3P: Production, Preparation, Process: Muda Muda

Mod 27 – 3P
GPS
MUDA MUDA
Cost Reduction Profit =

By Eliminating Waste Just-in-Time Price - Cost
GPS Depth Study Quality Cost Delivery

TAKT Time Map
Measures
3P:
NVA/VA-
Functions/Mgrs Safety Morale Capacity Tables
Jidoka Standard Total Visual

R Productive
(human Control
e
automation)
Operations Maintenance
d
Production,
e
p
l Setup Reduction Heijunka Poka-yoke
o Changeover (mistake
y
(Leveling) proofing)
m
e
Preparation,
n Multi-process Continuous
t
Operations Flow Kanban Andon
3P
RPIW Kaizen Kaikuku Prod
Prep
7 Flows
Factory Product/Patient Quantity Analysis
7 Flows
Medicine
Process
• Sweeping
• Sorting 7
4 No’s
• Simplifying 5S • Standardizing
• Self Discipline Wastes
Value Stream Mapping
ONE PIECE FLOW TAKT TIME PULL PRODUCTION

Global Production System © 1996-2013, John Black and Associates LLC
(modified from Hiroyuki Hirano, Productivity Press).
27 3P v20130529 1 ©1996-2013, John Black and Associates LLC

Committed Leaders Licensed Materials – USA Copyright Laws Apply
Mod 27 – 3P
“You should submit

wisdom to the company.
If you don’t have any
wisdom to contribute,
submit sweat. If nothing
else, work hard and don’t
sleep. Or resign.”
Taiichi Ohno
Licensed Materials – USA Copyright Laws Apply
Mod 27 – 3P
“Perhaps you are asking yourself,-
How can a manufacturing model be

applied to healthcare? Patients aren’t
products put together on an assembly
line.
That is certainly true and a perspective

never to be forgotten. But the patient
isn’t the product - they are the customer.
The product is defect-free healthcare.
And high quality, defect-free healthcare
is susceptible to the same improvement
methods (Lean) as other products or
John Black services. No different from building cars
President -
John Black and Associates, LLC or airplanes.”
www.johnblackandassociates.com

Mod 27 – 3P
“Toyota revolutionized our

expectations of production; Federal
Express revolutionized our
expectations of service. Processes
that once took days or hours to
complete are now measured in
minutes or seconds. The challenge is
to revolutionize our expectations of
health care: to design a continuous
flow of work for clinicians and a
seamless experience of care for
patients.”
Donald M. Berwick, MD
Former President and CEO, Institute for Healthcare Improvement
Mod 27 – 3P
Half of Everything
Lean = ½ Less
 ½ the human effort.
 ½ the space.
 ½ the equipment.
 ½ the inventory.
 ½ the investment.
 ½ the engineering hours.
 ½ the new product development time.

Mod 27 – 3P
World-Class Paradigm
The Important Number is Zero
Lost opportunity Customer

Dissatisfaction
MUDA
Breakdowns Misalignment
Non-value added Bureaucracy
Waste
Mod 27 – 3P
Taiichi Ohno’s Seven Wastes

Overproduction
Defective Time on Hand

Products (Waiting)
Transportation
Movement
Stock on Hand
Processing
(Inventory)

7
Mod 27 – 3P
GPS – Foundation Principle

Continuous
improvement
Money without adding: Inventory
People Space
Large Machines
A Single Goal: NO WASTE
Mod 27 – 3P
Impact of Lead-Time Reduction
Value
Typical
Added Non-Value Added
Company
Original
Lead Time
Traditional
Improvement VA NVA
Minor
Improvement
Kaizen
Waste VA NVA Major
Reduction Improvement
Time
9
Mod 27 – 3P
Value Stream Network
VSM
Mapping
Health Care Enterprise
Kanban
Hospital
3P
Kanban Standard
Work: SW
Right Size
Kaizen
Equipment
OR
3P
Steps SW
1.Identify value stream Kanban

Kaizen VSM
2.Make value flow
3.Pull value through
from supplier’s supplier SW SW SW SW SW
to customer’s customer
Kaizen Kaizen
4. Remove waste
5.Pursue perfection
VSM

Mod 27 – 3P
Production Preparation Process

Building Quality into Our Production System
What is 3P?
The model process for designing quality services
and appropriate production processes while best
embracing Rapid Process Improvement culture.
Q D T
The Best Quality At The Demand Proper Timing
Service Volume (TAKT Time)
Proper Cost
is a by-product of these other factors.

Mod 27 – 3P
Medications
Instruments
Inspection Systems
Creating the Links for Building In Quality

Mod 27 – 3P
Applying the
Principles of Simple/Flexible
U-Shaped Cells
Takt Time
Rapid Process Pull Ergonomics
One-Piece-Flow
Improvement Jidoka Poka-Yoke
Waste Elimination
Rectified Flow
HON INDUSTRIES
To Our Services
To Our Processes
13
Mod 27 – 3P
Ted Gachowski’s Journey

 Ted Gachowski
 Retired engineer
 Lymphoma since 1999
 Chemotherapy 6 hours each week
SEATTLE -- Up until five months ago, Ted Gachowski's weekly chemotherapy

appointment was one long, tedious slog through the Virginia Mason Medical
Center. Today, chemotherapy at Virginia Mason is a much shorter trip: The
distance from lab to exam room to treatment is less than 12 feet. Once
Gachowski is hooked up to his IV, he never has to leave the cheery private
room -- flat-screen television, computer, nursing supplies and bathroom are all
right there. And his physician, Henry O. Otero, is so close, "I can almost shout
to get him," said Gachowski, seated in a reclining chair as the drug dripped into
his arm. - Ceci Connolly, Washington Post, 2005
Mod 27 – 3P
And the bottom line is…

Ted’s
Before After % Change
Journey
Lead Time
(Arrival to 240
Start of minutes
90 minutes -63%
Treatment)
Non-Value 194
Added Time minutes
52 minutes -73%
Distance
Traveled
748 feet 181 feet -76%
Mod 27 – 3P
Why Do 3P?
DEVELO P EFFECTIVE SERVICES AND PROCESSES
A COM P ETITIVE WEAPON IN OUR INDUSTRY
RAP ID CONTINUOUS IMPROVEMENT

