Transcript Lean Processing and Standardization in Healthcare Quality

© 2011 Jones and Bartlett Publishers, LLC
Donald E. Lighter, MD, MBA, FAAP, FACHE
Professor, University of Tennessee, Knoxville
Lean Processing and
Standardization in
Healthcare Quality
© 2011 Jones and Bartlett Publishers, LLC
Lean Manufacturing
• Toyota – 1950s (Taiichi Ohno)
– International competition
– Quality issues
– Worker dissatisfaction and insecurity
– Pending layoffs
• Agreement with employees
– Lifetime security
– Workforce reductions
– Cooperation with improvement efforts
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Systems Concepts
• System – integrated series of parts with a
clearly defined function or goal
– Examples?
• Characteristics
– Each part has defined purpose
– Parts are interdependent
– Understand part’s function in system
– System is understood by interaction of parts
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Systems Thinking
• Ability to understand structure and function
of system
• Ability to understand interaction of parts
and synergism
• Resulting in
– Ability to lead system
– Ability to change system without deleterious
effects
– Ability to reduce detrimental effects of system
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Focus-Customer
• Highest quality
• Lowest cost
• Shortest lead
time
• Eliminate
muda
– What is
muda?
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Costumer-Focus
•
•
•
•
•
•
Productivity
Quality
Cost
Delivery time
Safety and environment
Morale
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Muda-Japenese concept of
Waste
• Human effort divided into:
– Actual work – valued by customer
– Auxiliary work – supports actual work
– Muda – creates no value
• Examples?
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Types of MUDA
Wasted
Motion
Knowledge
Disconnection
Inventory
Waiting
Conveyance
MUDA
Correction
(Rework)
Overproduction
Overprocessing
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Let’s examine MUDA
• How do these concepts fit health care?
– Overprocessing – doing more than the
customer requires
– Overproduction – making things that don’t sell
– Correction (rework) – fix defective services or
products
– Conveyance – problems with getting production
materials to site of production
– Inventory – unnecessary materials or products
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Other major concepts
• Mura – uneven processes (bumps in the
road)
– What situations in health care?
• Muri – “hard to do”
– Most often due to process design
– Variation
– Ergonomics
– Wrong tools
– Inadequate specifications
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Stability
• Four “Ms”
– Man(woman)
– Machine
– Material
– Methods
• Need for standards
– Clear image of desired condition
– Make abnormalities obvious
– Clear, simple, visual
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Visual Management
• Point of care graphic detail
• Simple, easy to
follow (examples?)
• Visual management
triangle
See
As A
Group
Know
As A
Group
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Act
As A
Group
Organization – The 5 (6) Ss
• Sort
• Set in order
• Shine
• Standardize
• Sustain
• (Safety)
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Organize the Workplace – The 5 Ss
• Sort
– Keep what you need, get rid of the rest
– Red-tag what’s not needed for disposition
• Red-tag removal process
• Red-tag “pause”
• Red-tag recycling and capital asset disposal
procedure
• Measure volume of red-tagged items
• Team decisions for disposal
– “Just in case” management – the pack rat
•
•
•
•
Set in order
Shine
Standardize
Sustain
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Organize the Workplace – The 5 Ss
• Sort
• Set in order
– Process planning to reduce waste
– Map processes using flowcharts, other
tools (remember the workflow chart?)
– Use visual systems to manage flow
• Shine
• Standardize
• Sustain
Lab/Nursing Station
Exam
Exam
Exam
Exam
Exam
Exam
Reception Desk
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Organize the Workplace – The 5 Ss
• Sort
• Set in order
• Shine
– Creation of a clean workplace
– Connotes a pristine work environment (e.g. work
habits, relationships)
– Use color to code process steps and
relationships
• Standardize
• Sustain
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Organize the Workplace – The 5 Ss
•
•
•
•
Sort
Set in order
Shine
Standardize
– Things tend to fall apart
– Make workflow methodical as much as possible
(examples?)
