and Andon
Jidoka and Andon

Jidoka is the ability to stop the process in the event

of a problem.
• Prevents defects from passing from one step
in the system to the next
• Enables swift detection and correction of
errors
Andon is a visual or audible signaling
device used to indicate there is a problem
in the process.
What is Jidoka?

Automation with a human touch

Practice of stopping a manual line or process when

something goes amiss

Also known as Autonomation

Healthcare example – Detection of drug drug interaction

and medication error through software
What is Jidoka?

Quality built‐in to the process

First used by Sakichi Toyoda at the beginning of the 20th

century

A pillar of the Toyota Production System

Healthcare example – 30 degree Head Elevation as a primary

tool for prevention of Ventilator Associated Pneumonia
Role of Jidoka

Autonomation is an important component of Lean

Manufacturing Strategy for high‐production, low‐ variety
operations, particularly where product life cycles are
measured in years or decades.
How Organization Can Benefit From Jidoka

Jidoka helps to detect a

problem earlier

Jidoka avoids the spread of

bad practices

A level of human intelligence

is transferred into
automated machinery
Kanban

Empty Empty
Kanban Kanban

Full Full
Kanban Kanban

Task 1 Task 2
Customer
Workstation Workstation
Order
1 2
Kanban
Single Minute Exchange of Die (SMED)
Used to reduce changeover or setup time, which is the time
needed between the completion of one procedure and
the start of the next procedure
Pioneered by Shigeo Shingo
Steps
1. Identify and classify internal and external activities
2. Separate internal activities from external activities
3. Convert internal setup activities to external activities
4. Apply changes to convert remaining internal activities
to external activities
5. Streamline all setup activities
Single Minute Exchange of Die (SMED)

Healthcare examples –
1. The changeover times in Operation Theaters, i.e.,
the time between the surgeries typically account
for high valued OT utilization time. These also
account for variations in OT scheduling effecting
overall utilization, increasing cancellation and
reducing revenue generation
2. The higher room arrangement and bedmaking
turn around times account for increased waiting
times for the patients waiting for admission
Flow and Pull

Continuous or single piece flow—move items (jobs, patients,

products) through the steps of the process one at a time
without interuptions or waiting.
Pull or just‐in‐time (JIT)—products or services are not produced
until the downstream customer demands them.
Heijunka—“make flat and level”; eliminate variation in volume
and variety of “production”
• Level patient demand
Advanced Access

Patients are unable to obtain timely primary care

appointments.
Advanced access scheduling reduces the time between
scheduling an appointment for care and the actual
appointment.
The goal is swift, even patient flow through the system.
Advanced Access - Advantages

Decreases no‐show rates

Improves patient satisfaction
Improves staff satisfaction
Increases revenue
• Higher patient volumes
• Increased staff and clinician productivity
Promotes greater continuity of care
• Increased quality of care
• More positive outcomes for patients
Advanced Access - Implementation

Advanced access challenges established practices and beliefs.

Balance supply and demand:
• Obtain accurate estimates of supply and demand.
• Reduce or eliminate backlog.
• Minimize the variety of appointment types.
• May need to:
• Adjust demand profiles.
• Increase availability of bottleneck resources.
Lean Templates
Lean Templates
Lean Templates
Lean Templates
Lean Templates
Lean Templates
Lean Templates
Lean Templates
Mistake Proofing – Defined

• Mistake‐proofing is the use of process or design

features to prevent errors or the negative impact of
errors.
• Mistake proofing is also known as poka‐yoke
(pronounced pokayokay), Japanese slang for
“avoiding inadvertent errors.”
• Shigeo Shingo formalized mistake‐proofing as part of
his contribution to the production system for Toyota
automobiles.
Mistake Proofing

• One description divides the process into two distinct steps:

• determining the intent of the action, and
• executing the action based on that intention.
‐ Failure in either step can cause an error.
• Mistakes are errors resulting from deliberations that lead to
the wrong intention. Slips occur when the intent is correct,
but the execution of the action does not occur as intended.
• Generally, mistake‐proofing requires that the correct
intention be known well before the action actually occurs.
Mistake Proofing Approaches

• The approaches to error reduction are diverse and evolving.

More innovative approaches will evolve, and more categories
will follow as more organizations and individuals think
carefully about mistake‐proofing their processes.
• Tsuda lists four approaches to mistakeproofing:
• Mistake prevention in the work environment.
• Mistake detection (Shingo's informative inspection).
• Mistake prevention (Shingo's source inspection).
• Preventing the influence of mistakes.
Mistake prevention at Work Environment – Norman Strategies

Natural Mappings Design one-to-one physical correspondence

between the arrangement of controls and the
objects being controlled.
Affordances Provide guidance about the operation of an
object by providing features that allow or afford
certain actions.
Visibility Make observation of the relevant parts of the
system possible.
Feedback Give each action an immediate and obvious
effect.
Constraints Provide design features that either compel or
exclude certain actions. Constraints may be
physical, semantic, cultural, or logical in nature.
 Mistake Detection

• Mistake detection identifies process errors found by

inspecting the process after actions have been taken.
Immediate notification that a mistake has occurred is
sufficient to allow remedial actions to be taken in order to
avoid harm.
• Shingo called this type of inspection informative inspection.
The outcome or effect of the problem is inspected after an
incorrect action or an omission has occurred.
• Informative inspection can also be used to reduce the
occurrence of incorrect actions. This can be accomplished by
using data acquired from the inspection to control the
process and inform mistake prevention efforts.
• Statistical Process Control (SPC) is a set of methods that uses
statistical tools to detect if the observed process is being
adequately controlled.
 Mistake Detection

• Mistake detection identifies process errors found by

inspecting the process after actions have been taken.
Immediate notification that a mistake has occurred is
sufficient to allow remedial actions to be taken in order to
avoid harm.
• Shingo called this type of inspection informative inspection.
The outcome or effect of the problem is inspected after an
incorrect action or an omission has occurred.
• Informative inspections are –
• Statistical Process Control – statistical tool to assess the process
control
• Successive Checks – inspections of previous steps
• Self Checks – devices to allow the users to assess their own quality
 Mistake Detection – Setting functions
•A setting function is the mechanism for determining that an error is about
to occur (prevention) or has occurred (detection).
•It differentiates between safe, accurate conditions and unsafe, inaccurate
ones.
Setting Function Description
Physical Checks to ensure the physical attributes of the
(Shingo's contact) product or process are correct and error‐free.
Sequencing Checks the precedence relationship of the
(Shingo's motion step) process to ensure that steps are conducted in the
correct order.
Grouping or counting Facilitates checking that matched sets of
(Shingo's fixed value methods) resources are available when needed or that the correct
number of repetitions has occurred.
Information enhancement Determines and ensures that information
required in the process is available at the correct time
and place and that it stands out against a noisy
background.
Mistake Detection – Control functions
Mistake Detection
Mistake Detection – Fall from Wheelchair