Mod 27 – 3P
Kaizen Alone May Vision

NOT Get Us
Where We Need
to Go
Improvement
Kaizen - Evolutionary Change
Kaikaku - Revolutionary Change
Time
Mod 27 – 3P
When is 3P Used?
Production
Changes Preparation Process
In Process Design
Demand Changes
Improve Service New Service

Delivery Introductions
Mod 27 – 3P
The New Way of Creating

Healthcare Services or Cells
3
Assured Quality
Product Development
TAKT Time
2 Ease of Service
Delivery
The Patient (internal or external)

Must be the Center of 3P Efforts

Mod 27 – 3P
What do you really

want to accomplish?
Develop a 3P Designed Machine for Cell X
Develop a Flow line for Lab W
Reduce floor space by 50% for new Oncology unit.
Design a Children's Hospital with no waiting rooms, 50% reduction

in walking for patients and families, 65% reduction in storage, the
coordination of the 7 Flows of Medicine to optimize quality and
safety, and to not exceed the target cost of $200 million.

Mod 27 – 3P
1. Determine Function
What is the Theme & Scope of Your Event
Product Process
HON
Allstee
Post on Wall/Board
Think about what you wish to accomplish...

NOT what is currently being used.
Mod 27 – 3P
2. Define the Essence of the Function

What are the Key Words?
Clamp
spin
turn K
E WORDS
Y
staple slide
Sketch What is Happening.

Mod 27 – 3P
3. Look for Examples of Keywords in Nature

Nature has spent millions of years refining these phenomena
Attach Cling
Move Shear
Spin
Adhere
Cover
Grip
Attach Cling
Float
Resist All Attempts to Use Man Made Examples. Hinge

Nature’s Examples are Often Simple and Pure.

Mod 27 – 3P
4. Sketch Examples, Examine What is Happening

Group Common Examples.
Shear
Do Your Homework
Sketch the Examples
Attach Hinge
Nature
Examine in Detail Group Common Examples
You MUST Look Deep into the Phenomenon to Understand.

What Must Take Place for This Phenomenon to Happen?
Mod 27 – 3P
5. Sketch Background and Conditions of Function

You must understand HOW the natural Phenomenon Operates
Muscle
From This: (Vastus Lateralis)
To This:
Socket Lining
105 degrees
rotation
What is now
Force uniform
happening or must 48- 94 degrees flex
happen in the Muscle

(Gracilus)
surroundings for this

function to take
place?
Mod 27 – 3P
6. Combine Ideas from Nature to Create Sketches

Each Team Member Develops Seven Designs or Seven Ways
Fly
Seven Proposals
Be Creative.
Do NOT Be Afraid to Propose Anything!
Mod 27 – 3P
7. Moonshine: Pick 7 Proposals to Build

Quick and Crude Beats Slow and Elegant
190
PROOF
MOONSHINE
Use Readily Available Materials To Build Your Prototypes.

Do NOT Make This Step Overly Complex.
Mod 27 – 3P
8. Conduct Experiments to Collect Real Data

How does each design perform against our criteria?
Document
Collect Real Data
The Data
#3
Even Though Your Model is NOT Perfect, it will Give
You Valuable Data on How to IMPROVE Your Design.
Mod 27 – 3P
9. Select the Three Best Designs, then…

Conduct MOONSHINE on the TOP 3 Designs
Established
Criteria
Design
Design #3
Evaluation
Demo/Explain
Design Top 3 Designs
You MUST Understand the Quality Required.

Keep Thinking...“Dimensions, Tolerances and Gauges.”
Mod 27 – 3P
10. Evaluate Data on Top 3 Designs

Keep MOONSHINING and Improving Design
Improve Designs
If Problems Arise...
Fix Them Right on the Spot, Don’t Talk About Them.
Keep TRY-storming....NOT Brainstorming.
Mod 27 – 3P
11. The TRIAL: Presenting to Management

Present the Best Product Designs
Production Engineering-Presenter
Proposal #1
Quality
Finance Controllers Sales
Process Design Equipment Proposals
Patient Flow
Material Control
Information
Hospital Layout System
Safety
Evaluation Committee
Have Models and Data Prepared for Viewing By Evaluation Committee.
These are Your Customers...They have to Buy the Designs From You
Mod 27 – 3P
What is a Medical 3P Workshop?

It is a week-long process where the complete production flow for a
service or group of services is mapped out in depth. Alternative process
methods are tried and tested, ranked in several categories, and modeled.
The result is often breakthrough production methods with drastically
improved efficiency, reduced cost and improved quality.
 Steps:
1. Define the project scope.
2. Define the cross-functional team membership.
3. Gather PQA data, lead times and cycle times.
4. Fishbone and analyze current processes.
5. Keeping the 7 flows of medicine in mind, create multiple (ideally 7) new
preferred processes.
6. Using the 7 flows, evaluate the options.
7. Narrow the options and present the results.
8. Model/simulate the preferred options with mock ups, models, flow
diagramming and time measurements.
9. Determine what equipment is needed to support the preferred processes.
10. Complete and implement the design.

Mod 27 – 3P
3P Results

Mod 27 – 3P
3P:
Virginia Mason Hospital Campus
Team member representation included:
Nursing, Pharmacy, Hospitalist Service, General
Surgery (VM and Group Health), Anesthesia, Graduate
Medical Education, Administration, Clinical Information
System, Facilities, Radiology, Peri-operative Services,
Cardiology, Emergency Services, Oncology,
Cardiac Cath Lab, Equipment and Supplies,
Kaizen Promotion Office.