• Sustain
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Organize the Workplace – The 5 Ss
•
•
•
•
•
Sort
Set in order
Shine
Standardize
Sustain
– Promotion
– Communication
– Training
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Total Productive Maintenance
• TPM =
– Preventive Maintenance
– Predictive Maintenance
– Total involvement
• Measures
– Resource availability
– Performance efficiency
– Overall resource
effectiveness
Resource Loss Pyramid
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Productivity Hits
• Six big losses
– Breakdowns
– Adjustment and set
up delays
– Idling and minor
stoppages
– Speed below
specifications
– Process defects
– Reduced yield
• Cause:
– Downtime
– Reduced
throughput
– Defects
– Accidents
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TPM Wages
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Standardized Work
• Basic principles
– No single best
way to do work
– Workers should
design work
– Purpose of
standardized
work is to provide
a basis for
improvement
• Optimize
PQCDSM
– Productivity
– Quality
– Cost
– Delivery time
– Safety and
environment
– Morale
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Maximize Human Resources
• People are usually the constraining factor
• Machines can produce muda (waste) if allowed to
produce constantly
• Small, simple machines preferable to large complex
machines (think microsystems)
– More human input for moving work in progress from
one machine to another
– Cheaper to purchase and run
– Simpler to repair
– Adjust to demand changes more quickly
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Labor Destiny
Work
Motion
(determined by customer demand)
(managers optimize motion)
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Advantages to Standardization
•
•
•
•
Process stability and reproducibility
Clear start and stop for each process
Organizational learning (CPGs)
Audit and problem solving (measurement
is key)
• Employee involvement and poka yoke
• Kaizen
• Training
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Prerequisites for Standardization
• Quality inputs
• Functioning process components (human,
machine)
• Input adequacy (no shortages)
• No wait time for work in progress
• Optimum safety
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Elements of Standardized Work
• Takt time must be understood
– Daily operating time/required daily output
– Not the same as cycle time (actual time per unit)
– Provides a target for production (e.g. number of
bills that should be produced in a given time),
from which cycle time requirements (throughput)
can be defined
• Work sequence must be defined
– Process steps in work flow (flowchart)
– Provides targets for improvement
• Inventory (in process stock) must be
optimized
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Measures of Standardized Work
• Production capacity statistic
– Capacity = operational time per shift/ (process
time + setup time/interval)
– Example: operating room
• Operational time per shift = 8 hours
• Process time = average surgical time
• Setup time/interval = time to turnover the room
between surgical procedures, e.g. to clean
equipment, restock, etc.
– This parameter is to determine capacity, not
throughput
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Improving safety with lean process management
Implications of lean – poka yoke
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Concepts We’ll Discuss
•
•
•
•
•
Cost of poor quality
Waste reduction
Zero Defect Quality ( ZDQ)
Understanding process errors
Poka-Yoke
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Resources
• AHRQ mistake proofing web site
– http://www.ahrq.gov/QUAL/mistakeproof/mistake9.htm
• Joint Commission International
– http://www.jointcommissioninternational.org/24839/
• John Grout’s mistake proofing web site
– http://www.mistakeproofing.com/
• IHI
– http://www.ihi.org/IHI/Topics/Improvement/Improveme
ntMethods/Changes/Error+Proofing.htm
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Cost of Poor Quality
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Cost of Poor Quality
• IOM report 1999 – 98K deaths per year
• Medication errors – pediatrics
– 4/10/08 – Joint Commission Alert: Prevent
Pediatric Medication Errors Children Are
Three Times More at Risk than Adults
• Patient safety from falls
– Rate – 4.3 per 1000 patient days
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Patient errors 2004-2006
•
Patient safety incidents – Medicare data
 1.12 million total patient safety incidents/41 million hospitalizations (~3%)
 $8.8 billion of excess cost
•
Post-op indicators worsened -> accounted for ~72 percent of all the potentially
preventable deaths
 post-operative respiratory failure
 post-operative pulmonary embolism or deep vein thrombosis
 post-operative sepsis
 post-operative abdominal wound dehiscence
•
AHRQ Patient Safety Indicators with the highest incidence rates (~63.4% of total)
 Decubitus ulcer
 Failure to rescue
 Post-operative respiratory failure
The fifth annual HealthGrades patient safety in American hospitals study, Available at: www.healthgrades.com,
April, 2008.