Mod 27 – 3P
Goals and Deliverables

The goal and theme of the 3P was:
 Design an incremental plan for campus development. At the plan’s core will be placement of our
inpatient services, from which required adjacencies (support services, departments, etc.) will be located to
meet our vision and 3P targets. The plan will focus on East Campus and Madison site development, and the
relationship of hospital based services to the ambulatory settings.
Boundaries:
 Develop a campus plan that is flexible to meet patient needs for the next 25-50 years.
 Focus will not be placed on specific space requirements or design within units or departments, but rather on
the relationship between departments and services on Main Campus.
 Scope will be within the current design of the East Campus Building (“shell” design must be used), approved
permitting specifications.
 We are licensed for 336 inpatient beds. Design will not incorporate any additional beds.
 The East Hospital Wing is to remain in place short term to meet bed capacity needs. Considerations for this
building can be made in the long term plan. Hospital Main wing will not be used for future patient care
activities. All seismic specifications currently defined will be followed.
 Sale or lease of current space is not within the scope of the 3P.
 All available space (including 1000 Madison) is to be considered to meet the future demand of inpatient care
services and must be designed within current entitlements (timelines, physical constraints, etc.)
Deliverables
 Determine primary bases for patient care.
 Plan for transition of patient care services to the East Campus.
 Determine focus of next 3P addressing planning for ongoing campus development.
Targets
 Facilitate care givers’ ability to provide safe, defect-free care.
 Promote progression of care and reduce patient lead time.
 Reduce lead time and travel distance for each of the 7 Medical Flows.

Mod 27 – 3P
Preparation Prior to the Event

 A planning team prepared 6 weeks in advance of the 3P to ensure that the
time of the team was value-added and focused on the goals and
deliverables for the week. Key preparation work included:
 Development of Hospital Takt Time – The hospital Takt Time was
complete with 2004 volumes for the key portals to the facility (ED, OR and
Direct Admissions) and high volume support areas (GI, Radiology, Heart and
Lab). Lead time calculations for each area were included. The spreadsheet
was setup with formulas to accommodate increases or decreases in volumes.
 Value stream maps were gathered for the above portals.
 Future projections were completed for changes in population for
the region and Medical Center extending to 2025. Point of use technology
information was collected for projections.
 Stakeholder feedback was obtained from all departments.
 Three 1/16th scale campus models were constructed for the team to measure
the seven flows in the current campus and determine future state.

Mod 27 – 3P
Identifying flow challenge

Using the tools of 3P
 The team began the week by learning the basics of 3P. Key concepts
covered included: Seven flows of medicine, patient (PQ) analysis and use of
the Takt Time spreadsheet. Key learnings:
 Understanding the 7 Flows is the foundation of 3P work.
 PQ Analysis is a method to group the flow of the patient by sequencing of
services. This is the first step to cell development and determination of
collocation of services.
 Takt Time is the key tool to determine the number of beds, rooms or
resources needed to provide service. This tool is critical to anticipate impact of
changes in volume.
 The team learned tools to help illustrate flow by using pictures instead of
words. Tools included fishbone, the seven ways exercise, and idea forms. The
team broke into four sub-teams by the high volume portals to the facility to flow
the current state:
 ED flow.
 Direct Admission.
 Inpatient and outpatient surgery.
 Outpatient procedure team.

Mod 27 – 3P
Translating the flow into the space

 In order to understand the current state a sub-team flowed the 7 flows of medicine for the ED admission,
direct admission, inpatient and outpatient surgery, and procedural care on a model with a different yarn color
for each flow. The current state visually showed wasted time traveling for patients, providers, equipment,
supplies and medications. It also showed “bottlenecks” in space and multiple handoffs causing opportunities
for defects.
 Each team continued to develop the future flow through the use of the fishbone, integrating idea forms from
the entire group and flowing the future state on a “hospital map” with yarn. The results of this work
continued to demonstrate innovation ideas to look at how the flow can determine how space is used.
Additional ideas integrated to future state include:
 ED Flow:
 Observation/admission unit collocated by ED to keep the patient moving. Flexibility to expand or contract based on
volume.
 Elevators adjacent to ED for flow of patients, supplies and equipment
 Direct Admit Flow
 Expand use of “smart card.”
 Use of information technology for information flow.
 Surgery Flow:
 Design of Surgical Plan center with MD offices integrated in space.
 Design of an outpatient center for any procedure from short stay surgeries to GI/Cardiology procedures.
 Continued design of CCU surgeries that would not go to recovery but direct to CCU.
 Procedure Care Flow
 Integration of “smart card” technology and expand to all services during stay.
 Supplies delivered by “interstitial core” and use of mechanical space.
 Interchangeable rooms used for all procedures.
 No nursing stations.

Mod 27 – 3P

Mod 27 – 3P
Functional Units for Future State Design

•Current state lead time •Future state – 50% reduction in lead time
Daily % tot. Time WALT Daily % tot. Time WALT
GI 60 58 89 52.4 GI 60 58 45 26.5
IR 15 15 180 26.5 IR 15 15 60 8.82
Bronch 3 3 89 2.62 Bronch 3 3 45 1.32
EP 11 11 142 15.3 EP 11 11 62 6.69
Cath 13 13 143 18.2 Cath 13 12 63 8.03
total 102 114.98 total 102 51.33
 Assumptions for space were made for each area based on Takt Time. Note many of the calculations are based on
current lead time. Assumptions with decreased lead times are noted
1. Direct Admit Pt Calculation assumptions:
 TT = 279’ LT = 6192 Demand: 1885 Time Available = 24 hrs/day
 Functional Units – 22 beds
2. ED Patient Flow: Peak time 1100 – 2100
 TT = 8’ LT= 190’ Time Available = 600 minutes (peak 10 hours of the day)
 Functional Units = 25 rooms (* at current lead time at 50% improved lead time = 11 – 12 rooms), X-ray (plain) –
need 2.7 machines, CT scanners 2, Chemistry TT 11.5, Heme 3.
 Adjacency: Radiology and lab in ED, parking, food services for patients and families, elevators for moving pts and
supplies Flexible monitored rooms for procedures, overnight stays. Supplies and equipment dropped down from
the ceiling
•TT = 600/102 = 5.8 min. •TT = 600/102 = 5.8 min.
Functional Units: LT/TT = 114.98/5.8 = 19 •Procedure Rooms: LT/TT = 51.333/5.8 = 8.9 rooms for current
rooms (current state lead time) volumes (future state)
WALT = weighted average lead time

Mod 27 – 3P
Reductions in Travel-Distance-Based
Flows in New Locations are:
Flow Before After % Change
Provider 1696 feet 442 feet 74 %
ED Patient w/CT scan 1208 feet 460 feet 62 %
Cardiac Cath Patient 580 feet 403 feet 30 %
Inpatient Surgery Patient 1180 feet 740 feet 37 %
Clinic Patient Admit 1050 feet 680 feet 35 %
Supplies 45,000 feet 3750 feet 92 %
 Innovative concepts:
 “Library Walls”– to expand and contract co-located spaces with utilities in the ceiling to allow for inexpensive cell
changes.
 Flexible space based on “grid” delivery of power, medical gases, air, etc., from the ceiling using “quick connect”
connections. Get plumbing and electrical out of cement to keep the lower space maximally flexible for the
future.
 “Lunchable” supplies for surgical/procedure kits. Drop into the room from above and then “drop” in the floor
(chutes and ladders) for disposal.
 Design a bed that has all the information attached –Cerner connection, equipment etc.
 1000 Madison Future ideas: Looking to the Horizon for our Future:
 Retail (food service) to support staff/patient needs/amenities and local neighborhood needs/amenities.
 Health/wellness center (Spa).
 Below grade parking with access to ED.
 Migrating OP Services here with above and below grade access.

Mod 27 – 3P
Work Plan and Key Learnings:

 The team completed a work plan summarized in newspaper (attached):
 Timeline and implementation of ideas to do immediately.
 Review with design team to translate concepts into designs and validate assumptions for beds and
space.
 Test the feasibility of ideas by implementing a process for patient feedback.
 Implement plan for April 3P to build on this work.
 In addition the key learnings for the team were:
 We are limited by our own reality and current view of the world as we look to the future.
 There is much that can and should be done that does not have to wait for construction for the
changes to start. We need to create our own sense of urgency today to eliminate waste
today. Our goal is to NOT build a new hospital with wasteful processes.
 “If you build it you will fill it” – we don’t want to do this!!
 Need to provide good parking - accesses into and out of the facility.
 Co-location makes a difference – we have not designed our plant to meet the needs of the patient.
 Shared resources and spaces – multi-use and multi-purpose rooms: vs. department ‘owned’.
 When you stretch something out you have to have something stick it there – It will snap back – we
will not sustain the changes.
 Flows have memory – or habits.
 Different view of “teams” – palette of care team members created for every patient.
 Separate patient flow from other flows.
 Patient flow follows parking.
 Tools help figure out the difference between what you think you need vs. what you really
need.
 The process is the foundation of what you are building.

Mod 27 – 3P
Saskatoon Children’s Hospital 3Ps

Mod 27 – 3P

Theme: Design a facility with care processes reflecting the same
scope and level of services as defined by the project in approximately
25,000 sq. m space and while respecting the planning principles
established.
Service Line Areas:
 Surgical Services
 Emergency
 Adult
 Child
 Maternal / Child
 Pediatric Outpatient
 NICU
 PICU
 Labor and Delivery
 Materials Management
 Support Services
 Food and Nutrition
 Laboratory

Mod 27 – 3P

Targets:
Decrease Space:
 Reduce surgical theaters from 5 to 3.
 Eliminate waiting rooms.
Reduce Walking:
 50% reduction for patient in maternity department.
 50% reduction for patients in pediatrics department.
Reduce Storage:
 Reduce Intrapartum ward storage by 65%.
 Reduce administrative/office areas by 50%.
Improve Patient Flow:

 Reduce lead time for patients moving through all departments.
 Coordinate 7 flows of medicine into the ideal state to add quality and
safety.
Mod 27 – 3P

Data sets us free

Mod 27 – 3P

Data sets us free

Mod 27 – 3P

Understand the current state so we can build for the future

Mod 27 – 3P

Understand the current state so we can build for the future

Mod 27 – 3P

Setting and Understanding Criteria
 Adjacencies:
 What departments must be co-located next to each other?
 What should be on the main floor versus top floor?
 Keeping patient care centralized on one unit (i.e. don’t move
laboring mom to numerous floors).
 Delivery Aspects:
 Just in time delivery of supplies, food products, medications.
 Minimal storage for equipment and supplies.
 Patient Safety:
 Design family-centered areas instead of waiting rooms.
 Easy way-finding.
 Staff Safety:
 Embed touchdown space as teaching space.

Mod 27 – 3P

Listen to the voice of the patient

Mod 27 – 3P


Mod 27 – 3P


Mod 27 – 3P

Creative Thinking
“Problems cannot be solved

by the same level of thinking
that created them.”
Albert Einstein

Mod 27 – 3P

Using the 7 ways

Mod 27 – 3P

Our 12-year-old Mind Set

Mod 27 – 3P

Our 12-year-old Mind Set

Mod 27 – 3P

Outcomes and Lessons Learned
 Have defined scope/goal from the start.
 Clearly articulate/communicate your scope/goal to team.
 Measurement and good data are critical to the process.
 Participation from patients is essential.
 Standard work is necessary for efficiency.
 Flexibility is achieved by breaking down department barriers.
 Interdisciplinary groups should always design facilities.
 Visualization is a key to understanding flow and processes.
 Simulation is enlightening, it changes peoples’ views on flow.
 We could have institutionalized poor processes in the facility design
& customers (external & internal) would not always be served well.
 Internal “expert" opinions are often wrong. Data and modeling
proved this.
Mod 27 – 3P
GPS
MUDA MUDA
Cost Reduction Profit =

By Eliminating Waste Just-in-Time Price - Cost
GPS Depth Study Quality Cost Delivery

TAKT Time Map
Measures
7 Flows of
NVA/VA-
Functions/Mgrs Safety Morale Capacity Tables
Jidoka Standard Total Visual

R Productive
(human Control
e
automation)
Operations Maintenance
d
e
p
l
o
y
m
Setup Reduction
Changeover
Heijunka
(Leveling)
Poka-yoke
(mistake
proofing)
Medicine
e
Module 22
n Multi-process Continuous
t
Operations Flow Kanban Andon
3P
RPIW Kaizen Kaikuku Prod
Prep
7 Flows 7 Flows
Factory Product/Patient Quantity Analysis Medicine
• Sweeping
• Sorting 7
4 No’s
• Simplifying 5S • Standardizing
• Self Discipline Wastes
Value Stream Mapping
ONE PIECE FLOW TAKT TIME PULL PRODUCTION

Global Production System
© 1996-2013, John Black and Associates LLC
(modified from Hiroyuki Hirano, Productivity Press).