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Patient Errors (cont.)
• 270,491 actual in-hospital deaths among patients
who developed one or more of the 16 patient safety
incidents,
– 238,337 deaths were attributable to patient safety incidents
and potentially preventable
– Medicare patients who experienced a patient safety incident
had a one-in-five chance of dying as a result of the
incident
• Medicare patients in the HealthGrades Distinguished
Hospitals for Patient Safety™ had a 43-percent lower
risk of one or more PSIs compared to patients at the
bottom ranked hospitals across all 13 PSIs studied.
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What if all of us performed well?
• If all hospitals performed at the higher
level:
– 220,106 fewer patient safety incidents
– 37,214 Medicare deaths avoided
– $2.0 billion savings during 2004 to 2006.
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Cost of defects
• Does it cost more to make processes
better?
– In most cases, NO!
• How does quality improve cost?
– Reduced waste
– Reduced re-work
– Reduced inspection costs
– Reduced liability of malpractice
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The 1-10-100 Rule
• As a product or service moves through the
production system, the cost of correcting
an error multiplies by 10 at each step
Activity
Cost
Patient discharge entered correctly
$1
Error detected in order in record room
$10
Billing error detected by customer
$100
Dissatisfied customer shares bad experience
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$1,000
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Waste Reduction
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Waste? We now what that this…
• Anything done during a work process that
adds cost, but does not add value for the
customer
• Objective – eliminate non-value added
work
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Categories of Waste
Wasted
Motion
Knowledge
Waiting
Disconnection
Inventory
MUDA
Conveyance
Correction
Overproduction
(Rework)
Continuous
improvement
involves the
continuous
elimination of
waste
Overprocessing
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Process for Eliminating Waste
Identify
waste
Measure
and
Improve
Muda
Search
for
causes
Start
CQI
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Elimination of waste through
continuous improvement
Approach
Tools
Strategy
Waste elimination
One piece flow
Throughput
improvement
Kaizen
Kanban
Reduced costs
CQI
6S
Quality first
Standard work
SPC
Poka Yoke
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Zero Defect Quality
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Zero Defect Quality (ZDQ)
• Primary goal of improvement efforts
• Targets:
– Defects
– Inventory excesses
– Wasted motion
– Unnecessary delays
– Misused resources
– Unused resources
– Ineffective processes
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One Advantage of ZDQ
• Maintain customer satisfaction and loyalty
– Increase volume
– Increase revenues
– Reduce liability
– Improve collection rates
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ZDQ: What Is It?
• Conformance to quality
requirements
• Defect prevention preferred to
inspection and correction
• No defects becomes the quality
standard
• Quality is measured in
appropriate metrics and financial
terms (concept of value)
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Phillip Crosby’s Steps to Zero
Defects
1.
2.
3.
4.
5.
6.
7.
8.
9.
Make it clear that the management is committed to quality
Form quality improvement teams with representatives from all departments
Assess and evaluate the quality awareness/concern of employees
Raise the quality awareness/concern of employees
Take actions to correct problems
Establish a committee for a zero defects program
Train supervisors
Hold a "zero defect day“
Encourage people to establish improvement goals for themselves and their
teams
10.Encourage employees to communicate to management the obstacles to attaining
improvement goals
11.Recognize those who participate
12.Establish Quality Councils
13.Do it all over again - the quality improvement program never ends
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Important Attribute of ZDQ System
• CULTURE!