Committed Leaders Licensed Materials – USA Copyright Laws Apply
Mod 27 – 3P
7 Flows of Medicine
1. Flow of Patients
2. Flow of Family
3. Flow of Providers
4. Flow of Information
5. Flow of Supplies
6. Flow of Medications
7. Flow of Equipment
Mod 27 – 3P
1. Flow of Patients
A. No patient waits.
B. Minimize patient walking; bring the
services to the patient.
C. Problems must force the process to stop.
D. Patient flow is in only one direction with
successive steps in order of processing.
E. Incorporate quality checks at each step of
the process with mistake-proofing
methods.
F. If there is single-piece flow,
schedulers/planners are not needed for
the process.
G. Understand Takt Time – meeting the
demand.
H. Use “between processes” time to
complete indirect patient care tasks.
Mod 27 – 3P
2. Flow of Family
A. Family and important relationships are
defined by the patient.
B. Family travels with the patient where
appropriate and as the patient desires.
C. Family is a respected part of the
patient care team.
D. Family concerns stop the process until
addressed.
E. Family is a respected source of
information about the patient.
F. Information should flow to the family
throughout the process as desired by
the patient.

Mod 27 – 3P
3. Flow of Providers
A. Understand Takt Time and cycle times of the
work.
B. Look for standard work – it is critical to people
flow.
C. Do not isolate people in “islands.”
D. Understand people movement especially if
across several process steps.
E. People are part of the process – when they
stop, the process should stop.
F. All supplies, instruments and materials should
be as close to the provider as possible.
G. Examine motion of hands, feet, and eyes.
H. Stand when possible – do not use chairs!
I. Do not tolerate rework!
J. Avoid unreasonableness (i.e., Muri).
Mod 27 – 3P
4. Flow of Medications
A. Single-piece flow with signal/pull from
provider.
B. Introduce point-of-use. Get as close as

possible to the point of use.
C. Kit medications where possible.
D. Make smaller, specialized “satellite”

pharmacies where possible.
E. Bring medications to the patient, no patient

walking.
F. No waiting for medications.

Mod 27 – 3P
5. Flow of Supplies
A. Do the supplies flow to point of use?
B. Just in Time – only material on-hand needed at
the right place and at the right time.
C. Make the flow visual for simple control.
D. Introduce min/max, or “2 bin” strategies to re-
supply point of use.
E. Presentation of materials and sequencing is key.
F. Quality is critical.
G. Inventory reduction strategies – use kanban for
total inventory reduction.
H. Think of flow upstream – to suppliers – is it Just
In Time? (JIT)

Mod 27 – 3P
6. Flow of Information
A. Information travels with patient.
B. When information flow stops, the process stops.
C. When designing the process, consider how
information flows.
D. Only the minimum information necessary to
perform the process should be released.
E. Introduce mistake proofing and go/no go gauges
to ensure the flow of correct information.
F. Information can come in many forms – signals,
lights, sounds, music, spaces, etc.
G. Information must facilitate pull processes, not
push.
H. “Open room” arrangements facilitate the flow of
information between providers and staff.
Mod 27 – 3P
7. Flow of Equipment
A. Arrange equipment in a sequence that facilitates
the flow of patients, providers and information.
B. Separate people from machine work (i.e., Jidoka).
C. Use equipment with narrow frontage. Think
“townhouse” not “ranch house.”
D. Operation in front – maintenance in back.
E. Right-sized, small, economical equipment on
wheels that is home-made.
F. “No money” and “no time” are just excuses.
G. Use of small, single-purpose machines with
in-process checks.
H. “No roots, no ivy, no anchors.”
I. Equipment must facilitate flexible arrangements
as demand and processes change.
J. Is there wasted machine movement?
Mod 27 – 3P

Mod 27 – 3P
The No’s of Health Care
No Silos “The World is

Flat”
Thomas Freidman

Mod 27 – 3P
# IN EXP.
ITEM COST STOCK DATE
Implant Hospital/
Cochlear $50K ea 15 2008 Factory Clinic
Implant
No Excess Just-in-Time
Inventory Supply

Mod 27 – 3P
Don’t Wear Look Everywhere

a Blindfold for Improvement
Opportunities

Mod 27 – 3P
No Anchor Get on Board!

Draggers

Mod 27 – 3P
No Waste Use Returnable

Packaging

Mod 27 – 3P
Don’t stick Be open to change

your head in and new concepts
the sand

Mod 27 – 3P
Don’t Use Use Ideas

Money

Mod 27 – 3P
If you fall down 7 times, get up 8

Mod 27 – 3P
People are the key to world class,

not technology
Mod 27 – 3P
Don’t hide Go and See

(Genchi Genbutsu)

Mod 27 – 3P

Why? Why?
Why? Why?
Why?
Don’t stop Ask “why?” five

asking “why?” times

Mod 27 – 3P
Never say Make perfection

“never” your goal

Mod 27 – 3P
Get out of Let your

the rut imagination soar!

Mod 27 – 3P
6
8
1 2 3 4 5 6 7 8 9 10
No chaos Follow standard work

Mod 27 – 3P
TODAY
2025
Don’t say Say NOW

someday

Mod 27 – 3P
No more Find the root

band-aids cause

Mod 27 – 3P
Yes!
No negative Only positive

thoughts ideas

Mod 27 – 3P
I document
after each
patient visit
Don’t batch One piece flow

Mod 27 – 3P
Don’t waste Take out the

steps wasted steps

Mod 27 – 3P

blah
blah
blah
blah
blah
Don’t have a Have big ears, big

big mouth eyes

Mod 27 – 3P
Don’t ignore Fix the problem

the problem

Mod 27 – 3P
Don’t keep Be inquisitive and

thoughts to persistent
yourself

Mod 27 – 3P
Get all the gears and processes

working together

Mod 27 – 3P
MACHINES
No ONE-WAY No Dinosaur Machines.

Machines We know what happened
Bring the part back to to the dinosaurs
the operator
Mod 27 – 3P
Sacred Cows make the BEST Burgers

Mod 27 – 3P
Use Equipment Necessary to Permit

One Unit Flow

Mod 27 – 3P
Keep Height of all Items in the Workplace

Very Low

Mod 27 – 3P
Don’t Build Think Small and

Big Ships with Responsible
Big Guns…

Mod 27 – 3P
Explanation is NOT Necessary

Mod 27 – 3P
3
P
Keep an OPEN Mind to Change and

New Concepts

Mod 27 – 3P
Machines
Avoid Machines with Loads of Unneeded

Accessories
Think Bare Bones…Add Options when
Necessary
Mod 27 – 3P
Pulling
Pushing
Which is Smoother?

Mod 27 – 3P
No Catalog Get your hands

Engineers DIRTY

Mod 27 – 3P

Wide Narrow & Deep
Frontages
Spaced far
apart Closely Spaced
Design Machines to be like

Townhouses, NOT Ranch-style Houses

Mod 27 – 3P
Don’t use Use TRYstorming

Brainstorming

Mod 27 – 3P
Machines Machines
Don’t Attach Roots and Vines to

Machines - Make them Easy to
Relocate

Mod 27 – 3P
CO$T Q
D
T
Don’t think about CO$T

Shoot for BEST: Quality, Demand
Amount, and Timing

Mod 27 – 3P
16 Catchphrases
1. Production Preparation should be lightning fast.
2. Equipment construction and layout should permit easy material flow.
3. Build additive equipment; no battleships.
4. Build equipment to allow easy changeovers.
5. Make equipment easy to disconnect and relocate.
6. Make versatile equipment that can easily be reconfigured.
7. Make operator stations narrow; deep is acceptable.
8. Both the equipment and layout should allow the operator to move easily. Open
room concept allows operators to see the big picture.
9. Eliminate machine waste; kaizen the motion of the machine.
10. Build equipment to fit into small, swift vertical flow lines.
11. Eliminate horizontal flow…this creates batch processing.
12. Production should be pulled along at Takt Time. Do not allow room or capability for
batching.
13. Build tooling/machines for rapid setups and quick changes.
14. Link machines to make work flow smoothly and avoid excessive WIP.
15. Use multiple lines to avoid constructed flow.
16. Continue pursuing the steps of jidoka by spiraling upward, continuously separating
machine tasks from human tasks.

Mod 27 – 3P
16 Catchphrases
1. Production Preparation should be lightning fast.

Mod 27 – 3P
16 Catchphrases
2. Equipment Construction and Layout should permit easy material flow.
Standard Work
①
②
③
④
Entry
Exit
Materials
Mod 27 – 3P
16 Catchphrases
3. Build additive equipment. No battleships.

Mod 27 – 3P
16 Catchphrases
4. Build equipment to allow easy changeovers.
Change-over Flowing gap Old product New product
5 4 5 4
A 3 F 3
RM 2 RM 1 2
5 4 4
B 3 E 3
RM 1 2 RM 1 2
5 4 5
C D 3
RM 1 2 RM 1 2
Mod 27 – 3P
16 Catchphrases
5. Make equipment easy to disconnect and relocate.
Machines

Mod 27 – 3P
16 Catchphrases
6. Make versatile equipment that can easily be reconfigured.
Big Dedicated
Machines

Mod 27 – 3P
16 Catchphrases
7. Make operator stations narrow. Deep is acceptable.
Ranch
Style
Layout
Wide and Shallow
Principle of Townhouse
Verticality Style
Reduced Layout
Footprint Narrow but Deep
Reduced Walking
1 step - station to station
Mod 27 – 3P
16 Catchphrases
8. Both the equipment and layout should allow the operator to move easily.
Open room concept allows operators to see the big picture.
Fixed
Layout
Standard work may be

changed to allow for
increased demand
without changing layout.

Mod 27 – 3P
16 Catchphrases
9. Eliminate machine waste. Kaizen the motion of the machine.
1. Switch on
2. Air cutting down (Muda)
3. Drilling
4.Air cutting up (Muda)
Air
cutting MUDA
Only this part adds

VALUE

Mod 27 – 3P
16 Catchphrases
10. Build equipment to fit into small swift vertical flow lines.

Mod 27 – 3P
16 Catchphrases
11. Eliminate Horizontal Flow. This creates batch processing.
Horizontal
Press Press Press Press Handling
NO FLOW
Weld Weld Weld Weld

Vertical Flow
Process
Paint Paint Paint Paint
Assy. Assy. Assy. Assy.
A B C D
Products

Mod 27 – 3P
16 Catchphrases
12. Production should be pulled along at takt time.
Do not allow room or capability for batching.
Don’t produce 7 units once per week

when the customer wants 1 per day.
1 1
Day Day
Takt Time = 1 Day

Mod 27 – 3P
16 Catchphrases
13.. Build tooling/machines for rapid setups and quick changes.
Ease of positioning

Mod 27 – 3P
16 Catchphrases
14. Link machines to make work flow smoothly and avoid excessive WIP.
Whoa!
NO MORE WIP
Five pieces
is Standard

Mod 27 – 3P
16 Catchphrases
15. Use multiple lines to avoid constructed flow.
F1
Model A
A1
Model B B1 F2
P1 A2
Model C
Model D B2 F3
F4 A3
Use Multiple and Rectified Flows

Model A B1 F1 P1 A1
Model B B2 F2 P2 A2
Model C B3 F3 P3 A3
Model D B4 F4 P4 A4
B = Blank F = Fabricate P = Paint A = Assembly

Mod 27 – 3P
16 Catchphrases
16. Continue pursuing the steps of Jidoka by spiraling upwards,
continuously separating machine tasks from human tasks.
Jidoka
7 Quality Check (Poka-Yoke)
6 Part Removal (Hanedashi)
5 Autonomation of Returns
4 Automation of Stops
3 Autonomation of Feed
2 Automation of Holding
1 Autonomation of processing

Mod 27 – 3P
QUESTIONS?