– Systems are at the root of errors
– not usually people
– Systems should be designed to
eliminate human errors –
MISTAKE PROOFING
– Managers must direct work to
mistake-proof systems
– Punitive culture not a productive
culture
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Four Components of ZDQ
• Point of Origin Inspection
• 100 % Audit Checks
• Immediate Feedback
• Poka-Yoke
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Inspection
• Three basic approaches
– Judgment/standards inspection
– Informative inspection
– Point of origin inspection
• Only Point of Origin Inspection has the
potential of eliminating defects
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Point of Origin Inspection
• Focus on prevention, as well as detection
• Each individual member of the team involved
in evaluating each element of work
continually
• No part passes to the next step if defective
• Each step becomes an inspection point, each
can halt the process to correct defect
Detect Error
Feedback/Corrective Action
• End result -> zero defects in finished product
or service
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Point of Origin Inspection is different
• “Inspection” done continuously
• Corrections can be made immediately
• Process output will have zero defects
• Staff members feel empowered, not
inspected
• Reduces need for specific inspection steps
in a process – all steps include inspection
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Point of Origin Inspection in health
care
• Stop point in pre-op
• Crew resource management
– Every member of the crew empowered to halt
process
– Every member esteemed for specific process
knowledge
– No team member assumed to have all
encompassing knowledge
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Everyday Examples of Mistake
Proofing
3.5 inch diskettes cannot be inserted unless diskette
is oriented correctly. This is as far as a disk can be
inserted upside-down. The beveled corner of the
diskette along with the fact that the diskette is not
square, prohibit incorrect orientation.
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Examples of Mistake Proofing
New lawn mowers are required to have a safety
bar on the handle that must be pulled back in
order to start the engine. If you let go of the
safety bar, the mower blade stops in 3 seconds
or less.
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We Learn From Other Industries
Drive Bar on Portable X-ray: The
drive bar is the steering mechanism of the portable xray unit. This bar must be depressed in order for the unit
to move. If the technologist takes their hands off of this
bar the portable immediately stops.
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Traditional Approach – Fix the
Human

“The old way of dealing with human error was to scold people, retrain them, and
tell them to be more careful … My view is that you can’t do much to change
human nature, and people are going to make mistakes. If you can’t tolerate them
... you should remove the opportunities for error.”

“Training and motivation work best when the physical part of the system is welldesigned. If you train people to use poorly designed systems, they’ll be OK for
awhile. Eventually, they’ll go back to what they’re used to or what’s easy, instead
of what’s safe.”

“You’re not going to become world class through just training, you have to
improve the system so that the easy way to do a job is also the safe, right way. The
potential for human error can be dramatically reduced.”
Chappell, L. 1996. The Pokayoke Solution. Automotive News Insights, (August 5): 24i.
LaBar, G. 1996. Can Ergonomics Cure ‘Human Error’? Occupational Hazards 58(4): 48-51.
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10 Types of Human Mistakes
 Forgetfulness
 Inadvertent or
sloppiness
 Misunderstanding
 Slow responses
 Wrong identification
 Lack of
standardization
 Lack of experience
 Willful (ignoring rules
or procedure)
 Surprise (unexpected
machine operation,
etc.)
 Intentional (sabotage)
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A Better Approach:
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Process Mistake Proofing
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Basic Principles
• Business activities consist of processes
• Information flow
• Financial resource flows
• Purchasing
• Care delivery
• All processes have the potential for producing
errors or defects
• All processes offer opportunities for the elimination of
errors and defects to improve quality
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Goal for Process Improvement
• Eliminate waste
• Systems thinking - understand each process
and its relationship to other processes
• Systems analysis – Identify the inputs and outputs of each process
– Know suppliers and customers of the process
– In 6s terms – SIPOC
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Sources of Improvement
Opportunities
• Variation!
• Process variation caused by:
– Lack of standardization
– Incorrect procedures
– Defective machines or equipment
– Non-conforming supplies or materials
– Human factors
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Tool for Mistake Proofing
• Process standardization
• Kanban – visual processes
• Continuous process management –
equipment management
• Ergonomics and human factor engineering
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Poka Yoke –
Steps to Error Proofing
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Poka-Yoke
POKA-YOKE
to avoid (yokeru) inadvertent errors (poka)
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Poka Yoke Results in Quality
Processes
Transformation = Quality production the 1st time
Specific inspection steps - eliminated
Transport
Dedicated services
Storage
Delay/wait
One piece flow
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Rapid Feedback
• Differs from traditional inspection systems
– Correction as soon as error is detected
– Address problems to avoid perpetuation of error
– Inspection steps become unnecessary
• Goal is to prevent defective processes from
continuing and leading to defective output
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7 Steps to Poka Yoke
1. Quality Processes - Design robust quality
processes to achieve zero defects.