Mod 27 – 3P
3P Contract
3P Architect Contract
The 7 Ways
Process-At-A-Glance Sheet
Product Design Evaluation
3P Process Evaluation Checklist
3P Project Form
3P Target Sheet
Construction / Building Supplies as Directed by JBA
Mod 27 – 3P
3P Contract Contract
To give full play to my team’s creativity
Creativity comes into existence by removing the hurdles in the way of
Each team member signs a creative thinking and idea generation.
Therefore, as one who tries to be creative, I do hereby promise to do
contract on Monday of the 3P the following to improve my creativity:
1) I will not judge (good or bad) another person’s idea.
week to ensure full disclosure 2) I will make every effort to overcome the hurdles in my own
thinking in order to generate useful ideas.
of creativity and a non- 3) I will not think in limited ways but will make every effort to
look at the problem from many angles and especially to get
ideas from nature.
judgmental approach to 4) I will make every effort to express my ideas openly and not fear
the laughter of others.
design. 5) I will return to my 12 year old mindset and will use this style of
thinking to generate useful ideas.
Contracts are posted in the

room.
Signature:______________________ Date:_______
Coach:__________________________________ Date: _______
Copyright 2013 John Black and Associates LLC

Permission not granted to copy

Mod 27 – 3P
3P Architect Contract Contract

The Architect’s Commitment
Each architect signs a The 3P is recognized as the inspired hard work from the participants. Therefore, as
the architect that will convert this creativity into a building, we do hereby commit
to the following:
contract on Monday of the 3P 1) We will hold to the designs created in the 3P.
week to confirm their role in 2) We will not make any changes to the design without the approval of the 3P
participants.
the 3P. Form follows flow, 3) When presenting any changes, no matter what the cause, we will listen to
and engage with the 3P participants always following their direction.
4) We will always respect the patient as the customer in the design process.
and the architect will hold 5) We will build in as much flexibility into the design as possible, understanding
and agreeing that Lean is about continuous improvement.
true to the designs created 6) We will work throughout the design process to reduce or eliminate each of the
seven wastes, working from schematic design into the building details.
by the participants.
Contracts are posted in the

room.
Signature:______________________ Date:_______
Coach:__________________________________ Date: _______
Copyright 2013 John Black and Associates LLC

Permission not granted to copy

Mod 27 – 3P
The 7 Ways
Each member of the team should work
independently, using the ideas from nature 1
to develop seven designs for the desired
function.
There are no restrictions and all ideas are

considered – even if not truly possible. 2 3
Each team member is thinking with a
creative, unbiased, and curious mind. Draw
pictures and use enough detail to be able
to explain your ideas to the other team 4 5
members.
Normally the first two or three designs will

come easily, however, to be able to
generate the seven designs, you may want 6 7
to examine and combine the mechanisms
from nature to assist you.

Mod 27 – 3P
3P JBA Reporting Requirements

Prior to Event Week
1. Create a Dropbox folder to hold all documents.

2. Ensure all logistics are confirmed with host site and supporting KPO: warehouse, clerical and
construction supplies, computer projector, 3P forms including contracts and evaluation tools,
posters of the No’s of Heath Care and 3P process, food, parking, maps.
3. Validate project form and target sheet completion at least 3 weeks prior to event week including
patient participants and architects.
4. Confirm all appropriate data has been collected.
5. Set all 30, 60, and 90 day conference calls.
6. Submit project form and target sheet to JBA consultant, Donna Kimball, 2 weeks prior to event
week.
During Event Week
1. Assist team lead with completion of newspaper.
2. Submit end-of-week report to John Black with “End-of-Week Report” in subject line of email at
the end of the week.
3. Summarize 3P evaluations, email to John Black and place in Dropbox folder.
After Event Week
1. Obtain target sheet from architect at 30, 60, 90 days and email copy to Donna Kimball.
2. Attend all follow ups as scheduled (i.e. 30, 60, 90 days).
3. Place 3P Event Report Out and all 3P documents in Dropbox folder and email Donna Kimball
to notify her of upload

Mod 27 – 3P
Process At A Glance
Name Process-At-A-Glance
___________________. Tact Time
One-Piece-Flow
Date Part:___________________ Process ________ of ________ Pull System
___________________.
Sequence
(1)
Material
Process
Sketch
(2)
Process
Method
(3)
Poka-Yoke
No-Go
Gauge
(4)
Tools
(5)
Jig/Fixture
Hanedashi
(6)
Machine

Mod 27 – 3P
Product Design Evaluation

Product Design 3P Evaluation
Product: _________________________________
Determine the criteria or attributes that are important to the “internal and external” customers. Many of these may
have been discussed during Step 1 of the Nakao Method. Please select this criteria before creating designs.
Vote each proposal against each of the criteria. Do one proposal at a time and base each score upon its own
merit. Do not evaluate against each other. Everyone votes 1-5. Do not average. Most repeated score should be
recorded. This evaluation is an addition to the 3P Process Evaluation Sheet to assist in narrowing the selection
of alternative designs; it is not intended to replace the 3P Process Evaluation and should not be used for such.
Design
Proposals
Criteria or Attributes 1 2 3 4 5 6 7
10
11
12
13
14
Total:
Rating: 5 = Excellent; 4 = Above Average; 3 = Average; 2 = Below Average; 1 = Poor; 0 = N/A

Mod 27 – 3P

Process:_________________________________
Vote each proposal one at a time based upon its own merit. Do not evaluate against each other.
Everyone votes 1 -5. Do not average. Most repeated score should be recorded.
Proposals
Production Method Qualifiers 1 2 3 4 5 6 7
S-1 Properly Guarded - Safety devices in place.
S-2 Passes Ergonomic Evaluation (no postural deviations >1).
S-3 Proper waste collection. Maintains clean workplace.
S-4 Low level of regulatory issues (environment, fire, safety, etc.).
Q-1 Quality Requirements known - NOGO gauges.
Q-2 Defects less than .03%.
Q-3 POKA-YOKE built into the process.
Q-4 Level of Autonomation achieved. (Level 7 would be a “5”).
C-1 Capital Investment (less is better).
C-2 Low level of approval to obtain materials to build.
C-3 Known technology.
C-4 Top notch tooling is used in the process.
C-5 Minimum MOONSHINE time is required.
C-6 Smaller and Simpler than current process.
C-7 Maintenance free. Easy autonomous maintenance.
H-1 Ability of the Process to meet TAKT time.
H-2 Creates ONE-piece flow.
H-3 Creates a PULL system.
H-4 MUDA-less process.
H-5 Change-overs (less than one minute).
H-6 Fits the CHAKU-CHAKU concept.
H-7 THROW-IN loading. Max. 2 seconds operator time.
H-8 Space Utilization. Townhouse design.
H-9 Mobility: On wheels. No roots or vines.
H-10 Number of RPIWs conducted on this process (More is better).
Total:
Rating: 5 = Excellent; 4 = Above Average; 3 = Average; 2 = Below Average; 1 = Poor; 0 = N/A
S=Safety; Q=Quality; C=Cost; L=Your “Local” Production System

Mod 27 – 3P
3P Project Form
This document is a summary of the information contained in the proposal. Its purpose is to give the judicator an “at a glance” look at the
proposal being evaluated. It contains summaries of the following documents contained in the proposal.
Roles and Participants: These are the core people and stakeholders involved in the event from the role of sponsor, team
and sub-team lead, project manager, audit leader and KPO support down to the content experts and participants including
patients and the architect.
Takt Time Calculations: Multiple Takt Times will be determined based on services provided and forecasted demands
spanning from 5 – 20 years.
-3P Workshop Project Form-
Process Flow: The patient flow the 3P is focusing 3P Project# & Project Name: Date:
If linked to past projects, note event #s & names here:
on is documented here in a high-level format. Note
Sponsor: Current Situation:
the other 6 flows are inherently involved but the Team Leader:
Sub Team Leader:

focus remains on the patient’s flow. Project Manager:

Audit Leader:
KPO Support:
Content Experts (if applicable) Department
Current Situation: Provide enough detail to allow 1.
2.
the reader to understand the need and sense of 3.
4.
urgency for this project. Use data to support the Team Members (Participants) Department
Must be present all 5 workshop days – do not exceed 25 participants
statements such as, “20% of patients are waiting 1.

2.
over 90 minutes to be seen”. 3.
4.
5.
6.
7.
3P Deliverables: The goal of the 3P is 8.
9.
articulated in enough detail to provide focus for 10.
11.
the 3P. 12.
13.
14.
3P Targets / Boundaries, Other Departments 15.
Takt Time Calculations: 3P Deliverables:

Affected: This defines the parameters of the 3P
and addresses any peripheral considerations.
Process Flow: 3P Targets / Boundaries / Other Departments Affected:

Mod 27 – 3P
3P Target Sheet
3P Target Progress Report and Results Sheet
3P # and Name: Report Out Date:
Departments: Sponsor:
Product/Process: Team Leader:
TAKT Time: Audit Lead / KPO Support :
(assigned by Sponsor)
MEASURES BASELINE TARGET 30 DAYS 60 DAYS 90 DAYS FINAL PERCENT

CHANGE
Space (Sq. Ft.)
Inventory
Walking Distance (ft)
Part Travel Distance
Lead time (h:mm:ss)
Quality (# Defects)
Productivity Gain Output

Input
5S-Envirnmntl, Health & Safety
Environment, Health & Safety
Set-Up
Cycle Time (mm:ss)
Capacity
Remarks:


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Mod 27 – 3P

Cost Reduction Profit =

GPS Depth Study Quality Cost Delivery

Jidoka Standard Total Visual

Value Stream Mapping

ONE PIECE FLOW TAKT TIME PULL PRODUCTION

27 3P v20130529 1 ©1996-2013, John Black and Associates LLC

“You should submit

“Perhaps you are asking yourself,-

How can a manufacturing model be

That is certainly true and a perspective

27 3P v20130529 3 ©1996-2013, John Black and Associates LLC

“Toyota revolutionized our

27 3P v20130529 5 ©1996-2013, John Black and Associates LLC

Lost opportunity Customer

Non-value added Bureaucracy

Taiichi Ohno’s Seven Wastes

Defective Time on Hand

27 3P v20130529 7 ©1996-2013, John Black and Associates LLC

GPS – Foundation Principle

Impact of Lead-Time Reduction

1.Identify value stream Kanban

27 3P v20130529 10 ©1996-2013, John Black and Associates LLC

Production Preparation Process

27 3P v20130529 11 ©1996-2013, John Black and Associates LLC

Creating the Links for Building In Quality

Ted Gachowski’s Journey

SEATTLE -- Up until five months ago, Ted Gachowski's weekly chemotherapy

And the bottom line is…

A COM P ETITIVE WEAPON IN OUR INDUSTRY

RAP ID CONTINUOUS IMPROVEMENT

27 3P v20130529 16 ©1996-2013, John Black and Associates LLC

Kaizen Alone May Vision

Improve Service New Service

The New Way of Creating

The Patient (internal or external)

27 3P v20130529 19 ©1996-2013, John Black and Associates LLC

What do you really

Develop a 3P Designed Machine for Cell X

Develop a Flow line for Lab W

Reduce floor space by 50% for new Oncology unit.

Design a Children's Hospital with no waiting rooms, 50% reduction

27 3P v20130529 20 ©1996-2013, John Black and Associates LLC

Think about what you wish to accomplish...

2. Define the Essence of the Function

Sketch What is Happening.

27 3P v20130529 22 ©1996-2013, John Black and Associates LLC

3. Look for Examples of Keywords in Nature

Resist All Attempts to Use Man Made Examples. Hinge

27 3P v20130529 23 ©1996-2013, John Black and Associates LLC

4. Sketch Examples, Examine What is Happening

Examine in Detail Group Common Examples

You MUST Look Deep into the Phenomenon to Understand.

5. Sketch Background and Conditions of Function

happen in the Muscle

surroundings for this

6. Combine Ideas from Nature to Create Sketches

7. Moonshine: Pick 7 Proposals to Build

Use Readily Available Materials To Build Your Prototypes.

8. Conduct Experiments to Collect Real Data

9. Select the Three Best Designs, then…

You MUST Understand the Quality Required.

10. Evaluate Data on Top 3 Designs