2. Utilize a Team Environment- leverage the team’s
knowledge, experience to enhance improvement
efforts.
3. Elimination of Errors -Utilize robust problem
solving methods to drive defects towards zero.
4. Eliminate the “Root Cause” of The Errors - Use
the 5 Why’s and 2 H’s approach
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Poka Yoke Steps
5. Do It Right The First Time - Utilizing resources
to perform functions correctly the “first” time.
6. Eliminate Non-Value Added Decisions – Find
waste and cut those steps
7. Implement an Incremental Continual
Improvement Approach –
BEEP!
– Implement improvement actions immediately
– Focus on incremental improvements
– Target is 100%
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Poka Yoke in Health Care
• A Poka Yoke device or procedure is one that
easily identifies a flaw or error to prevent
incorrect parts of a process from being
propagated
– Any method that can help caregivers or operators
avoid mistakes
– The Lean Healthcare concept recognizes that the
optimal location to prevent or correct mistakes is at
the point of creation of the problem
– Late recognition of a mistake or defect is never as
efficient and typically has a cumulative effect
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Approaches to Poka Yoke
• Error proofing (poka yoke) is a technique
of preventing errors
– By designing the process, equipment, and
tools so that a procedure literally cannot be
performed incorrectly
– Example: Use of visual or other signals to
indicate a risk of error, e.g. end tidal CO2
detector to indicate a rising CO2 level in an
intubated patient
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Poka Yoke and Point of Origin
Inspections
• Proactive Approach
– A fully implemented ZDQ system involves
poka-yoke at each step during the process
– Errors that are detected are immediately
eliminated or the process may be stopped
– Example: incompatible name and wristband
ID detected at pre-op stopping point
– Example: bar coding medications
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Poka Yoke and Informative
Inspections
• Reactive approach
• Check occurs at the end of the process
• Can be an operator check at the end of the
process or a successive check at the beginning
of the next process
• Not 100% effective, will not eliminate all defects
• Effective in preventing defects from being passed
to next process
• Creates waste
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Two Types of Error Proofed
Systems…
• Control system
– Humans not required to shut down the process
– High capability of zero defects
• Warning system
– Useful if automatic shut off system is not an option
– Warning or alarm system used to get user’s attention
• Dials
• Lights
• Sounds
• Color coding
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Poka Yoke Responses
• Control approach
– Shuts down the process when an error occurs
– Keeps the suspected problem issue or part in
place rather than passing it on
• Warning approach
– Signals the operator to slow or stop the
process and correct the problem or move the
defect offline
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Poka Yoke Methods
• Three approaches
– Contact method
– Counting method
– Motion-sequence method
• Each method can be used in either control
or warning system
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Contact Method
• Detects contact between some sensing
unit and a part of the process
– Example: end tidal CO2 detector inline with
respiratory apparatus for intubated patient
– May have capacity to stop the process
(control) or warn of potential error in process
(warning)
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Counting Method
• Used when a specific number of
operations, pieces, or volumes are
required within a process
– Example: IV pumps that shut off and alarm
when a drug solution is infused
– Control – machine shuts off or process stops
– Warning – indicator notifies operator of
condition
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Another Approach to counts…
• Detecting incorrect counts after a
procedure ends
– Example: sponge count after surgical
procedure
– Variance from expected triggers corrective
action to ameliorate error
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Motion Sequence Method
• Sensors determine if a specific condition or
step in the process has occurred or has
occurred out of sequence
– Warning or control approaches may be used
– Example: color coding system or checklist in
office to ensure that each step of patient visit
has been completed, e.g. to ensure that nurse
has checked for lab results before MD sees
patient
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Poka Yoke Means Error Free
• Applications in health care are broad
• Requires staff empowerment
• Capability of stopping process or taking
error offline for correction
• Crew resource management ensures staff
empowerment and vigilance
• No more excuses!
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